Symptomatic Ureteropelvic Junction Obstruction Research Articles

Supranormal differential renal function on MAG3 scan in children with ureteropelvic junction obstruction – Prevalence and pyeloplasty during follow-up

Children with suspected ureteropelvic junction obstruction (UPJO) may present with a paradoxical ipsilateral supranormal differential renal function (snDRF) on 99mTechnetium mercaptoacetyltriglycine scintigraphy (MAG3 scan). The aim was to investigate the prevalence of snDRF, the risk of pyeloplasty among children with UPJO and snDRF, and to explore the experience of snDRF among international pediatric urologists. A retrospective cohort study of children with suspected unilateral UPJO who underwent MAG3 scan at four hospitals in Sweden between 2005 and 2020. SnDRF was defined as DRF ≥55%. Normal DRF was defined as DRF 45-54%. Primary outcome was risk of pyeloplasty. Indications for pyeloplasty were loss of >10%-points of differential renal function (DRF), ipsilateral DRF <40%, or symptomatic UPJO. Logistic and cox regressions were performed in univariate and multivariable analyses, adjusting for age, gender, year, laterality, antenatal hydronephrosis, anterior-posterior diameter (APD), and kidney size. An international questionnaire regarding the management of snDRF was developed and distributed to pediatric urologists. The prevalence of snDRF was 19%. SnDRF was more common in boys, children with antenatal hydronephrosis, children undergoing their first MAG3 scan at a younger age, and in the left kidney. After further exclusion of 70 children with DRF <45%, a total of 264 were included for longitudinal follow-up of median 6.6 (IQR 2.5-11.5) years. SnDRF was not associated with increased risk of pyeloplasty (adjusted OR 0.98 (95% CI 0.41-2.33), p=0.96, and adjusted HR 1.00 (95% CI 0.53-1.91), p=0.99) or time to pyeloplasty (1.1 years vs. 1.6 years, p=0.40). Among the 79 surveyed pediatric urologists, a majority would not change clinical UPJO-management based on the presence or absence of ipsilateral snDRF. There are only a few studies considering the need of pyeloplasty based on the presence of snDRF and this is the first survey among pediatric urologists on its management. With more included patients than previous studies, this study showed a snDRF prevalence of 19%, congruent with the findings of others. The underlying cause of snDRF is debated, but it cannot solely be explained as an artifact of hydronephrotic kidneys. Further studies on the clinical implications of snDRF are warranted, since DRF influences the decision to operate. A fifth of all children with suspected UPJO presented with ipsilateral snDRF on initial MAG3 scan, and snDRF was not associated with a greater risk of pyeloplasty. Supported by a large group of international pediatric urology colleagues, this study concludes that the same clinical follow-up and management apply, regardless of presence of snDRF.

Ureteropelvic junction obstruction (UPJ) due to congenital crossing of the renal vessels (CRV): Comparison of the pre- and postoperative features of UPJO with and without CRV.

We evaluated the differences in demographic characteristics of patients with and without underlying crossing renal vessels (CRVs) operated for unilateral symptomatic ureteropelvic junction obstruction (UPJO). We identified the features of patients who had undergone open, laparoscopic and robotically assisted laparoscopic pyeloplasty at our institution from July 2000 to January 2021. The ratio of renal parenchymal thickness (RPT; ratio between the kidney with UPJO and the healthy kidney), pelvic diameter and kidney functions were recorded. A total of 641 patients were operated for UPJO; 448 were male (69.8%) and 193 (30.1%) were female; 257 had right-side (40%) and 384 (60%) left-side disease. Fifty-eight patients (9%) were found to have CRV (operated on to treat CRV). The age at diagnosis was 6.51 ± 5.09 years in the CRV (+) group and 1.82 ± 1.37 years in the CRV (-) (p < 0.001). The age at surgery was 8.00 ± 4.71 and 4.27 ± 3.54 years, respectively (p < 0.001). At the time of diagnosis, the RPT measurement was significantly better in CRV (+) compared to CRV (-) group (0.71 ± 0.2 vs. 0.64 ± 0.23, p = 0.043) and initial renal functions were 45.53 ± 8.99% and 42.99 ± 11.65% in CRV (+) and (-) groups respectively. At the time of surgery, the RPTs were 0.60 ± 0.24 and 0.63 ± 0.21 in CRV (+) and (-) groups and these values were also correlated with split renal functions (36.28 ± 15.81% and 41.80 ± 14.26%, respectively). Renal functions were significantly decreased in CRV (+) group (p = 0.027). Significant parenchymal improvements were noted during the first postoperative year. The RPTs were 0.71 ± 0.2 and 0.77 ± 0.19 in the CRV (+) and CRV (-) groups, respectively (p = 0.27) in that time; the improvements continued to increase to postoperative third year (0.74 ± 0.20 and 0.78 ± 0.19 respectively; p = 0.939). In patients with CRVs, renal functions seemed to be preserved in the early stages, however it should be kept in mind that sudden obstruction and loss of kidney function might develop in the follow up period.

Outcomes of Robot-Assisted Laparoscopic Pyeloplasty Based on Degree of Obstruction on Preoperative Tc-99 MAG-3 Renal Scintigraphy.

Objective: Management of symptomatic ureteropelvic junction (UPJ) obstruction with hydronephrosis and discordant Tc-99 mercaptoacetyltriglycine (MAG-3) renal scintigraphy is challenging. In this study we describe long-term outcomes of patients who underwent robot-assisted laparoscopic pyeloplasty for the correction of symptomatic UPJ obstruction with discordant preoperative Tc-99m MAG-3 renal scintigraphy. Methods: Patients undergoing robot-assisted laparoscopic pyeloplasty for symptomatic UPJ obstruction at a single academic center from 2009 to 2021 were retrospectively reviewed. Patients were categorized into three groups with varying degrees of obstruction based on preoperative MAG-3 imaging: Group 1: no obstruction (Lasix T1/2 clearance <10 minutes), Group 2: equivocal obstruction (Lasix T1/2 clearance 10-20 minutes), and Group 3: obstruction (Lasix T1/2 clearance >20 minutes. Pyeloplasty success was defined as resolution of symptoms and improvement/stable computed tomography (CT) imaging or MAG-3 scintigraphy. Failure was defined as persistence of symptoms with either obstruction on functional imaging, worsening hydronephrosis, or subsequent intervention. Results: A total of 125 cases were identified, with a median patient age of 35 years. Dismembered pyeloplasty technique was performed in 98.4% of cases. Median preoperative split renal function on MAG-3 scintigraphy was the only statistically significant (p = 0.003) difference in preoperative characteristics between the three groups. There were 15 postoperative complications, with a rate of Clavien-Dindo grade 3 or higher complications of 4.8%. Overall pyeloplasty success was 92.8%, with success rates of 100% (15/15) and 97% (32/33) in the no obstruction and equivocal obstruction groups, respectively. Median time to pyeloplasty failure was 20.4 months. Conclusion: Robot-assisted laparoscopic pyeloplasty is a safe and effective surgical intervention for correcting UPJ obstruction. Patients with symptoms of UPJ obstruction and discordant functional imaging studies demonstrate similar or improved success rates after pyeloplasty compared with patients with documented high-grade obstruction. Based on these findings preoperative renal scan may not be reliable in appropriate selection of candidacy for pyeloplasty.

Functional outcomes after robot-assisted pyeloplasty for ureteropelvic junction obstruction: A bi-centre experience.

Robot-assisted pyeloplasty (RALP) for patients with clinically symptomatic ureteropelvic junction obstruction (UPJO) is increasing and needs assessment. Patients who underwent RALP for UPJO in two academic centres were included. Demographic and perioperative data were collected retrospectively. UPJO was evaluated by imaging pre- and post-surgery. Patients had follow-up consultations 3,6 and 12 months post-surgery. Global success was defined as a clinical response plus radiographic evidence of no further obstruction 3-months post-surgery. Overall 214 patients (median age: 40 years [interquartile range:30.3-54.0]) were included. Fourteen patients (6.5%) had undergone previous surgery for UPJO. Thirty patients (14%) suffered complication: urinoma (n = 13; 6.1%), pyelonephritis (n = 15; 7%) and retroperitoneal haematomas (n = 2; 0.9%). Repeated early surgery was necessary in eight patients (3.6%). Seven patients had a recurrence of UPJO and six (2.9%) underwent repeated surgery. Radiological success rate was 96.7% whereas global success rate was 91%. RALP was a reliable, effective and safe treatment for UPJO with a high global and radiologic success rate.

V05-03 ROBOTIC URETEROCALICOSTOMY: TIPS AND TRICKS

You have accessJournal of UrologyUpper-Tract Reconstruction (V05)1 Apr 2020V05-03 ROBOTIC URETEROCALICOSTOMY: TIPS AND TRICKS Jonathan Schmidt*, James Steward, Jay Sulek, Kevin Heinsimer, and Chandru Sundaram Jonathan Schmidt*Jonathan Schmidt* More articles by this author , James StewardJames Steward More articles by this author , Jay SulekJay Sulek More articles by this author , Kevin HeinsimerKevin Heinsimer More articles by this author , and Chandru SundaramChandru Sundaram More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000874.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureterocalicostomy is a well-described but rarely-performed operation for the treatment of complicated ureteropelvic junction (UPJ) strictures, particularly in the settings of a completely intrarenal pelvis, horseshoe kidney, or failed pyeloplasty. In this video, we demonstrate a robotic-assisted laparoscopic approach to this procedure, while highlighting key steps and offering recommendations on surgical technique. METHODS: A robotic-assisted laparoscopic ureterocalicostomy was performed in a 43 year old female for a complicated, symptomatic UPJ obstruction at our academic institution. Informed consent was obtained for the procedure and for the use of images and video. Preoperative workup included a retrograde pyelogram and CT urogram demonstrating a UPJ stricture, completely intrarenal pelvis, dilated lower pole calyx, and thinning lower pole parenchyma. A radionucleotide renal scan demonstrated a right split function of 42.3% and left split function of 57.7%. T1/2 max on the right was 27.1 minutes and 10.8 on the left. The da Vinci surgical system was used to perform the procedure. Each critical step of the procedure was demonstrated and narrated with a focus on surgical technique. Patient follow up was 6 months. RESULTS: We demonstrate the successful creation of the ureterocalicostomy highlighting critical steps of the operation. These include retrograde pyelogram and ureteral stent placement, kidney parenchyma and hilum exposure, ureteral exposure and transection, closure of the UPJ, clamping, excision of the lower pole of the kidney, and the uretero-calyceal anastomosis. The stent was removed at 1 month. At 3 months a renal ultrasound demonstrated lower pole calcyceal enlargement but overall resolved hydronephrosis. The patient reported resolution of pain at 6 months. CONCLUSIONS: This video demonstrates the utility and feasibility of a minimally-invasive ureterocalicostomy for the adult patient and provides detailed recommendations on surgical technique. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e470-e470 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Schmidt* More articles by this author James Steward More articles by this author Jay Sulek More articles by this author Kevin Heinsimer More articles by this author Chandru Sundaram More articles by this author Expand All Advertisement PDF downloadLoading ...

Laparoscopic ureterocalicostomy in children: The technique and feasibility

Ureterocalicostomy is a salvage technique commonly used for failed pyeloplasties; it has also been reported as a primary procedure in ureteropelvic junction obstruction (UPJO). This video describes the technique of laparoscopic ureterocalicostomy for primary UPJO in a child with a malrotated kidney and parenchymal thinning. A 13-year-old girl with symptomatic UPJO was found to have a malrotated kidney with a high posterior insertion of the ureter. A laparoscopic dependent ureterocalicostomy over a double-J stent was performed. The postoperative course was uneventful, with excellent clinical and radiological outcomes. Literature review revealed only two reports of this laparoscopic procedure as a primary surgery in children (one with intrarenal pelvis associated to urolithiasis and the other with a malrotated kidney). Laparoscopic ureterocalicostomy is a safe and feasible option in selected cases with parenchymal thinning due to atypical UPJ anatomy or failed pyeloplasty.

255 A Peripelvic Renal Cyst Resulting in Clinically Symptomatic Ureteropelvic Junction Obstruction

255 A Peripelvic Renal Cyst Resulting in Clinically Symptomatic Ureteropelvic Junction Obstruction

Necessity of routine diuretic renography after pyeloplasty in adult patients with symptomatic ureteropelvic junction obstruction

Necessity of routine diuretic renography after pyeloplasty in adult patients with symptomatic ureteropelvic junction obstruction

The clinical charactaristics analysis of the acute symptomatic ureteropelvic junction obstruction in children

Objective To analyze the clinical charactaristics of acute symptomatic the ureteropelvic junction obstruction (UPJO) in children, who present abdominal pain as the primary symptom. Methods Retrospective analysis was performed in children of UPJO, who claimed abdominal pain as the primary symptom in our hospital from January 2009 to December 2016. Totally 48 cases were included.40 boys, 8 girls .38 cases were dignosed as left UPJO, the others were right. The mean age was 7.2y (range 2.0-15.6y). Most patients are school age children. Renal ultrasonography was repeated to record the changes from the symptomatic to the asymptomatic stage. Diuretic renogram examination (ECT) was used to confirm UPJO and assess DRF(differential renal function)in all patients. Results 30 cases (62.5%) presented sole abdominal pain, while the other 18 cases (37.5%) had combined symptoms, such as nausea and vomiting, and hematuria. 9 cases (20.5%) had abdominal pain only once, while the other 39 (79.5%)cases had recurrent abdominal pain. All cases showed significant differences in renal pelvis dilation and renal parenchyma thickness between the period of occurrence of abdominal pain[(35.5±17.1)mm, (7.2±4.9)mm] and normal condition[(23.4±18.4)mm, (8.9±5.6)mm] (P 40%. All patients were followed up for 45.6 months, no abdominal pain was ever reported. Conclusions Acute symptomatic UPJO in children is more common in school-age children. The abdominal pain is intermittent, recurrent. It may happen with other symptoms. There is a significant increase in renal pelvis dilation and a decrease in renal parenchyma thickness on ultrasonography when the abdominal pain occures. US performed during the onset of abdominal pain and non-abdominal pain is an important method for the diagnosis of acute symptomatic UPJO in children. Key words: Abdominal pain; Hydronephrosis; Ultrasonography; Ureteropelvic junction obstruction

Percent of Tracer Clearance at 40 Minutes in MAG3 Renal Scans Is More Sensitive Than T1/2 for Symptomatic Ureteropelvic Junction Obstruction

To increase the diagnostic sensitivity of standard MAG3 diuretic renal scans for ureteropelvic junction obstruction (UPJO) by exploring the utility of an alternative measurement P40, the percentage of maximal tracer counts present at 40 minutes. Patients with strong clinical and anatomic evidence for UPJO may have a normal T1/2, making definitive diagnosis difficult. We reviewed the charts of 142 consecutive patients who underwent successful laparoscopic or robotic-assisted laparoscopic pyeloplasty for UPJO between 2005 and 2015. Both pre- and postoperative renal scan images were available for 37 symptomatic patients with primary unilateral UPJO and 2 kidneys. We defined P40 as the percentage of maximal tracer counts present at 40 minutes. We identified the upper limit of normal (97.5th percentile, +2SD) for P40 using the preoperative renal scans from the unaffected kidney. We compared the sensitivity of P40 to T1/2 to identify symptomatic UPJO. In our cohort, 51% of symptomatic patients (n = 19) had a normal T1/2 (median 8.9 minutes; interquartile range: 7.5 minutes) and 49% (n = 18) had an abnormal T1/2 (median: 40 minutes; interquartile range: 0 minute). None of the patients had an abnormal P40 on their unaffected kidney. All patients with an abnormal T1/2 also had an abnormal P40. P40 increased the sensitivity of the renal scan from 49% (n = 18 of 37) to 73% (n = 27 of 37) when compared to T1/2. The majority of patients (95%) demonstrated an improvement in P40 after pyeloplasty. P40 markedly increases the sensitivity of a renal scan for diagnosing symptomatic UPJO and may be another valuable marker in addition to T1/2 to document functional improvement in drainage after pyeloplasty.

Use of Contrasted Computerized Tomography as a Surrogate for Nuclear Medicine Renogram to Categorize Renal Function in the Setting of Ureteropelvic Junction Obstruction

To use basic measurements on contrasted computerized tomography (CT) to reliably determine whether a kidney with ureteropelvic junction obstruction (UPJO) is definitively functional (≥30% differential renal function [DRF]) or nonfunctional (≤10% DRF), obviating the need for nuclear medicine renogram (RG) to determine DRF. This is a single institution, retrospective cohort of patients diagnosed with UPJO who underwent either pyeloplasty or nephrectomy between December 2004 and December 2014. Included patients had both preoperative mercaptoacetyltriglycine RG and contrasted CT within 180 days of each other. Patients with stents or nephrostomy tubes were excluded. A total of 49 patients were included. The strongest correlation between differential CT measurements and DRF on RG existed by multiplying the cortical area by the average cortical Hounsfield units (Pearson's r = 0.90, P < .001). Using an equation derived from linear regression and cutoff values generated by receiver operator curve (ROC) analysis, CT equation-estimated DRF values of ≥40% and ≤10% correlated with "definitively functional" RG values of ≥30% (100% specificity) and with "definitively nonfunctional" RG values of ≤10% (100% specificity), respectively. In 30 out of 49 cases, CT could have replaced RG. RG is the gold standard in determining quantitative DRF. However, the treatment algorithm for a kidney with symptomatic UPJO hinges on categorized function: "functional" (repair) or "nonfunctional" (remove). Appropriate measurements on contrasted CT can categorize definitively functional or nonfunctional kidneys with UPJO, negating the need for RG to obtain DRF in a majority of cases. This study design favors real-world application with potential to reduce medical expenditure and delay in definitive treatment.

PD14-08 CORRELATION BETWEEN CONTRASTED CT SCAN AND NUCLEAR MEDICINE IMAGING TO DETERMINE DIFFERENTIAL RENAL FUNCTION IN URETEROPELVIC OBSTRUCTION

INTRODUCTION AND OBJECTIVES: Nuclear medicine renogram (RG) is the gold standard in determining differential renal function. However, the treatment decision for symptomatic ureteropelvic junction obstruction (UPJO) hinges on a dichotomous decision regarding the affected kidney: functional vs. nonfunctional. We predict that basic measurements taken from a contrasted CT scan can be used to reliably determine whether a kidney with UPJO is definitively functional or nonfunctional, thus obviating the need for a RG in many cases. METHODS: This is a single institution, retrospective cohort of patients with UPJO who either underwent pyeloplasty or nephrectomy between December 2004 and December 2014. Included patients had both a pre-operative contrasted CT and a RG within 180 days of each other. Patients were excluded if a stent or nephrostomy tube was present at the time of the images. A single observer performed renal measurements on contrasted CT scans to predict the results obtained from RGs. RESULTS: 56 patients were included in the study. By using renal measurements with default imaging software to calculate the average cortical area and average cortical Hounsfield units, there exists a strong correlation between differential CT measurements and differential renal function on RG (Pearsons r 1⁄4 0.92, p < 0.00001). Using an equation generated by linear regression, CT measurements predicting 39% and 10% function correlated with RG values of 30% (100% specificity) and 10% (100% specificity), respectively, on ROC analysis. Using these cut-off values, over half (30/56) of the RGs would be considered unnecessary for determination of differential renal function. CONCLUSIONS: Contrasted CT in UPJO patients may be utilized to identify definitively functional or definitively nonfunctional kidneys, negating the need for RG prior to appropriate operative intervention in many cases. Our study is the largest homogenous UPJO cohort to evaluate the correlation between CT and RG, does not require additional imaging software, and maintains 100% specificity for determining clearly functional and nonfunctional kidneys when using appropriate cut-offs. The study design favors real-world application, and these findings show great potential in reducing medical cost and time to treatment without sacrificing quality or confidence in medical care.

Robotic-assisted Laparoscopic Pyeloplasty: Analysis of Symptomatic Patients With Equivocal Renal Scans

To review the objective and subjective success rates of robotic-assisted laparoscopic pyeloplasty in symptomatic patients with radiographic findings suggestive of uretero-pelvic junction obstruction (UPJO), but equivocal renal scans (diuretic T1/2 <20 minutes). We reviewed 77 patients with symptomatic UPJO, who underwent robotic-assisted laparoscopic pyeloplasty between August 2006 and March 2013. We grouped patients by renal scan findings into 1 of 2 groups, obstructed (diuretic T1/2 ≥20 minutes) or equivocal (diuretic T1/2 <20 minutes). All patients were symptomatic and had radiographic findings suggestive of UPJO (eg hydronephrosis). Mean age was 40.7 years (range 17-80) with 70% female. UPJO occurred 44% left and 56% right, with 92% presenting with flank pain. Of 77 patients, 45 had obstruction on renal scan, with 41 (91%) having resolution of obstruction postoperatively and 44 of 45 (98%) having complete resolution of their initial symptoms. Thirty-two patients had equivocal findings with mean diuretic T1/2 of 12.6 minutes (range: 5.5-19.26) on renal scan. In this latter group, patients had significantly less of a decrease in their diuretic T1/2 postoperatively (4 vs 64 minutes, P = .018) and reported less pain resolution (53% vs 98%, P ≤.001) than group 1. Many studies have demonstrated excellent success of pyeloplasty, with most series including patients meeting strict diagnostic criteria for obstruction. Our study examines outcomes in patients with clinically symptomatic UPJO and equivocal diuretic renography. In our cohort, equivocal patients were significantly less likely to have subjective resolution of symptoms than patients in the obstructed group.

Management of ureteropelvic junction obstruction in horseshoe kidneys by an assortment of laparoscopic options

We report our experience with laparoscopic management of ureteropelvic junction obstruction in horseshoe kidneys. Between February 2004 and March 2014, 15 patients with horseshoe kidneys and symptomatic ureteropelvic junction obstruction underwent laparoscopic management at our national referral centre. Depending on the anatomy and presence of obtrusive vessels or isthmus, we performed either dismembered, Scardino or Foley YV pyeloplasty, or Hellstrom vessel transposition. Patients were initially evaluated by ultrasonography, then diuretic scintiscan at 4 to 6 months, and followed by yearly clinical and sonographic exams. This study included 11 male and 4 female patients between the ages of 4 to 51 year (average 17.7). The left kidney was involved in 12 patients (80%). Operation time was 129 minutes (range: 90-186), and patients were discharged within 2.8 days (range: 1-6). Although 8 (53.3%) patients had crossing vessels, of which 6 required transposing, the Hellstrom technique was solely used in 3 cases, of which notably 1 case failed to resolve and required laparoscopic Hynes within the next year. Eight cases underwent dismembered pyeloplasty, 2 Foley YV, 1 Scardino flap and 1 required isthmectomy and vessel suspension. At the mean follow-up of 60 (range: 18-120) months, the overall success rate was 93.3%. To our knowledge, this represents the largest report on laparoscopic pyeloplasty for horseshoe kidneys, providing the longest follow-up. Our findings confirm prior reports supporting laparoscopy and furthermore show that despite the prevalence of crossing vessels, transposition alone is seldom sufficient.

Is Routine Postoperative Diuresis Renography Indicated in All Adult Patients After Pyeloplasty for Ureteropelvic Junction Obstruction?

To determine if routine follow-up diuresis renography is indicated in all adult patients after pyeloplasty for ureteropelvic junction obstruction (UPJO). A multicenter retrospective analysis was conducted in adults who underwent pyeloplasty for symptomatic UPJO between January 2002 and August 2012. Patients with unilateral UPJO demonstrated on diuresis renography, treated with pyeloplasty, and aged >18 years at time of surgery were included in the study. Patients with contralateral renal abnormalities, genitourinary anomalies, and those who declined renography during follow-up were excluded. All eligible patients underwent diuresis renography approximately 3 months postoperatively. Minimal follow-up was 12 months. Patients were divided into 2 groups: patients with persistent pain at 3 months after pyeloplasty and patients who became asymptomatic. Treatment failures in each cohort were identified. Comparisons were performed using the Fisher exact test. A total of 100 pyeloplasties were performed. Of them, 90 were eligible for the study. Mean age was 40 years. Mean follow-up was 21 months. Seventy-three patients (81.1%) became pain free after pyeloplasty. One patient (1.4%) had worsening of differential renal function despite unobstructed drainage on diuresis renogram. None of the patients in the asymptomatic cohort was identified to have unequivocal drainage obstruction on postoperative renogram. Seventeen patients (18.9%) remained symptomatic with pain at 3 months after pyeloplasty; 3 (17.6%) of those patients with loin pain after pyeloplasty were confirmed to have persistent obstructed drainage postoperatively on diuresis renogram (P <.001). All 3 patients required insertion of ureteric stents and/or revision surgery (P <.007). In our series, adult patients who became pain free after unilateral pyeloplasty for UPJO did not have persistent obstruction of renal drainage on renography. Routine diuresis renogram to assess drainage and differential renal function in patients who become pain free after pyeloplasty for UPJO may not be necessary. If objective evidence of postoperative outcome is required, then a single renogram at 3 months is recommended.

Renal Function After Laparoendoscopic Single Site Pyeloplasty

Outcomes after laparoendoscopic single site pyeloplasty are limited to small cohort studies with short-term followup. We evaluated the clinical and renal function outcomes of what to our knowledge is the largest laparoendoscopic single site pyeloplasty cohort to date with a mean followup of 12 months. Consecutive patients diagnosed with symptomatic ureteropelvic junction obstruction who underwent robotic or conventional laparoendoscopic single site pyeloplasty were entered into the study. Patient demographics, and preoperative and postoperative renal function outcomes were recorded. Diuretic renogram was performed after stent removal, at 6 months and yearly thereafter. The cohort included 31 conventional and 22 robotic laparoendoscopic single site pyeloplasties. Four laparoendoscopic single site surgeries (7.8%) were converted to another procedure due to failure to progress. Mean ± SD followup was 12.1 ± 10.7 months and 22 patients had at least 12 months of followup. No intraoperative complications occurred. Complications developed postoperatively in 11 patients (21%), of which 9 were Clavien grade 3 or greater. Preoperative symptoms resolved in 49 of 51 cases (96%). Severe obstruction (half-time greater than 20 minutes) was seen in 32 of 44 patients (73%) at presentation and obstruction resolved (half-time 20 minutes or less) in 41 (93%). Mean preoperative and postoperative half-time was 24.6 ± 13.4 and 8.3 ± 4.1 minutes, respectively, for an improvement of 16.3 ± 12.3 minutes (p <0.01). Laparoendoscopic single site pyeloplasty is safe and efficacious. The laparoscopic and robotic techniques provide excellent outcomes in terms of symptomatic relief and radiographic resolution of obstruction.

The Three-Trocar Laparoscopic Pyeloplasty: Tips and Tricks on Technical Aspects

Introduction: Laparoscopic pyeloplasty (LP) is the first-line option for management of ureteropelvic junction obstruction (UPJO).1,2 Initially, this procedure was described using four or five ports; however, newer approaches use three-trocars aiming for minimal invasión,3,4 which may complicate the procedure. We present a video of the three-trocar technique step by step, with several tips and tricks to improve the performance. Patients and Methods: Seven patients (mean 44 years old range: 31–58) underwent Anderson-Hynes three-trocar LP for symptomatic UPJO. The three-port transperitoneal technique was done. A 10-mm trocar was placed directly through the umbilicus and two 5-mm trocars in a triangular arrangement. To improve exposure of the UPJ and reduce the dissection time, the surrounding tissues may be retracted with clips or sutures applying the puppet maneuver, with special caution to avoid incorporating the bowel into the retraction devices. The proximal ureter may be lifted with similar maneuver, like a suture sling to simplify the UPJ dissection and further on the spatulation.5 In some cases, kidney stones may be removed using a nephroscopy with carbon dioxide (CO2), inserting a flexible cystoscope into the renal pelvis. This technique may be applied to avoid accumulation of irrigation fluid into the peritoneal cavity, connecting the gas cannula to the irrigation channel of the endoscope to insufflate CO2. It works well for stones located in the anterior calicos, but is not useful in the posterior calicos.6 The ureteral spatulation may be simplified through stabilization of UPJ by the remaining attachment to the renal pelvis, by the suture sling of the ureter and by a grasper holding.7 The performance of the dismembered pyeloplasty may be improved and simplified applying the Hammock maneuver, which stabilizes the line of anastomosis anchoring the suture to the surrounding tissues with clips, with caution to avoid incorporating the bowel again. Finally, the percutaneus antegrade ureteral stent placement may be done through a 14-gauge angiocatheter,8,9 previous to complete the anastomosis. Results: The average operating time of the pyeloplasty was 187 minutes. No open conversions were required. There were no perioperative complications. Subjective and objective success was obtained in six of seven patients. Conclusions: The three-trocar LP is a secure and feasible technique for the correction of UPJO. The maneuvers shown in this video may simplify the procedure. No competing financial interests exist. Runtime of video: 9 mins 49 secs

Lessons from 90 consecutive laparoscopic dismembered pyeloplasties in a residency program

Objective. The aim of this study was to report on the safety and efficacy of 90 consecutive laparoscopic pyeloplasties carried out in a university hospital. Material and methods. The outcomes of 90 transperitoneal dismembered pyeloplasties that were performed by residents at the hospital from March 2004 to March 2010 were analyzed. All of the surgeries were performed because of symptomatic ureteropelvic junction obstruction. The laparoscopic Anderson–Hynes dismembered technique was used in all cases, and a double-J stent was routinely placed and left in place for 4 weeks. The patients were followed up clinically and with imaging studies. Clinical data, outcomes and complication rates for the patients were retrospectively reviewed using a prospectively maintained database. Results.The mean patient age was 38.9 (10–80) years, and 46 patients (51.1%) were males. The mean operative time was 222.5 (125–400) min. The surgery was completed laparoscopically in 96.6% of cases (87 patients). Conversion was required owing to technical difficulties in three cases. Overall, four (4.4%) patients had major complications. Seventy-six of the 87 patients (87.3%) presented improvements in symptomatology at a median follow-up of 39.7 (6–75) months. Conclusion. Laparoscopic pyeloplasty is feasible and associated with high success and low complication rates, even in a residency program.

Laparoendoscopic Single-Site (LESS) Pyeloplasty for Horseshoe Ureteropelvic Junction Obstruction

Pyeloplasty in horseshoe kidneys can be challenging due to aberrant vasculature, renal malrotation, and ectopic location. Fewer than 20 cases of minimally invasive (MIS) pyeloplasty in horseshoe kidneys have been reported in the literature to date. We herein report the first 2 cases of laparoendoscopic single-site (LESS) pyeloplasty for UPJ obstruction in horseshoe kidneys. Two patients with symptomatic ureteropelvic junction obstruction in horseshoe kidneys were treated with an Anderson-Hynes LESS pyeloplasty. This was performed using three 5-mm trocars through a single umbilical incision, plus an accessory 3-mm port at the anterior axillary line to facilitate suturing and subsequent drain placement. Both patients had BMI <23. The operative times were 204 minutes and 171 minutes. Blood loss was negligible, and no intraoperative complications occurred. To date, 9-month renography for patient 1 demonstrates stable renal function and unobstructed drainage. After stent removal, patient 2 was asymptomatic. In experienced hands, LESS reconstructive techniques are applicable to complex renal anomalies. LESS pyeloplasty for UPJ obstruction associated with horseshoe kidneys is feasible, safe, and effective in select patients.

Comparison between intravenous urography and computed tomography urography in diagnosing ureteropelvic junction obstruction.

Dear Editor, We read with interest the article by Xie et al. (1) in a previous issue of Nephro-Urology Monthly (October 2011), regarding the comparison between intravenous urography and computed tomography urography in diagnosing ureteropelvic junction obstruction. As previously described, pathological lesions at the ureteropelvic junction are classified into intrinsic and extrinsic abnormalities. In the case of intrinsic pathology, increased collagen and ground substances between the muscle bundles have been demonstrated in many studies (2). Additionally we have recently found that intrinsic UPJ obstruction samples have a dissolved smooth muscular coat and an overexpression of extracellular matrix proteins, together with a depleted nerve supply (3). Hypoplastic adynamic ureteral segment was also recently shown to be the cause of the lack of adjustment to increased workloads (high urine volume). Ureteral bands and kinks were defined, especially in older children with symptomatic Ureteropelvic junction obstruction obstruction (4). Although the authors compared intravenous pyelography with computed tomography urography in this paper, we should not forget the importance of diuretic renography as a noninvasive test, to determine the severity and functional significance of ureteropelvic urine transport problems in children. This test is the most widely used one and it is very helpful in deciding the final result, whether the operation is essential or not, before the operation. Some centers have pointed out that their current imaging modality of choice is CT urography, which is particularly useful in showing the anatomy of aberrant vessels, secondary kinks and adhesions (4). Associated renal anomalies (horse-shoe kidney, duplex kidney etc.) can be clearly demonstrated as well with a comparable radiation exposure to standard intravenous pyelogram.