Secondary Pelvi-ureteric Junction Obstruction Research Articles

Contemporary diagnosis and management of pelvi-ureteric junction obstruction.

Pelvi-ureteric junction obstruction (PUJO) is defined as a functionally significant impairment of the flow of urine from the kidney's renal pelvis into the proximal ureter. Symptomatically, the patient may experience flank pain, recurrent infections, stone formation, and impairment of renal function. Although many cases of intrinsic PUJO are diagnosed at birth, a minority of patients may present in adulthood with previously silent disease or develop secondary PUJO to other causes. PUJO is therefore broadly categorised into both primary and secondary PUJO. A wide array of diagnostic scans and tests are available to aid in diagnosing and monitoring patients with PUJO. In patients with compromised renal function or symptomatic PUJO that require intervention, minimally invasive techniques are the 'gold standard' for surgical intervention. This review will detail the endoscopic, laparoscopic, and robotic options available to the urologist practicing in 2021, including the use of autografts and other emerging technologies.

Laparoscopic Treatment for Secondary Ureteropelvic Junction Obstruction

Background: Pelviureteric junction obstruction (PUJO) is one of the most frequent congenital anomalies of the urinary tract system. It is associated with pain, hydronephrosis, urinary tract infections, and eventually loss of renal function. Objective: To evaluate our institution in laparoscopic management of pelviureteric junction obstruction after failed open or laparoscopic surgery for pyeloplasty. Patients and methods: This study was conducted on 45 patients in two centers, Aswan Urology Department, and Sohage Urology Department. All of them have secondary pelviureteric junction obstruction. Results: This study included 24 females and 21 males, with the mean age of 30.2 ± 7.5 years (range 21 to 45 years), failed previous repair on the left side was in 29 cases while it was in 16 cases on the right side. Regarding BMI, it ranged from 21 to 30 with mean of 24.9 ± 3.1 kg/m2. The mean time after failure of primary pyeloplasty in both genders was 21.3 ± 8.2 months with a range of 10-38 months. The preoperative total renal function by DTPA was 80.7 ± 26.5. All cases were done laparoscopically without conversion to open surgery with a mean operative time of 154.9 ± 25.4 minutes (range from 80 to 185 minutes). The intra operative etiological finding of previous failure were peripelvic fibrosis and scarring in 34 cases, proximal ureteric stricture in 4, missed lower pole crossing vessels at initial surgery in 5 and a kink at the PUJ associated with redundant pelvis in two patients. Conclusion: Laparoscopic pyeloplasty is an effective minimal invasive alternative to open surgery in treatment of secondary pelviureteric junction obstruction.

Laparoscopic Versus Open Pyeloplasty for Management of Secondary Ureteropelvic Junction Obstruction

Background: Ureteropelvic junction obstruction (UPJO) causes hydronephrosis and progressive renal impairment may ensue if left uncorrected. Open pyeloplasty remains the standard against which new techniques must be compared. Objective: To evaluate the laparoscopic management of secondary pelvi-ureteric junction obstruction regarding the operative time. Bleeding requiring blood transfusion intraoperative complication, hospital stays short- and long- term complication, and the rate of success in comparison to open repair in literature. Patients and methods: This study was conducted at the Urology Department of Aswan and Sohag University Hospitals. In the period from April 2016 to April 2020, a total of forty-five patients with secondary PUJ obstruction fulfilling the inclusion criteria were admitted for undergoing laparoscopic pyeloplasty. Results: The median follow-up period was 24 months (6-36 months). The mean of operative time (LPP) was 154.9± 25.4 minutes, ranged from 80 to 185 minutes, and the mean of blood loss was 77.8±32.8 ml, ranged from 30 to 190 ml. The mean value of hospital stay of our patients was 3.8±1.2 days, ranging from 2 to 7 days, and the mean of follow-up was 5.6±2.15 months, ranged from 3 to 24 months. During the follow up there were three patients who experienced postoperative obstruction, our success rate was 93.3%. Conclusion: Laparoscopic pyeloplasty regarding cost-effectiveness, success rate, complications, and outcome the disadvantages of longer operative time of laparoscopi pyeloplasty, and the long learning curve, is more superior to open pyeloplasty in shorter hospital stay, early convalescence, and low postoperative analgesic requirements.

Laparoscopic Versus Open Pyeloplasty for Management of Secondary Ureteropelvic Junction Obstruction

Background: Ureteropelvic junction obstruction (UPJO) causes hydronephrosis and progressive renal impairment may ensue if left uncorrected. Open pyeloplasty remains the standard against which new techniques must be compared. Objective: To evaluate the laparoscopic management of secondary pelvi-ureteric junction obstruction regarding the operative time. Bleeding requiring blood transfusion intraoperative complication, hospital stays short- and long- term complication, and the rate of success in comparison to open repair in literature. Patients and methods: This study was conducted at the Urology Department of Aswan and Sohag University Hospitals. In the period from April 2016 to April 2020, a total of forty-five patients with secondary PUJ obstruction fulfilling the inclusion criteria were admitted for undergoing laparoscopic pyeloplasty. Results: The median follow-up period was 24 months (6-36 months). The mean of operative time (LPP) was 154.9± 25.4 minutes, ranged from 80 to 185 minutes, and the mean of blood loss was 77.8±32.8 ml, ranged from 30 to 190 ml. The mean value of hospital stay of our patients was 3.8±1.2 days, ranging from 2 to 7 days, and the mean of follow-up was 5.6±2.15 months, ranged from 3 to 24 months. During the follow up there were three patients who experienced postoperative obstruction, our success rate was 93.3%. Conclusion: Laparoscopic pyeloplasty regarding cost-effectiveness, success rate, complications, and outcome the disadvantages of longer operative time of laparoscopi pyeloplasty, and the long learning curve, is more superior to open pyeloplasty in shorter hospital stay, early convalescence, and low postoperative analgesic requirements.

Outcomes of Robot-Assisted Ureterocalicostomy in Secondary Ureteropelvic Junction in Adults: Initial Experience Using Da Vinci Xi System with Near-Infrared Fluorescence Imaging.

Aim: To report the surgical technique and early outcomes of robot-assisted ureterocalicostomy (RAUC) with near-infrared fluorescence (NIRF) in the management of secondary pelvi-ureteric junction obstruction (PUJO) in adults. Materials and Methods: The data of 6 patients who underwent RAUC using Da Vinci Xi system with NIRF technology between November 2017 and April 2019 were retrospectively reviewed. Indication was secondary PUJO due to previous failed pyeloplasty. The outcome variables evaluated include operative time (total and console), length of hospital stay, blood loss, and complications. Success was defined as the absence of pain and radionuclide scan demonstrating nonobstructive drainage and improvement/stabilization of split function of the renal moiety. Results: The mean (range) patient age was 33.7 (18-41) years. Total mean (range) operating time was 178 (140-240) minutes and mean console time was 135 minutes. Estimated mean blood loss was 115 (50-200) mL and average hospital stay was 6.1 (5-8) days. There were no conversions to open or laparoscopic surgery. Clavien-Dindo complications occurred in 2 patients. (Grade I-1 and Grade II-1). After a median (range) follow-up of 15 (6-22) months, all 6 patients had successful clinical and radiological outcomes. Conclusion: RAUC is a safe and feasible technique with acceptable outcomes in the setting of secondary PUJO. The utility of NIRF in determining vascularity of the ureter seems to be promising in this setting. Multi-institutional prospective studies with large patient cohort are necessary to validate the role of robotic platform in ureterocalicostomy in the reoperative settings.

Laparoscopic management of pelvi-ureteric junction obstruction after failed open surgery or Laparoscopic pyeloplasty in adults

Objectives: a prospective study of our experience and midterm results of laparoscopic pyeloplasty (LP) for patients who have failed open or Laparoscopic pyeloplasty in adults. Patients and methods: Thirty two patients with failed open pyeloplasty were reviewed; all of them had transperitoneal dismembered LP. All procedures were performed by experienced laparoscopist during a period of two years. Results: The study group consisted of 14 men and 18 women with the mean age of 29± 6 years. Mean operative time was 123± 22 minutes. Mean hospital stay was 4.7 ± 2.3 days. Mean follow-up was 5.6 ± 2.15 months (range 3-9 months). The overall success rate for secondary LP was 90.6%. There was no conversion to open surgery. Intraoperative and postoperative complications were 9.4 and 12.5% respectively. Conclusions:LP is a safe and viable treatment option for secondary pelviureteric junction obstruction with high success rate but with long operative time. A good experience in laparoscopic reconstructive procedures is a prerequisite for optimal results.

Robot-assisted ureterocalycostomy: A single centre contemporary experience in adults

ObjectiveTo present our technique and experience of robot-assisted ureterocalycostomy (RAUC) in managing secondary pelvi-ureteric junction obstruction (PUJO) in adults. Patients and methodsWe retrospectively reviewed all patients from our centre who underwent RAUC, between 2011 and 2015, for secondary PUJO resulting from previous surgical intervention. Six procedures in five patients, including a bilateral RAUC were performed. The median (range) patient age was 33.7 (18–41) years. The outcome variables included operative time, duration of hospital stay, and objective evidence of unimpeded drainage on urography. ResultsThe mean (range) operating time was 172 (144–260) min and estimated blood loss was 100 (50–250) mL. There were no conversions to open or laparoscopic surgery, and no intraoperative complications. Two patients had Clavien–Dindo Grade I complications that were managed conservatively and one patient had a Grade IIIb complication, which required balloon dilatation and re-stenting. After a median (range) follow-up of 11 (7–48) months, five of the six renal units had successful outcomes. ConclusionThe robot-assisted approach appears to be ideally suited for redo cases demanding fine dissection with meticulous suturing. In our present series of adult patients, we could safely and successfully perform RAUC with minimal morbidity. However, a larger multi-institutional outcome analysis is required to substantiate the role of the robot-assisted approach in performing UC.

The management of secondary pelvi-ureteric junction obstruction - a comparison of pyeloplasty and endopyelotomy

The management of secondary pelvi-ureteric junction obstruction - a comparison of pyeloplasty and endopyelotomy

The management of secondary pelvi‐ureteric junction obstruction – a comparison of pyeloplasty and endopyelotomy

To review our experience in the management of secondary pelvi-ureteric junction obstruction (PUJO) comparing endopyelotomy with pyeloplasty. We retrospectively analysed our database of 58 patients having undergone operative management of PUJO after failed primary management, including 41 with failed pyeloplasty and 17 failed endopyelotomy. Outcomes included mercapto-acetyltriglycine (MAG3) drainage capacity, symptomatic control and need for further intervention. Success was defined as freedom from failure in all three. Patients undergoing secondary pyeloplasty had better outcomes than endopyelotomy for symptomatic success (87.5% vs 74%), resolution of obstruction on MAG3 renography (96% vs 74%), and no need for further intervention (96% vs 71%). Overall success was 87.5% for pyeloplasty compared with 44% after secondary endopyelotomy. Outcomes of pyelopasty for secondary PUJO were superior when compared with endopyelotomy.

Management of secondary pelviureteric junction obstruction

Pelviureteric junction obstruction (PUJO) of the kidney can lead to a number of different clinical manifestations, which often require surgical intervention. Although the success of pyeloplasty and endopyelotomy are good, there are still a number of patients who fail primary treatment and develop secondary PUJO. These treatment failures can be a challenging cohort to manage. This article aims to provide a comprehensive overview on the surgical options available to the urologist for managing secondary PUJO as well as providing some guidance on assessing factors that will influence management decisions.

Laparoscopic Pyeloplasty: A Versatile Alternative to Open Pyeloplasty

Objective: To report the safety, efficacy and versatility of laparoscopic pyeloplasty (LPP) in treatment of pelviureteric junction obstruction (PUJO). Patients and Methods: From January 2002 to November 2006, 185 patients (186 units; 182 with primary and 4 with secondary PUJO) underwent LPP (transperitoneal approach in 184; retroperitoneal approach in 2). A double J stent was placed antegradely in 121 (68.4%) units, cystoscopically in 50 units (28.2%), and 6 units (3.4%) were stentless. Patients were followed up clinically, with additional diuretic renogram. Results: Surgery was completed laparoscopically in 177 units, and conversion was required in 9 (4.8%) units. Pyeloplasty was dismembered in 143 units, Foley YV plasty in 26 units, and Fenger pyeloplasty in 8 units. The median estimated blood loss, operative time and hospital stay were 50 ml, 180 min and 4 days, respectively. Overall, 18 (9.6%) patients had complications. Improvements in drainage patterns of 167 out of 177 units (94.3%) were shown on a renal scan at a median follow-up of 39 months (range: 3–63 months). Conclusion: LPP is a safe, effective and versatile method for treatment of PUJO, which is applicable to all age groups, even in the presence of secondary stones, crossing vessels and secondary PUJO.

Robotic Anderson‐Hynes pyeloplasty: 5‐year experience of one centre

To present our 5-year experience with robotically assisted laparoscopic pyeloplasty (RALP), as LP has been shown to have similar success rates as open surgery, but standard LP requires high operative skills and a correspondingly long period of training, limiting its widespread availability, and RALP is easier and quicker to learn due to facilitated intracorporeal suturing. In all, 92 patients had transperitoneal RALP for pelvi-ureteric junction obstruction (PUJO) using the daVinci system (Intuitive Surgical, Sunnyvale, CA, USA). A transperitoneal dismembered Anderson-Hynes procedure was used in all cases. Three robotic ports and one assistant port were used in all cases while a JJ stent was left indwelling for 6 weeks. Both primary PUJO (including horseshoe kidneys in 80 cases) and secondary (in 12 cases) were considered eligible. The follow-up included ultrasonography, excretory urography and renal scintigraphy. The mean follow-up was 39.1 months; PUJO was successfully resolved in 89 patients (96.7%) while three required additional procedures. Haemorrhage into the collecting system and urine extravasation occurring early after surgery were the causes of failure. The mean (range) operative duration, including the set-up of the robot, was 108.34 (72-215) min; the mean duration of docking and surgery significantly decreased with experience (P < 0.001). The mean hospital stay was 4.57 days. Split renal function improved from 37.6% to 41.9%. No cases of secondary PUJO were recorded during extended follow-up. RALP using the daVinci system is safe and effective, achieving similar long-term success rates to open surgery. The three-dimensional versatility of the robot enables the surgeon to recapitulate the open procedure. The results were durable with no cases of late complications, corroborating the accuracy of robot-assisted intracorporeal suturing and the subsequent quality of the pelvi-ureteric anastomosis. Moreover, the robotic approach was easy and quick to learn for both the surgical and the technical staff. Therefore, RALP is our preferred technique to treat PUJO.

Antegrade endopyelotomy for pelvi-ureteric junction obstruction in children.

To compare the results of repairing pelvi-ureteric junction (PUJ) obstruction by percutaneous endopyelotomy in children with a similar series carried out in adults. Nine children with primary (six) or secondary (three) PUJ obstruction were treated using a one-stage cold-knife percutaneous endopyelotomy. The success and morbidity rates were compared with a series of 61 adults with primary (46) or secondary (15) PUJ obstruction treated similarly. In children, endopyelotomy was successful in five of six with primary and two of three with secondary PUJ obstruction, with a mean follow-up of 30 months (range 18-56). In the adults, endopyelotomy was successful in 38 of 46 (83%) with primary and 12 of 15 with secondary PUJ obstruction, an overall success rate of 82%, with a mean follow-up of 42 months (range 9-86). There was no statistical difference in the success rates with primary and secondary endopyelotomy between adults and children (P = 0.58). Failures were associated with high-grade hydronephrosis, a stenotic segment > 1.5 cm long and technical problems. Morbidity occurred in one of nine children and 3.2% of the adults. This early experience suggests that percutaneous endopyelotomy can be performed safely and successfully in children with primary PUJ obstruction. However, in secondary stenosis, the results were less than optimal. Larger series should be analysed to form definitive conclusions on the role of endopyelotomy for the treatment of PUJ obstruction in children, given the high rate of success of open pyeloplasty and its minimal morbidity.

Retrograde balloon dilatation for pelviureteric junction obstruction.

A total of 49 retrograde balloon dilatations for pelviureteric junction (PUJ) obstruction were carried out on 43 pelviureteric junctions in 42 patients from 1986 to 1991. The majority (34/43) were performed as primary treatment for PUJ obstruction, with 9 patients having a history of previous open pyeloplasty. Follow-up ranged from 3 months to 4 years (mean 18 months). Clinical improvement, as assessed by absence of symptoms, was seen in 34 cases (80%). There was either no change or an improvement in renographic findings (t1/2 time and/or split function) in 40 patients (93%). Of the 9 patients who were undergoing secondary treatment, 5 showed clinical improvement and 8 showed no change or renographic improvement. Nine patients required 12 further procedures, of which 5 were interval nephrectomy. Balloon pyelolysis is a simple procedure with good results over a 4-year follow-up period. It is less effective for the treatment of secondary pelviureteric junction obstruction. It has a low morbidity and no mortality, involves a short hospital stay and allows an immediate return to full activity. It is therefore an attractive alternative to open pyeloplasty as first-line treatment for PUJ obstruction.

Endopyelotomy for pelvi-ureteric junction obstruction in children.

Endopyelotomy or percutaneous pyeloplasty has become an attractive alternative to open pyeloplasty in adult patients in recent years. However, the experience and reports of this procedure in the paediatric population have been limited to date. We report our experience in paediatric patients undergoing this procedure. Seventeen children with primary (14) or secondary (3) pelvi-ureteric junction (PUJ) obstruction were consented for endopyelotomy over a 3-year period. Patient age ranged from 4 months to 16 years, and the male to female ratio was 11:6. Percutaneous nephrostomy was established in 5 patients prior to endopyelotomy either for diagnosis or for drainage of an acutely obstructed upper tract. The remaining 12 had endopyelotomy as a one-stage procedure. The average duration of the procedure was 103 min (range 60-150 min) and the average hospital stay was 5 days (range 3-9 days). Follow-up averaged 15 months (range 3-36 months). Endopyelotomy was successful in 10/13 patients (77%), unchanged in 1, and failed in the remaining 2. We believe that percutaneous pyeloplasty can be safely and successfully performed in children with primary and secondary PUJ obstruction.

Ureteroscopic Pyelolysis for Pelviureteric Junction Obstruction

The development of endourological techniques for the treatment of upper urinary tract disease has concentrated mainly on the endoscopic treatment of upper urinary tract stones. The relief of pelviureteric junction obstruction (PUJ) by percutaneous pyelolysis has recently been reported and the use of the flexible uretero-pyeloscope has also been described. We describe the use of a rigid uretero-renoscopy to relieve strictures causing secondary pelviureteric junction obstruction in two cases.