Surgery For Ureteropelvic Junction Obstruction Research Articles

Simultaneous laparoscopic surgery for ureteropelvic junction obstruction and retrograde intrarenal surgery for nephrolithiasis

Objective: To determine the surgical possibilities of the one-stage laparoscopic repair in the obstructed ureteropelvic junction (UPJ) complicated with nephrolithiasis in combination with the retrograde intrarenal surgery.Case report: The patient A., a 36-year-old male complaining about dragging pains in the right lumbar region was admitted to Urology Unit No. 1 of Krasnodar Regional Clinical Hospital No. 2. The patient underwent ultrasound examination, CT, and dynamic renal scintigraphy. The findings were as follows: the enlargement of pelvicalyceal system in the right kidney (calyx up to 22 mm, pelvis up to 50 mm), 5 calyx concrements and 2 pelvic concrements 6 to 8 mm in size, obstruction at the level of the right UPJ up to 10 mm in length, III grade hydronephrosis on the right according to Lopatkin classification.Conclusions: The combination of laparoscopic surgery and retrograde intrarenal surgery with the flexible ureteroscope and holmium laser is an effective and safe method for the treatment of UPJ obstruction complicated with nephrolithiasis.

Sonographic follow-up after pyeloplasty: a large, retrospective cohort analysis.

Routine scintigraphy after surgery for uretero-pelvic junction obstruction (UPJO) is discouraged, making ultrasound the preferred option for follow up. Yet, interpretation of sonographic parameters is rarely straightforward. We reviewed 111 cases including 97 pyeloplasty (52 open, 45 laparoscopic) and 14 pyelopexy during a 7-year period. Pre- and postoperative pelvic antero-posterior diameter (APD), cortical thickness (CT) and pelvis/cortex ratio (PCR) was measured serially. 85% were free of symptoms by 1year. Only 11% had complete resolution of hydronephrosis. Eleven (10.4%) needed a redo procedure. Mean reduction in APD was 32.6%, 45.8%, and 51.7% at 6weeks, 3 and 6months respectively. CT increased by an average 55.9%, 75.6% and 107.6% while PCR reduced by 6.9, 8.0 and 8.8 at given intervals. Comparison of open and laparoscopic procedures showed no significant difference. Review of failed pyeloplasty showed failure of reduction in APD (APD > 3cm or < 25% reduction) and PCR (PCR > 4) as early indicators for failure. Both APD and PCR are reliable indicators of success and failure following pyeloplasty while CT alone is not as useful. Laparoscopic procedures are non-inferior to standard open surgery.

Robotic surgery for ureteropelvic junction obstruction and urolithiasis.

Robotic surgery for ureteropelvic junction obstruction and urolithiasis.

Urinary HSP70 can predict the indication of surgery in unilateral ureteropelvic junction obstruction.

Distinguishing hydronephrosis that requires surgical intervention is a clinical challenge. The aim of this study is to determine the level of urinary heat shock protein 70 (HSP70) in children who required surgery for ureteropelvic junction obstruction and its potential use as a biomarker for prediction of surgery in children with isolated unilateral hydronephrosis. The data of 43 children with ureteropelvic junction obstruction who underwent pyeloplasty, 25 patients with non-obstructive dilation (NOD) and 30 healthy children (control group) were collected prospectively for this study. Preoperative and postoperative urinary HSP70/Cr levels were also analyzed in 30 children in the pyeloplasty group who had available follow-up information. HSP70 levels were assessed using ELISA. The median age of the pyeloplasty group was 13months (IQR 7-36months), NOD group was 42.5months (IQR 16-73) and it was36months (IQR 24-47.5) in the control group. The mean preoperative urinary HSP70/Cr was significantly higher in the pyeloplasty group when compared to controls as well as the NOD group (150.6pg/mgCr vs. 65.0pg/mgCr and vs. 64.7pg/mgCr, p < 0.001 and p < 0.001, respectively). The urinary HSP70 levels significantly decreased in the postoperative period (151.5 vs 79.5, p < 0.001). Using the cutoff value of 94.7pg/mgCr, the sensitivity and specificity of urinary HSP70 for predicting the risk of surgical intervention were 69.7% and 68%, respectively (AUC = 0.689). Urinary HSP70 may be used as an adjunct tool to clinical parameters to identify patients that would require surgery due to ureteropelvic junction obstruction.

A comparative study on the Efficacy of Retroperitoneoscopic Pyeloplasty and Open Surgery for Ureteropelvic Junction Obstruction in Children.

Objectives:To compare the therapeutic effect of retroperitoneoscopic dismembered pyeloplasty and open ureteropelvic junction plasty on the ureteropelvic junction obstruction (UPJO) in children.Methods:After the retrospective analysis of clinical data, 78 children with ureteropelvic junction stenosis treated from January, 2012 to June, 2018 were divided into two groups: OP (open pyeloplasty) group (38 cases) and LP (laparoscopic dismembered pyeloplasty) group (40 cases) according to the surgical methods. The operation time, intraoperative bleeding volume, postoperative length of stay (LOS), postoperative complication rate, postoperative hydronephrosis improvement and other indicators were compared between the two groups.Results:All patients underwent surgery successfully, without conversion to open surgery in LP group. The incidence of postoperative urine leakage and the recovery of hydronephrosis between LP group and OP group 12 months after operation showed no statistically significant difference (P>0.05). The intraoperative bleeding volume, the incidence of postoperative retroperitoneal hematoma, and the postoperative LOS in LP group were lower than those in OP group, while the operation time was longer than that in the OP group, with statistically significant difference (P<0.05).Conclusion:Retroperitoneoscopic dismembered pyeloplasty had similar effect with open dismembered pyeloplasty, but faster recovery and fewer complications, so it has become the preferred treatment method for UPJO in children.

Changes in differential renal function after pyeloplasty in infants and children

Ureteropelvic junction obstruction (UPJO) is one of the most common causes of hydronephrosis in pediatric populations. Many need surgical intervention. The aim of surgery is preserving renal function and reducing symptoms such as urinary tract infections and pain. The objectives were to evaluate differential renal function (DRF) in infants and children after surgery for UPJO and to identify factors predicting postoperative improvement. The difference in outcomes between patients with antenatal hydronephrosis and those diagnosed later was evaluated. A total of 85 children (63 boys and 22 girls) aged 0-16 years, treated for UPJO with dismembered pyeloplasty, were followed up as per a structured protocol including ultrasounds and renal scans (MAG-3) pre-operatively and three and 18 months postoperatively. Five children with bilateral or single kidney UPJO were excluded. Patient records were retrospectively reviewed, and the patients were grouped as per prenatal (group 1, n=23) or postnatal (group 2, n=57) diagnosis. Univariable and multivariable logistic regression analyses searching for factors predicting >5% postoperative improvement in DRF on the obstructed side were performed. Factors included in analyses were age at diagnosis and surgery, sex, type of presentation, cause of obstruction, estimated glomerular filtration rate, pre-operative DRF, anteroposterior diameter (APD), APD/renal parenchymal thickness, and grade of hydronephrosis as per the Onen alternative grading system (grade 1-4). Pre-operative DRF on the obstructed side was a mean of 42% (standard deviation, 12), with no difference between the groups. The median age at surgery was 0.9 (0.2-10) and 8.1 (0.6-16) years in groups 1 and 2, respectively (P<0.001). The majority had unchanged DRF 18 months postoperatively, 19 (27%) patients improved by >5%, and one deteriorated. The proportion of patients with improved DRF was higher in group 1 (n=10; 45%, P=0.026). Anteroposterior diameter, APD/parenchymal thickness, pre-operative DRF, and antenatal diagnosis were predictors in the univariable analyses, and high APD (odds ratio [OR] = 1.1, P=0.0023), antenatal diagnosis (OR = 0.23, P=0.048), and low pre-operative DRF (OR = 0.90, P=0.0045) built the best model of independent factors predicting improvement in DRF in multivariable analyses (Summary Figure). The limitation of the study is that it is retrospective, but it has the advantage of auniform follow-up protocol, including patients from a five-year period, with few lost to follow-up. The results can be of interest in evaluating factors of importance for predicting recovery of function in obstructive uropathies in children. The majority of children had preserved or improved function after surgery for UPJO. Those with an antenatal diagnosis displayed a greater ability to catch up in DRF, and high APD, antenatal diagnosis, and low pre-operative DRF were independent predictive factors of an improvement in renal function after pyeloplasty.

Identification of transcripts associated with renal damage due to ureteral obstruction as candidate urinary biomarkers.

Renal obstruction is a common cause of renal failure in adults and children and is suspected when hydronephrosis is detected on imaging. Because not all cases of hydronephrosis are associated with renal damage, biomarkers are needed to guide intervention to relieve obstruction. We performed gene expression profiling on the kidneys from adult mice over a detailed time course after obstruction and compared these data with a neonatal model of bilateral high-grade obstruction induced by conditional deletion of the calcineurin β1 gene. Having identified a set of 143 transcripts modulated in both adult and neonatal obstruction, we tested their expression in a model of short-term obstruction (1 day), where renal damage is transient and reversible, and long-term obstruction (5 days), where significant renal damage is permanent. A significant number of transcripts increased early after obstruction, and later normalized, while 26 transcripts remained elevated 10 and 28 days after relief of 5 days of ureteral obstruction. With the use of qPCR, elevated levels of several of these candidate RNA biomarkers of renal damage were detected in urine from obstructed mice. In addition, several of these candidate RNA biomarkers of damage resulting from obstruction were detectable in catheterized urine samples from children undergoing surgery for ureteropelvic junction obstruction. Measurement of urinary transcripts modulated in response to renal obstruction could serve as biomarkers of renal damage with important clinical applications.

Evidence of Variation by Race in the Timing of Surgery for Correction of Pediatric Ureteropelvic Junction Obstruction

We used a national pediatric database to investigate the association of patient race with timing of surgery for ureteropelvic junction obstruction. The Kids' Inpatient Database is a national database containing 5.5 million pediatric hospitalizations (patients younger than 21 years) during the years 2000 to 2003. We used International Classification of Disease-9 codes to identify patients undergoing pyeloplasty, and investigated patient and hospital factors associated with timing of surgery using multivariable linear and mixed models. A total of 2,989 patients underwent pyeloplasty. Mean patient age was 72.3 months (median 36). Of the patients 69.3% were male and 66.0% were white. White patients were significantly older than nonwhite patients (82.3 vs 52.8 months, p <0.0001). The proportion of patients undergoing surgery during the first 12 months of life also varied by race (31.3% among white vs 46.9% among nonwhite patients, p <0.0001). Other factors associated with younger age included male gender (p = 0.0002), hospital volume and teaching status (p <0.0001), and Medicaid insurance (p <0.0001). Socioeconomic status at the zip code level was not associated with timing of surgery. Using a multivariable mixed model to adjust for all variables, including random effects of individual hospitals, nonwhite race was still associated with earlier surgery (p = <0.0001). This study confirms that nonwhite patients undergo pyeloplasty an average of more than 2.5 years earlier than white patients (even after adjusting for insurance status and other factors). Future research should elucidate the clinical factors that influence surgical decision making in ureteropelvic junction obstruction, including socioeconomic and cultural factors among families and providers, as well as possible biological differences between racial groups in the natural history of ureteropelvic junction obstruction.

Retroperitoneoscopic pyeloplasty: Using reconstructive methods based on intraoperative findings

Reconstructive laparoscopic procedures have been recognized as a less invasive treatment than conventional open procedures. However, although the laparoscopic pyeloplasty has also been accepted as useful, few findings have been reported relevant to the retroperitoneal approach. To elucidate its effectiveness and safety, laparoscopic surgery via the retroperitoneal approach was examined in our institution. Furthermore, the importance of laparoscopic observation for ureteropelvic junction and urine passage ureteropelvic junction without indwelling ureteral stent. Between July 1998 and December 2004, 13 men and 15 women underwent laparoscopic retroperitoneal surgery for ureteropelvic junction obstruction. The mean patient age was 33.6 years (range: 13-70 years). Methods of repair were determined by intraoperative findings for the relationship between the ureteropelvic junction and surrounding vessels. An indwelling ureteral stent was removed before initiating laparoscopic operation to observe the relationship between ureteropelvic junction and aberrant vessels more precisely. An aberrant renal vessel was found in 13 patients (46%). Dismembered pyeloplasty was carried out in 21 patients, Y-V plasty in five patients and Hellstrom technique in two patients. Ureteral transposition was not required in dismembered pyeloplasty cases. All patients achieved retroperitoneoscopic pyeloplasty without open conversion. The mean operative time was 272 min (range: 155-490 min). The mean estimated blood loss was 44 mL (range: 10-200 mL). No major complications were observed during the intraoperative period, but urinary tract infection occurred in two patients in the postoperative period. In all patients except one, obstruction was improved or resolved. Laparoscopic retroperitoneal surgery is not only able to repair ureteropelvic junction obstruction, but can also be done safety and less invasively. We believe that laparoscopic observation without indwelling stent will contribute to a more appropriate choice of pyeloplasty.

Robotic surgery for ureteropelvic junction obstruction

Robotic surgery for ureteropelvic junction obstruction is an evolving technique. We review the current literature related to this technique and discuss the current technique and outcomes of robotic pyeloplasty. Recent advances in robotic-assisted surgery have allowed the successful completion of complex reconstructive procedures in the pediatric population, including the robotic-assisted laparoscopic pyeloplasty. Robotic-assisted laparoscopic pyeloplasty can be performed by either a transperitoneal or a retroperitoneal approach. Overall, the procedure is safe, efficacious, and may have particular benefits over open surgery. The evolution of laparoscopic surgery in pediatric urology has been limited by the challenge of laparoscopic suturing. Robotic systems may offer the means to overcome this major impediment of laparoscopic surgery. The results of this review demonstrate that robotic-assisted laparoscopic pyeloplasty is safe, technically feasible, and efficacious in the pediatric population, and may be comparable to a contemporary series of open pyeloplasty. As the technology continues to evolve, the efficiency of the robotic system is likely to improve; however, the ultimate role of robotic-assisted or computer-assisted surgical systems remains unclear. To further determine the role of robotic systems in the management of ureteropelvic junction obstruction, rigorous prospective research is needed that combines surgical and technical outcomes with overall subjective or cosmetic outcome and economic analysis.

NEPHROSTOMY TUBE DRAINAGE WITH PYELOPLASTY: IS IT NECESSARILY A BAD CHOICE?

Despite continued controversy regarding the optimal method of urinary diversion after dismembered pyeloplasty in children, we have treated the majority of our patients with postoperative nephrostomy tubes and no stents. We report our experience. The records of all patients who underwent surgery for ureteropelvic junction obstruction from August 1985 to October 1998 and were treated only with a nephrostomy tube after pyeloplasty were reviewed for hospital course, complications and postoperative followup. All patients had a perinephric Penrose drain as well as a Foley catheter placed for bladder drainage. A total of 137 pyeloplasties were performed in 132 patients, including 5 with bilateral ureteropelvic junction obstruction, using only nephrostomy tube drainage with an average followup of 2.1 years. Initial nephrostograms demonstrated good drainage across the repair with no extravasation in 91% of patients. Subsequent nephrostograms revealed a widely patent anastomosis in the remaining cases. No patient had postoperative obstruction, or required secondary pyeloplasty or nephrectomy. Urinary tract infection developed in 2 patients (1.5%). Mean hospitalization was 4.4 days. There was a significant difference in length of stay in the last 5 years compared to that in previous years (3.4 versus 5.8 days, p <0.05) and hospital stay continues to decrease. Use of only a nephrostomy tube after pyeloplasty resulted in few complications and an open anastomosis in 100% of cases. Nephrostomy drainage not only serves as a protective mechanism, but also allows easy access for radiographic studies before removal of the tube. In addition, nephrostomy tube drainage does not prolong hospitalization and the tube may be easily removed on an outpatient basis without further anesthesia.

RENAL HISTOLOGY IN URETEROPELVIC JUNCTION OBSTRUCTION: ARE HISTOLOGICAL CHANGES A CONSEQUENCE OF HYPERFILTRATION?

Purpose There are few reports of pathological kidney findings in ureteropelvic junction obstruction in pediatric patients. The role of hyperfiltration in the genesis and progression of these changes has been a matter of debate. We determine whether segmental sclerosis is evidence of hyperfiltration and renal damage in children who underwent surgery for ureteropelvic junction obstruction. Materials and Methods We retrospectively analyzed the clinical records of 38 children with a mean age of 4.4 years with ureteropelvic junction obstruction. Histological changes in biopsies (39 renal units) and nephrectomy specimens (2 renal units) were compared with clinical history, imaging studies and urinary protein excretion. Results Renal histology was essentially normal in 75% of the biopsies. Focal dilatation of Bowman's space and occasionally of the collecting tubules was noted in a third of this group. Abnormal changes consistent with renal damage were present in 25% of the biopsies, including variable degrees of interstitial chronic inflammation, eosinophilic acellular material within Bowman's space and focal concentric glomerulosclerosis. Severe changes, chronic interstitial fibrosis and inflammation, and diffuse glomerulosclerosis were only found in nephrectomy specimens, while eosinophilic acellular material and glomerulosclerosis were observed in 7 biopsies. In all of these renal units there was evidence of hyperfiltration with bilateral or unilateral ureteropelvic junction obstruction with a contralateral multicystic dysplastic kidney. Urinary protein excretion in 19 patients was increased in obstructed compared with normal contralateral kidneys (p <0.05). Conclusions Hyperfiltration should be considered a mechanism involved in the progression of histological changes in kidneys with ureteropelvic junction obstruction. We suggest that early surgical correction be considered in obstructed kidneys at risk for hyperfiltration.

Percutaneous Surgery for Ureteropelvic Junction Obstruction (Endopyelotomy): Technique and Early Results

We incised ureteropelvic junction obstruction in 31 patients with a cold knife direct-vision urethrotome inserted through a percutaneous nephrostomy tract. In 12 patients renal calculi were removed endourologically during the same session. There were no immediate complications and nephrostograms showed adequate drainage in all cases. Of these patients 8 had previously undergone open pyeloplasty without success. The longest followup is almost 2 years. There have been 4 failures and, thus, the success rate is 87.1 per cent.

Intubated Ureterotomy: Experimental Work and Clinical Results

Intubated Ureterotomy: Experimental Work and Clinical Results