Resolution Of Ureteropelvic Junction Obstruction Research Articles

Incidence of pathologic postobstructive diuresis after resolution of ureteropelvic junction obstruction with a normal contralateral kidney

Postobstructive diuresis (POD) after unilateral pyeloplasty or percutaneous nephrostomy (PCN) tube insertion for ureteropelvic junction obstruction (UPJO) in patients with a normal contralateral kidney is not well described. The objective of this study was to determine the incidence and characteristics of POD after relief of unilateral UPJO in patients with a normal contralateral kidney. Children who underwent a unilateral pyeloplasty or PCN for UPJO from 2010 to 2017 with a normal contralateral kidney were retrospectively reviewed. Postobstructive diuresis was defined as urine output (UO) of >300% of expected UO. Patients with a solitary kidneyor those who underwent bilateral pyeloplasty or bilateral PCN tube placement were excluded. Out of 396 children meeting inclusion criteria, seven (1.8%) developed POD (4 after pyeloplasty and 3 after PCN tube placement). Median age at intervention was 1.7 years (range 11 days-18 years); median weight was 11.4kg (range 3.7-54.2kg). Postobstructive diuresis was more likely to occur in patients with grade 4 hydronephrosis (3.0%) and larger kidneys and if a PCN tube was placed before pyeloplasty. There was no significant difference in age, gender, kidney laterality, or function between those who developed POD and those who did not. Postobstructive diuresis was managed with additional intravenous fluids and electrolyte monitoring. Median initial postprocedure UOwas 5.9mg/kg/hr (range 3.2-10.0mg/kg/hr). In five children who underwent PCN in whom UOcould be differentiated between kidneys, median initial postprocedure UOwas 6.1mg/kg/hr (range 2.5-9.1mg/kg/hr) from the affected side and 0.8mg/kg/hr (range 0.4-0.9mg/kg/hr) from the unaffected side. The median length of time to resolution of POD was 3 days (range 2-4 days). One patient developed significant acidosis and lethargy that improved with intravenous fluid management. Mild hyponatremia developed in two, hypokalemia in one, hypophosphatemia in one, acidosis in one, and hypoglycemia in 1 patient. A low but clinically significant risk of POD occurring after relief of unilateral UPJO in children with a normal contralateral kidney is described. Limitations include retrospective analysis and small sample size due to the rarity of the condition. Postobstructive diuresis after decompression of UPJO in patients with a normal contralateral kidney is a rare event (1.8%). However, POD does occur, and patients should be carefully monitored after these procedures given the potential for significant dehydration and electrolyte disturbances.

Comparative, Prospective, Case-Control Study of Open versus Laparoscopic Pyeloplasty in Children with Ureteropelvic Junction Obstruction: Long-term Results.

We compare open pyeloplasty (OP) versus laparoscopic pyeloplasty (LP) in children in a multicenter, prospective, case-control study. From May 2007 to March 2009, a program was established at Hospital Garrahan, the reference center, to perform LP with a mentoring surgeon that would attend the institution once a month. Every new case of ureteropelvic junction obstruction (UPJO) diagnosed in the reference institution was offered to participate in the study. If the patient was enrolled, it was scheduled for LP. The following patient diagnosed with UPJO was operated on with open technique and served as a case-control. In three other facilities, patients were only offered LP and had a matched control open case at the reference institution. The first end point of the study was patient recovery: analgesia requirement and length of hospitalization (LOH). The second end point of the study was resolution of UPJO in long-term follow-up for the two techniques. Demographic data, surgical time, perioperative complications, analgesia requirement, analgesia score during hospitalization, LOH, and outcome were recorded. Both groups received the same postoperative indications for pain control. Parents were asked to assess pain in their children every 4 h postoperatively and to complete a pain scale chart to which the nurses were blinded. Fifteen OP and 15 LP were compared. Groups were similar with regard to sex, age, weight, and laterality. Mean surgical time was longer in LP than in OP group (mean 188 versus 65 min) (p < 0.01). Hospitalization was shorter for LP group with a mean of 1.9 versus 2.5 days for OP group (p < 0.05). Postoperative analgesia requirement was significantly higher in the OP group with a mean use of morphine of 1.7 versus 0.06 mg/kg in the LP group (p < 0.05). Pain scores were similar in both the groups. At a mean follow-up of 58 months there were no failures. In this prospective comparative cohort, LP was a longer procedure than OP. Both procedures had the same efficacy and complication rates, but patients undergoing LP needed fewer narcotics for pain control and had a shorter hospitalization.

Laparoendoscopic Single-site Pyeloplasty: Outcomes of an International Multi-institutional Study of 140 Patients

To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes. LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed. The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m(2); 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan. This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

Comparison of Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Adults and Children: Lessons Learned

We compare the technical details and surgical outcomes of adult and pediatric laparoscopic pyeloplasty, and discuss the lessons learned from these comparisons. A total of 46 patients underwent laparoscopic pyeloplasty for repair of ureteropelvic junction obstruction between August 2006 and April 2010. Patients were divided into 2 groups-adults (older than 16 years, 21 patients) and children (15 years or younger, 25 patients). Medical records and surgical videos were reviewed with particular attention to patient characteristics, procedures and surgical outcomes. Crossing vessels were more common in adults (p <0.05). After June 2009 we tried to perform a transmesenteric approach for left ureteropelvic junction obstruction, and actually performed this procedure for 3 of 5 adults (60%) and 8 of 10 children (80%). There was no significant difference in median operative times between adults and children. However, mean time required for exposure of the ureteropelvic junction in children (54 minutes) was less than that in adults (81 minutes, p <0.005). Mean time required for ureteropelvic anastomosis tended to be longer in children. Postoperative complications were noted in 3 adults and 1 child. Percentage reduction in anteroposterior diameter of the renal pelvis was significantly greater in children than in adults (p <0.05). Successful resolution of ureteropelvic junction obstruction was observed in 90.0% of adults and 95.5% of children. Understanding of the key surgical steps of adult and pediatric laparoscopic pyeloplasty can provide for the improvement of laparoscopic skills, and facilitate procedures in adult and pediatric populations.

Management of the Failed Pyeloplasty

Purpose We present our experience with repeat surgery for persistent ureteropelvic junction obstruction. Materials and Methods We retrospectively reviewed the records of patients who underwent pyeloplasty for ureteropelvic junction obstruction between 1984 and 1994, focusing on those who underwent repeat surgery for persistent ureteropelvic junction obstruction after initial pyeloplasty. Results During the 10-year period 127 pyeloplasties were done by a single surgeon (R. D. W.). Three cases of persistent ureteropelvic junction obstruction occurred in this primary pyeloplasty series (success rate 97.6 percent). During the same period 9 other patients were referred to us from elsewhere for persistent ureteropelvic junction obstruction after initial pyeloplasty (total 12 patients). Ten patients underwent repeat pyeloplasty with a postoperative stent in place. Two patients needed nephrectomy at the initial repeat procedure and 1 of the 10 repeat pyeloplasty patients ultimately underwent nephrectomy. Six patients who had recurrent ureteropelvic junction obstruction were younger than 6 months at the time of the original pyeloplasty. Excessive urinary drainage was noted in 2 of our 3 cases of failed pyeloplasty. Thus, in 9 patients satisfactory resolution of obstruction was achieved by repeat pyeloplasty (salvage rate 75 percent). Conclusions Persistent ureteropelvic junction obstruction is an uncommon complication after pyeloplasty. Infants who undergo pyeloplasty may be more prone to persistent obstruction after pyeloplasty. Prolonged urinary drainage seems to be a harbinger of persistent ureteropelvic junction obstruction. Careful repeat pyeloplasty with attention to preservation of the blood supply and meticulous watertight anastomosis led to satisfactory resolution of ureteropelvic junction obstruction in 75 percent of the cases.

Management of the Failed Pyeloplasty

We present our experience with repeat surgery for persistent ureteropelvic junction obstruction. We retrospectively reviewed the records of patients who underwent pyeloplasty for ureteropelvic junction obstruction between 1984 and 1994, focusing on those who underwent repeat surgery for persistent ureteropelvic junction obstruction after initial pyeloplasty. During the 10-year period 127 pyeloplasties were done by a single surgeon (R. D. W.). Three cases of persistent ureteropelvic junction obstruction occurred in this primary pyeloplasty series (success rate 97.6%). During the same period 9 other patients were referred to us from elsewhere for persistent ureteropelvic junction obstruction after initial pyeloplasty (total 12 patients). Ten patients underwent repeat pyeloplasty with a postoperative stent in place. Two patients needed nephrectomy at the initial repeat procedure and 1 of the 10 repeat pyeloplasty patients ultimately underwent nephrectomy. Six patients who had recurrent ureteropelvic junction obstruction were younger than 6 months at the time of the original pyeloplasty. Excessive urinary drainage was noted in 2 of our 3 cases of failed pyeloplasty. Thus, in 9 patients satisfactory resolution of obstruction was achieved by repeat pyeloplasty (salvage rate 75%). Persistent ureteropelvic junction obstruction is an uncommon complication after pyeloplasty. Infants who undergo pyeloplasty may be more prone to persistent obstruction after pyeloplasty. Prolonged urinary drainage seems to be a harbinger of persistent ureteropelvic junction obstruction. Careful repeat pyeloplasty with attention to preservation of the blood supply and meticulous watertight anastomosis led to satisfactory resolution of ureteropelvic junction obstruction in 75% of the cases.