Repair Of Ureteropelvic Junction Obstruction Research Articles

Epidemiology of Infantile Ureteropelvic Junction Obstruction in the US

To describe sex- and diagnosis-specific comorbidities, outcomes, and secular trends associated with ureteropelvic junction obstruction (UPJO) in a large, real-world population diagnosed with hydronephrosis in infancy. We identified all infants ≤1year old with ≥1 claim in the Optum Clinformatics 2007-2020 nationwide population database and used univariable and multivariable Cox regression analyses to estimate associations of demographic and clinical characteristics of infants with a UPJO diagnosis with surgical status. Of 22,349 infants with hydronephrosis (1.1% of infants; males-1.4%, females-0.7%), 1722 (7.7%; 7.9%-males, 7.2%-females) had UPJO. Follow-up was ≥1year in 1198 (70%) and ≥3years in 555 (32%) cases, and UPJO repair was performed in 542 children (31.5%; 32.3%-males, 29.5%-females); 77.7% within 1year and 97.3% within 3years. UPJO repair was associated with prior urinary tract infection (UTI) (hazard ratio (HR) 1.41, 95% confidence interval (CI) 1.12-1.76) and South (HR 1.42, 95% CI 1.14-1.78) or Midwest (HR 1.60, 95% CI 1.26-2.04) geographic region but did not change over time. This population-based study provides a real-world view of postnatally diagnosed hydronephrosis, focusing on UPJO, for which 522 cases (∼1/3) had ≥3years continuous coverage. UPJO-associated comorbidities were more common in females, and the frequencies of UPJO-associated surgery and comorbidities were higher than in other studies. Other than UTI, no other associated kidney or urinary tract diagnoses were associated with UPJO repair. We identified unique sex- and diagnosis-specific differences in associated comorbidities and interventions in children diagnosed with UPJO in the first year of life.

Robot-assisted laparoscopic pyeloplasty is a valid option for ureteropelvic junction obstruction repair in adults with congenital renal abnormalities: a case series study

BackgroundCongenital renal anomalies are rare but may be associated with obstruction of the ureteropelvic junction. Given the rarity of simultaneous ureteropelvic junction obstruction [UPJO] and renal anomalies in the adult population, there is limited literature on approaching these patients. We report our experience with robotic assisted laparoscopic pyeloplasty for UPJO repair in this subset of patients.MethodsData on adult patients with simultaneous congenital renal abnormalities and UPJO who underwent robotic assisted laparoscopic pyeloplasty between 2008 and 2020 was reviewed. Pre-operative data, intraoperative parameters as well as post-operative data including symptom resolution and radiologic findings were recorded.ResultsTen patients, 4 female and 6 males, with a mean age of 47 years were identified as having simultaneous congenital renal abnormalities and UPJO. Anomalies identified were horseshoe kidney in four patients, duplex kidney with obstruction of one moiety in two patients, malrotated kidney in two patients, and pelvic kidney in two patients. Eight out of ten were symptomatic at presentation with flank pain being the most common symptom. Eight patients underwent robotic pyeloplasty via the dismembered technique, while two underwent robotic Y-V pyeloplasty. With a mean follow up time of 13 months, 8/9 (88%) symptomatic patients enjoyed symptom resolution. Post-op renogram was available for nine patients and showed resolution of obstruction in all patients (100%). One patient developed a urine leak which was managed successfully with drainage.ConclusionsRobotic assisted laparoscopic pyeloplasty is a safe, feasible and effective surgical approach in management of adult patients with concomitant UPJO and renal anomalies.

Mini-laparotomy in-situ pyeloplasty for repair of the ureteropelvic junction obstruction: Outcome of 150 cases.

To evaluate the functional and cosmetic outcomes of using the mini-laparotomy technique In Situ pyeloplasty to repair UPJ obstruction in young infants less than 6 months. Between January 2014 and March 2020, 150 young infants (less than 6 months) diagnosed with unilateral ureteropelvic junction obstruction (UPJO) and treated by mini-laparotomy In Situ pyeloplasty were included in this analysis. Once the UPJ has been identified, it was grasped by an Allis forceps for gentle traction. Two facing transverse incisions were made in the dilated pelvis facing the upper ureter. The transverse ureteric incision was then opened longitudinally. An anastomosis was done between the most dependent part of the lower lip of the pelvis and the apex of ureteric spatulation using 6/0 polyglactin (Vicryl®) sutures in the direction of "out-in-in-out." Follow-up was scheduled for 1 month and then every 3 months for a year with abdominal ultrasonography. DTPA was done for all patients 1 year after repair. The mean age was 3 ± 0.5 months, and the mean follow-up was 1.5 ± 0.3 years. Our technique was done in all included patients with a functional success of 96% (all patients restored normal function, and no obstruction was reported). Parents were satisfied with the cosmetic appearance of the wound in 91% of cases. Major complications occurred in 4% of cases. Successful repair of ureteropelvic junction obstruction in young infants can be achieved by using mini-laparotomy In Situ pyeloplasty technique with satisfactory functional and cosmetic outcomes.

MP42-06 ASSESSING THE ACCURACY OF PREOPERATIVE RADIOGRAPHIC IMAGING IN DETERMINING URETERAL STRICTURE LENGTH AT TIME OF ROBOTIC URETERAL RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP42-06 ASSESSING THE ACCURACY OF PREOPERATIVE RADIOGRAPHIC IMAGING IN DETERMINING URETERAL STRICTURE LENGTH AT TIME OF ROBOTIC URETERAL RECONSTRUCTION Labeeqa Khizir, Alain Kaldany, Hiren V. Patel, and Sammy E. Elsamra Labeeqa KhizirLabeeqa Khizir More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Hiren V. PatelHiren V. Patel More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: During robotic ureteral reconstruction, accurate measurement of ureteral stricture length is important for surgical planning. We aimed to determine the accuracy of using conventional fluoroscopic imaging compared to ureteroscopy and direct measurement with measuring tape during intra-operative robotic repair. METHODS: A retrospective review was conducted for 15 patients with ureteral stricture disease at a single institution treated with robotic repair. Data was collected regarding etiology of ureteral stricture disease, measured preoperative radiographic stricture length on fluoroscopy, and measured intraoperative robotic stricture length. A Wilcoxon matched-pairs rank test was performed to compare ureteral length measurements. RESULTS: The most common etiologies of ureteral stricture were prior medical history of stone disease (n=10), prior ureteropelvic junction obstruction repair (n=3), and other iatrogenic causes (n=2) (Table 1). A majority of patients had ureteral stricture repair using buccal mucosa (n=7) or appendiceal onlay (n=6) grafts (Table 1). A total of 11 patients (73%) had >1 cm difference in stricture length between radiographic and robotic measurement (Figure 1). Of these patients, 73% (n=8) had prior medical history of stone disease (Table 1). The intraoperative robotic length was significantly longer compared to preoperative radiographic length (Median difference 1.2 cm, 98% CI 0.15-2.3, p<0.05) (Figure 1). CONCLUSIONS: Conventional preoperative radiographic measurement significantly underestimates the ureteral stricture length compared to intraoperative measurement. This may have clinical significance in influencing operative planning, technique, and the length of graft that is harvested. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e568 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Labeeqa Khizir More articles by this author Alain Kaldany More articles by this author Hiren V. Patel More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

Robot-assisted Laparoscopic Pyeloplasty: Experience of a Single Pediatric Institution, Including Long-term and Safety Outcomes

To evaluate the efficacy and safety of robot-assisted laparoscopic pyeloplasty (RALP) and describe the short and long-term outcomes of pediatric RALP. We retrospectively reviewed all patients ..±21 years old who underwent primary RALP from 7/2007 through 12/2019. Patients were excluded from postoperative analysis if follow-up data after stent removal was not available. The primary outcome was surgical success, defined as radiographic improvement of hydronephrosis without need for reoperation. Secondary outcomes were time to reoperation and 90-day complication rate. A total of 356 patients underwent primary repair of ureteropelvic junction obstruction during the study period; 29.ßpatients were limited to intraoperative data due to lack of follow-up imaging. Radiographic improvement at latest follow-up was seen in 308/327 (94.2%). Ten of 327 patients (3.1%) underwent reoperation: 7 were identified within 1 year of RALP and 3 were identified over 1 year after RALP. The median time to reoperation was 13.0 months (IQR 9.3-21.7). We defined long-term as>3 years after pyeloplasty. Over one-third (122/327, 37.3%) of the cohort had>3 years of follow-up, none of whom developed evidence of recurrent obstruction requiring reoperation beyond 3 years. Complications occurred within 90 days of surgery in 20/327 (6.1%). This largest single-institution series confirms short- and long-term surgical effectiveness and safety of RALP. Our data also indicate that most patients who needed reoperation were identified within 1 year, and reoperation more than 3 years after RALP is rare.

Percutaneous management of ureteropelvic junction obstruction.

The development of endoscopic and minimally invasive techniques has revolutionized the treatment of ureteropelvic junction obstruction (UPJO). Patients can now undergo successful UPJO repair without the morbidity and complications associated with open surgery. Laparoscopic and robotic repair has supplanted open surgery as the gold standard, but percutaneous endoscopic treatment remains a relevant alternative to more invasive surgery. This review will focus on the percutaneous approach for the treatment of UPJO. Percutaneous endopyelotomy was popularized during the 1980 s due to advances in the field of endourology, allowing for well tolerated and reliable percutaneous access to the kidney. After percutaneous access to the kidney is achieved, the narrowed ureter at the UPJ is incised in a full thickness fashion in the posterolateral position from the ureteral lumen to the periureteral fat. Success rates for this procedure are nearly 90% at high-volume centres. The ideal patient who has success with percutaneous endopyelotomy has a short segment of narrowing less than 2 cm, no crossing vessel, good ipsilateral renal function and mild hydronephrosis. Although the development of laparoscopic and robotic approaches to pyeloplasty has produced outcomes that surpass those of percutaneous endopyelotomy, it remains a viable option in the appropriately selected patient, but success rates tend to decrease with longer follow up.

Feasibility, safety and effectiveness of laparoscopic transperitoneal pyeloplasty in children: Ain Shams University early experience

Background/purposeLaparoscopic pyeloplasty (LP) is now widely recognized as a minimally invasive alternative for the surgical repair of ureteropelvic junction obstruction (UPJO) in paediatrics. In this work, we aim to evaluate the feasibility, safety and effectiveness of LP in our early experience.Patients and methodsBetween April 2019 and April 2020, patients presented with indication for surgical repair of UPJO were offered laparoscopic transperitoneal Anderson-Hynes pyeloplasty. Demographic data, preoperative investigations, operative data and intra- or postoperative complications, as well as short and mid-term follow-ups were recorded.ResultsDuring the specified period, 13 patients underwent LP (8 girls and 5 boys) with a median age of 12 months (range from 5 to 150 months). There was no conversion to open approach with operative time ranging from 120 to 240 min (mean = 175 ± 34 min). No intra- or postoperative complications were encountered. One to 2 years postoperative follow-up was performed (median = 18 months) in 11 patients. One patient discontinued follow-up after 1 month and another after 6 months. Follow-up PAUS showed a reduction in the anteroposterior diameter of the renal pelvis in all cases. Postoperative diuretic renal scans (DTPA renography) were done for three patients with a persistent anteroposterior diameter of the renal pelvis greater than 20 mm which showed improvement in the washout. All patients had a good cosmetic outcome.ConclusionIn our early experience in LP, we found the procedure a safe, feasible and effective technique in managing UPJO in children and infants with good cosmetic outcome.Level of evidenceThis is a case series study (level IV evidence).

EDITORIAL COMMENT

New techniques for the treatment of ureteropelvic junction obstruction (UPJO) and proximal ureteral strictures continue to evolve, including buccal ureteroplasty,1 appendiceal interposition,2 and even gonadal vein grafts.3 However, the Anderson-Hynes dismembered pyeloplasty remains the gold standard for repair of UPJO since it was first described in 1949 because of its durable outcomes and relative technical simplicity. While advances in minimally invasive surgical technique have improved procedural morbidity, the true technical principles of the pyeloplasty have remained the same for almost 80 years.

Clinical and radiographic outcomes following salvage intervention for ureteropelvic junction obstruction.

ABSTRACTPurpose:We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO).Materials and Methods:A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both.Results:Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF.Conclusions:Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.

Impact of successful pediatric ureteropelvic junction obstruction surgery on urinary HIP/PAP and BD-1 levels

In the pediatric patient whose ureteropelvic junction obstruction (UPJO) is not always symptomatic, imaging is the most common means of detecting surgical success. There is interest, however, in other means of post-operative monitoring. A panel of antimicrobial peptides (AMPs) has been previously found to be elevated in UPJO, but the impact of surgical correction on these AMPs is unknown. To determine if elevated levels of candidate urinary AMP biomarkers of urinary tract obstruction decrease following UPJO repair. Pediatric patients undergoing surgical correction of an UPJO were recruited for participation. Bladder urine from uninfected consenting/assenting patients was collected immediately prior to surgery and then at least 6 months afterward. Based on prior studies demonstrating significant elevation of beta defensin 1 (BD-1), hepatocarcinoma-intestine-pancreas/pancreatitis-associated protein (HIP/PAP), cathelicidin (LL-37), and neutrophil gelatinase-associated lipocalin (NGAL) in patients with UPJO versus control patients, we performed enzyme-linked immunosorbent assays on these four AMPs to compare their expression before and after surgical intervention. If found to significantly decrease, AMP levels were compared to healthy controls. AMP levels were normalized to urine creatinine. Results were analyzed with paired t test or Wilcoxon test using Graphpad software. Correlation was calculated using Pearson or Spearman correlation. A p-value of <0.05 was considered significant. 13 UPJO patients were included in this study; 9 were male (69%). Age at surgery was a median of 4.3 years (average 6.1, range 0.4-18.4 years). Follow-up urine samples were collected a median of 27.4 months after surgery (average 27.4; range 7.8-45.3 months). All 13 patients had clinical improvement and/or signs of improved hydronephrosis on post-operative imaging. HIP/PAP and BD-1 significantly decreased in post-surgical samples compared to pre-surgical samples (p=0.02 and 0.01, respectively); NGAL and LL-37 did not significantly change. Overall, HIP/PAP decreased in 12 patients (92%) and BD-1 decreased in 11 patients (85%). BD-1 levels after successful repair were not different from healthy controls (p=0.06). Urinary biomarkers of obstruction should detect significant obstructive pathology as well as reflect its resolution. This would enable their use in post-operative monitoring and augment current methods of determining successful surgical outcome through imaging. The AMPs HIP/PAP and BD-1 are significantly elevated in UPJO but then significantly decrease after pyeloplasty, with BD-1 returning to healthy control levels. As a result, these AMPs could serve as markers of successful surgical intervention.

Risk Factors and Management Options for the Adult Failed Ureteropelvic Junction Obstruction Repair in the Era of Minimally Invasive and Robotic Approaches: A Comprehensive Literature Review.

Guidelines for the management of pyeloplasty failure remain elusive given the rarity of this condition and the difficulty of integrating and analyzing reported outcomes given the varying definition of failures. In this article, we aim to review the existing literature on risk factors that may influence the surgical outcomes of reconstructive pyeloplasty for ureteropelvic junction obstruction. Furthermore, we discuss management options and review success outcomes of treatment options for patients with pyeloplasty failure.

Five-Year experience with pyeloplasty using intubated and nonintubated techniques

Background: Ureteropelvic junction obstruction (UPJO) is an obstruction of urine flow from the renal pelvis to the ureter. This condition can be caused by congenital and acquired due to intrinsic or extrinsic factors. UPJO due to acquired conditions such as secondary to inflammation, passage stones, or ureteric folds is less common. In case of suspected UPJO, the critical decision to be made depends on the correlation between the radiologic findings and the physiologic picture. There have been recent and serious trials to perform the surgical repair of UPJO without intubation, with reservation of double J (DJ) stents and nephrostomy tubes for complex cases. The Aim of Study: The aim of the study was a comparison of the time of drain removal, hospital stay, complications, and the end result of surgery in intubated and nonintubated UPJO repair. Patients and Methods: A retrospective case serious study performed in Urological Departments at Benghazi Medical Center and Al-Hawari Urology Center by reviewing 51 files of consecutive patients of UPJO admitted to the department of urology from May 2010 to 2015. All patients were diagnosed using different diagnostic tools. Forty-three cases underwent reconstructive surgeries as follows: 41 (95.3%) patients underwent Anderson-Hynes-dismembered (A-H-D) pyeloplasties and 2 (4.7%) patients underwent VY Foley pyeloplasties. Out of 41 cases underwent A-H-D pyeloplasties, there were six cases underwent concomitant pyelolithotomy. Results: The time of removal percutaneous perinephric tube drain was 7th to 9th postoperative days and 7.9 ± 0.5 days. The postoperative hospital stay for all cases range from 7 days to 10 days and the mean was 8.0 ± 0.8 days. Conclusions: Despite both intubated and nonintubated techniques of UPJO repair are comparable regarding the hospital stay postoperative complication, the tubeless surgical repair of UPJO is more suitable for children and superior to the intubated technique regarding the cost of DJ stent and nephrectomy tube.

Laparoscopic repyeloplasty after failed open repair of ureteropelvic junction obstruction: a case-matched multi-institutional study

Objective: The aim of this study was to retrospectively review the experience and midterm results of laparoscopic pyeloplasty (LP) in patients with previous failed open pyeloplasty in comparison to primary LP.Materials and methods: Thirty-two patients who had undergone previous failed open surgery for management of ureteropelvic junction obstruction (UPJO) were reviewed. The patients underwent transperitoneal dismembered LP. All operations were performed by the same laparoscopist from March 2009 to June 2013. Surgical results were compared to 72 patients who underwent primary LP carried out by the same surgeon during the same period.Results: The laparoscopic repyeloplasty group consisted of 14 men and 18 women. The mean age was 29 ± 6 years. The mean operative period was 133 ± 42 and 110 ± 57 min; the mean length of stay in hospital was 2.7 ± 2.3 and 1.3 ± 2.1 days; and the mean follow-up period was 32.4 ± 14 and 29.3 ± 11.2 months in the secondary and primary LP groups, respectively. The success rate was 90.6% for secondary LP and 94.4% for primary LP. There was no conversion in either group. The percentage of intraoperative and postoperative complications in secondary LP was 9.4% and 12.5%, respectively, compared with 0% and 5.6% in the primary LP group.Conclusions: Laparoscopic repyeloplasty is a safe and viable treatment option for secondary UPJO, with a success rate similar to that of primary repair but with longer operative time. Considerable experience in laparoscopic reconstructive procedures is a prerequisite for optimal results.

Pediatric Robot-assisted Redo Pyeloplasty With Buccal Mucosa Graft: A Novel Technique

To report a novel approach of pediatric robot-assisted redo pyeloplasty with buccal mucosa graft (BMG). An Institutional Review Board-approved retrospective review of all patients undergoing robot-assisted redo pyeloplasty with BMG at our institution was performed. For all patients, the following ports were used: one 8.5 mm camera, two 8 mm robotic, and one 5 mm assistant. Initial dissection was performed laparoscopically and robotically, and the ureter was incised longitudinally along the anterior surface. The robot was undocked, and BMG was harvested from the inner cheek. The robot was then redocked, and grafts were delivered via the 8 mm robotic port and anastomosed as anterior onlay grafts using 5-0 or 6-0 absorbable monofilament suture. Omentum was quilted over the graft as a vascular backing. Ureteral stents were placed intraoperatively and left in situ for 8 weeks. Foley catheters were removed on postoperative day 3. All patients received intravenous ampicillin and gentamicin preoperatively, with antibiotics discontinued within 24 hours. Three patients underwent robot-assisted redo pyeloplasty with BMG. Patient characteristics are seen in Table1. Mean number of prior surgeries for ureteropelvic junction obstruction repair was 2 (1-3), and mean length of stricture was 4.3 cm (2.5-6). At a median follow-up of 10 months (5-26), all patients are asymptomatic with stable or improved ultrasound. Robot-assisted redo pyeloplasty with BMG is safe and feasible in the pediatric population. Long-term follow-up is needed to determine the durability of these grafts.

Reoperative Laparoscopic Ureteropelvic Junction Obstruction Repair in Children: Safety and Efficacy of the Technique

Failure after pyeloplasty for ureteropelvic junction obstruction in children may occur in up to 10% of cases. Therapeutic options include Double-J® stent placement, endoscopic treatment and reoperation. Laparoscopic and robotic reoperative modalities seem safe and efficacious, although pediatric series are limited in the literature. We report the largest known series of reoperative laparoscopic ureteropelvic junction obstruction repair in children and compare this approach to primary laparoscopic pyeloplasty. We reviewed all children undergoing laparoscopic pyeloplasty at a single institution from 2004 to 2015. Reoperative laparoscopic ureteropelvic junction obstruction repair was compared to primary pyeloplasty. Groups were analyzed regarding demographics, operative time, complications, length of hospital stay and success, defined by improvement of symptoms, ultrasound and renogram. We identified 11 cases of reoperation (8 redo pyeloplasties and 3 ureterocalycostomies) and 71 primary pyeloplasties. Groups were not different in age, gender or weight. Median followup was 37 months. Median time between primary pyeloplasty and reoperation was 34 months. Median operative time was 205 minutes for the reoperative group and 200 for primary pyeloplasty (p = 0.98). Length of stay was longer in the reoperative group (p = 0.049), although no major complications were recorded in this group. All reoperative cases and 96% of primary pyeloplasty cases remained asymptomatic following surgery (p = 0.99). Postoperative improvement was similar for both groups on ultrasound (90% for reoperation vs 92% for primary pyeloplasty, p = 0.99) and renogram (80% vs 88%, p = 0.6). Laparoscopy seems to be safe and effective for management of failed pyeloplasty in children. Based on our data, reoperation is as safe and effective as primary pyeloplasty.

Laparoscopic vs Open Pyeloplasty in Children: Results of a Randomized, Prospective, Controlled Trial

Open dismembered pyeloplasty is the preferred repair for ureteropelvic junction obstruction. Minimally invasive techniques have been applied to the original open approach but no clear advantage has been demonstrated for these technological advances. We evaluate outcomes between transperitoneal laparoscopic and open pyeloplasty in children. All children 1 to 18 years old with ureteropelvic junction obstruction requiring operative repair were offered enrollment in the study. Patients were prospectively randomized to either laparoscopic or open pyeloplasty through a flank incision. A total of 50 patients in the laparoscopic group and 48 in the open group were enrolled from 2005 to 2014. Mean followup was similar between the groups (13.7 months in the laparoscopic group vs 12.3 months in the open group, p = 0.54). The only significantly different outcomes were for mean operative time, which was 139.5 minutes (range 94 to 213) in the laparoscopic group and 122.5 minutes (83to 239) in the open group (p <0.01), and mean length of stay, which was 25.9 hours (18 to 143) in the laparoscopic group and 28.2 hours (16 to 73) in the open group (p = 0.02). Analgesic usage, success rate, total charges and all parameters in children older than 11 years were similar between the groups. Open and laparoscopic dismembered pyeloplasty are comparable and effective methods for repair of ureteropelvic junction obstruction. Although operative time was statistically shorter in the open group and length of stay was shorter in the laparoscopic group, the clinical significance of these variables is questionable. The approach to repair may best be based on family preference for incision aesthetics and surgeon comfort with either approach, rather than more classically objective outcome measures.

Surgical results of anderson-hynes dismembered pyeloplasty without internal drainage in adults with ureteroplevic junction obstruction.

Background:Anderson-Hynes dismembered pyeloplasty is the gold standard therapeutic approach to ureteropelvic junction obstruction (UPJO). Use of a drainage method to protect the suture line from leakage is a matter of controversy.Objectives:We have compared the surgical outcome of Anderson-Hynes dismembered pyeloplasty for UPJO repair, with or without internal stenting.Patients and Methods:Eighty-two patients with UPJO were evaluated from 1996 to 2002. Complicated or emergent cases were excluded. Classic standard dismembered pyeloplasty was performed. Internal drainage, with a double j catheter, was performed in several patients, randomly. Another drain was also placed in the retroperitoneal space. The follow-up of patients was planned weekly, with patient visits and urine analysis and intravenous pyelography (IVP) and diethylene-triamine-pentaacetate (DTPA) scan after one month.Results:The study group consisted of 51 male and 31 female patients, who were mostly in the age range of 20 - 40 years. Comparing the two techniques of pyeloplasty with or without internal drainage, there was no significant difference between groups regarding extravasation and anastomosis complications, such as leakage, stenosis, urinoma formation or evidence of obstruction on postoperative IVP or DTPA scan. However, a higher incidence of catheter related urinary symptoms and flank pain was reported among those with internal stent.Conclusions:Pyeloplasty, with adequate spatulation, hemostasis and a watertight anastomosis, represents the mainstay of successful pyeloplasty and there may be no significant benefit for urethral stenting, especially in non-complicated cases.

Robot-Assisted Retroperitoneal Pyeloplasty

Introduction: Robot-assisted laparoscopic surgery has been widely adopted for the surgical repair of ureteropelvic junction obstruction, and the majority of these pyeloplasty surgeries are performed by a transperitoneal approach. Retroperitoneal robotic surgery has been applied to renal surgery and offers direct access to the kidney, renal pelvis, and ureter. There are several theoretical advantages of the retroperitoneal approach. It avoids manipulation and potential injury of the bowel and adjacent organs, and in the event of urine leakage, any fluid will be collected and isolated within the retroperitoneum. In this video, we demonstrate the technique of retroperitoneal robot-assisted dismembered pyeloplasty with a crossing vessel. The patient is a 42-year-old woman with symptomatic left flank pain, hydronephrosis, and obstruction on diuretic renal scan. Materials and Methods: We collected the data from 64 consecutive patients, each with a primary ureteropelvic junction obstruction, operated between April 2012 and December 2013. Of those patients, 48 had a robotic transperitoneal pyeloplasty while the last 16 consecutive cases utilized a robotic retroperitoneal approach. The decision to transition to a retroperitoneal approach was initially based on surgeon's preference and presence of prior abdominal surgery and not impacted by patient's characteristics. All patients were operated by a single surgeon with the da Vinci Si system. There were no drains left in any of the cases. Information about perioperative data, complications, and postoperative functional outcome was collected. Results: When utilizing the transperitoneal approach, there was a median operative time of 192 minutes, mean estimated blood loss (EBL) of <50 mL, hospital length of stay of 1.1 days, and no complications. For the retroperitoneal approach, we found a median operative time of 162 minutes, EBL of <50 mL, hospital length of stay of 1.2 days, and one case was converted to an open pyeloplasty due to failure to progress. There was no significant difference between the transperitoneal and retroperitoneal approaches. Conclusion: Robot-assisted retroperitoneal laparoscopic pyeloplasty is feasible and technically possible for the repair of ureteropelvic junction obstruction. The retroperitoneal approach offers similar outcomes to transperitoneal surgery with a potentially shorter operative time and rapid identification of the ureteropelvic junction anatomy. Additionally, there is reduced bowel manipulation and risk of injury, and there is an isolated retroperitoneal space in the event of urine leakage. The authors declare that no competing financial interests exist. Runtime of video: 7 mins 24 secs

Postoperative evaluation of hydronephrosis due to the way of pyeloplasy (dismembered / non-dismembered).

Central European Journal of Urology106Cent European J Urol 2014; 67: 106-107 10.5173/ceju.2014.01.art25In recent years, we have seen rapid development of minimally invasive procedures in urologic oncology, but also in corrective surgery of congenital defects, including ureteropelvic junction obstruction (UPJO). After a period of testing the endoscopic treatment of UPJO, currently the majority of patients undergo laparoscopic or robotic surgery. Recently, single port laparoscopy (LESS) has become an optional technique in the urological armamentarium. Laparoscopic treat -ment of UPJO in adults has been established as the “gold standard” means of curing this quite common disease. Nowadays it draws much attention as it is one of the very few urological laparoscopic operations that can be done relatively easily by a laparoscopist with limited experience, and as such, resembles the case of cholecystectomy for general surgeons [1, 2]. Abundant literature offers much data about very good postoperative functional results of laparascopy: equal to open surgery and with the known advantage of min -imal invasiveness. In contrast, many authors contin-ue to commission research of functional supervision of patients after UPJO repair, since the disappearance of hydronephrosis observed in the ultrasound over a longer period of time may also result from the deterio -ration of renal function. However, it is surprising that the authors very seldomly give precise details about how long after the procedure the final outcome was evaluated and which diagnostic tools should be used. In the current issue of CEJU, Isoyama and co-oper-ators present a very interesting paper inspired by data coming from paediatric surgeons that the hy-dronephrosis after UPJO repair may subside very gradually, probably as the elastic properties of the renal pelvis may differ individually. According to the authors, this has two practical consequences. Firstly, provided that there are no remaining symptoms , the judgement of the result of surgery should be post-poned, as there is still time for improvement, even as long as two years after the operation. Secondly, serial ultrasound may be a valuable alternative to more invasive diagnostic tests, such as intravenous pyelography (IVP) or diuretic renogram, during the follow-up. It is worth noting that, in our opinion, the evaluation of the hydronephrosis stage changes should be sought for each patient individually, as a step in the laparoscopic partial resection of the en-larged renal pelvis. In some cases immediately af-ter surgery, with radical removal of the excess renal pelvis, the hydronephrosis is no longer observed [3]. The ultrasound evaluation of the functional effect of the surgery, by reducing the hydronephrosis, seems to be useful in the case of non-dismembered pyelo-plasy, since the treatment is limited only to the lon-gitudinal cut of UPJO and transverse suture without resection of the stenosed part of the renal pelvis [4].The study is small as it is based on the analysis of only 16 patients, but may give urologists some scientific sup-port for consultation of patients after UPJO surgery, who do not have symptoms, but are uncertain about the outcome, especially if there is some persistent hydro-nephrosis. From the Isoyama paper, we may conclude that the resolution of hydronephrosis may take even two years and may be followed very well by measure-ments from subsequent ultrasound evaluations, which are better that USG tests done separately. It can spare the patient unnecessary tests or maybe sometimes even prevent an unnecessary re-do operation. More-over, subsequent ultrasound measurements of the size of the renal pelvis in the improvement of kidney func-tion, after dismembered pyeloplasty of UPJO, in our opinion, provide an interesting noninvasive diagnostic option, but should be carried out individually, taking into account the extent of renal pelvis resection during surgery for each patient. If there are still any doubt as to the effect of the treatment, diuretic renogram and IVP remain the standard diagnostic procedures.Editorial referring to the paper published in this issue on pp. 101–105

Laparoscopic Pyeloplasty in Children with Horseshoe Kidney

Laparoscopic pyeloplasty for ureteropelvic junction obstruction associated with horseshoe kidney has been described in adults but seldom in young children. We describe our experience in 10 children treated successfully with laparoscopic dismembered pyeloplasty. Eight boys and 2 girls with a mean age of 8 years (range 0.7 to 16.5) underwent laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction associated with horseshoe kidney between 2002 and 2012. Presenting symptoms were abdominal pain (3 patients), urinary tract infection (2), abdominal mass (1) and hematuria (1). Horseshoe kidney was diagnosed preoperatively in all cases but 1. The anastomosis was done by running or interrupted 5-zero or 6-zero resorbable sutures and drained by a Double-J® stent. Laparoscopic dismembered pyeloplasty was feasible in all cases. Mean operating time was 220 minutes (range 180 to 260). Anatomical abnormalities included anteriorly crossing vessels at the ureteropelvic junction in 6 cases (polar vessels in 4, ureteropelvic junction posterior to an abnormal branch of vena cava in 1 and renal vein in 1) and high ureteral insertion in 4. Two children underwent an extensive reduction pyeloplasty. Mean hospital stay was 3.2 days (range 1 to 8). Mean followup was 50 months (range 4 to 132). All patients were asymptomatic with significant improvement of dilatation. The transperitoneal laparoscopic approach is adapted for pyeloplasty in children with horseshoe kidney. This procedure allows global exploration of the upper tract and efficient identification of anatomical anomalies, especially crossing vessels. Although our series is small, it is the first known description specific to horseshoe kidney in children and demonstrates that this approach has lasting effectiveness in young children.