Percutaneous pyeloplasty

Ureteroscopic holmium laser endopyelotomy for ureteropelvic junction stenosis after pyeloplasty

INTRODUCTION

Pyeloplasty is a standard and highly successful treatment for ureteropelvic junction obstruction. However, stenosis is a late complication causing symptom recurrence. The purpose of this study was to evaluate the use of holmium laser stenosis incision-"laser endopyelotomy"-to manage this.

PATIENTS AND METHODS

Fifteen adult patients were referred for loin pain recurrence after pyeloplasty. Subsequent to ureteropelvic junction stenosis confirmation with intravenous urogram and dynamic isotope renogram investigations, the patients underwent ureteroscopic laser endopyelotomy. Eleven patients had stents in situ before endopyelotomy. Ureteric stents (7F) were placed for 6 weeks postprocedure when ureteroscopy was repeated and stents removed. All patients had repeat intravenous urogram and renograms at 3 months postprocedure.

RESULTS

Patients presented at a median of 3.2 years (range, 9 months to 8 years) after pyeloplasty (nine open dismembered, three Culp, and three laparoscopic). Three patients (all nonstented) required a second incision. All patients were discharged from hospital within 23 hours with no complications. Symptomatic improvement was documented in all of the patients, and improved drainage was recorded in the 3-month nuclear scans.

CONCLUSION

Laser endopyelotomy is an appropriate minimally invasive procedure for postpyeloplasty stenosis. Results are better in patients with ureteric stents in situ before the procedure.

Percutaneous endopyelotomy for ureteropelvic junction obstruction

Percutaneous endopyelotomy was performed 13 times on 11 patients with primary and secondary UPJ obstruction between 1994 and 2002. Excretory urogram revealed improvement in ten of eleven patients. One of the ten successfully treated patients required repeated endopyelotomy. Endopyelotomy failed in one patient, who had secondary UPJ obstruction that had been stenosed by granuloma caused by a ureteral stone. As the patient had UPJ obstruction of high insertion type with thinned renal parenchyma, nephrectomy was performed after repeated endopyelotomy. Compared with open pyeloplasty, percutaneous endopyelotomy is less invasive and is cosmetically advantageous.

Laparoscopic dismembered pyeloplasty: 50 consecutive cases

OBJECTIVE

To test the hypothesis that laparoscopic dismembered pyeloplasty offers the same good results as open pyeloplasty, but without the disadvantages of the loin incision (which is painful, prolongs hospitalization and prevents a return to normal activities for several weeks) in the treatment of pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

Fifty consecutive consenting patients presenting with PUJ obstruction underwent laparoscopic dismembered pyeloplasty carried out by one surgeon using an extraperitoneal approach.

RESULTS

Two (4%) procedures were converted to open surgery. The mean (range) operative duration was 164 (120-240) min. Fifteen (30%) of the patients had their ureter transposed anterior to a crossing lower-pole vessel; 22 (44%) patients had a separate renal pelvic suture line. The mean (range) postoperative parenteral analgesic requirement was 19.1 (0-111) mg of morphine sulphate. The mean (range) hospitalization was 2.6 (2-7) days. Two (4%) patients had complications. After a mean (range) follow-up of 18.8 (3-72) months all but one patient, who had failed endopyelotomy, had a normal renogram and were symptom-free.

CONCLUSION

These results suggest that a loin wound is not necessary for a successful outcome after dismembered pyeloplasty, and that in expert hands laparoscopic dismembered pyeloplasty should now be considered the standard of care.

Simplified approach to percutaneous endopyelotomy

The purpose of this report was to describe a safe, simple, and rapid approach to percutaneous antegrade endopyelotomy. In contrast to standard percutaneous endopyelotomy techniques, in this procedure, the endopyelotomy stent is placed at the outset. The endopyelotomy incision is then made with an acorn-tipped Bugbee electrode directly down onto the stent, in a manner analogous to a ureteral meatotomy in the bladder. The advantage of this approach is twofold. Primary placement of the stent helps to define the appropriate site and direction for the endopyelotomy incision, allowing marsupialization of the proximal ureter into the renal pelvis. Use of this technique also obviates the need to pass a large-caliber stent after the endopyelotomy incision has been made, thereby avoiding a potential risk of ureteropelvic junction disruption. Clinical and radiographic follow-up was available in 29 (76%) of 38 patients who underwent this procedure. Success, defined as a resolution of symptoms and decrease in calicectasis, was achieved in 24 (83%) of the 29 patients. We have found primary placement of an endopyelotomy stent and use of electrocautery as a cutting mode safely facilitates a precise endopyelotomy incision.

Percutaneous endopyelotomy

Percutaneous endopyelotomy, introduced over 15 years ago, is a well-established alternative to open operative pyeloplasty for management of ureteropelvic junction (UPJ) obstruction. Although several variations of the technique have been described, the goal in all cases is to develop a full thickness incision though the obstructing proximal uretra that extends out to the peripyeloureteral fat and heals over an internal stent. Though a percutaneous endopyelotomy can be considered for almost any patient with primary or secondary UPJ obstruction, it is particularly valuable in the setting of upper tract stones that can then be managed simultaneously. This article reviews the indications, techniques, and outcomes of percutaneous endopyelotomy.

Endourologic management of benign ureteral strictures with and without compromised vascular supply

OBJECTIVES

To retrospectively assess the efficacy of balloon dilation, endopyelotomy/ureterotomy, and stenting alone in the management of benign ureteral strictures with intact or compromised vascular supply.

METHODS

One hundred fourteen patients with benign ureteral strictures were assessed after at least a 2-year follow-up (range 2 to 16 years, mean 6.3). Balloon dilation was performed in 81, endopyelotomy/ureterotomy with temporary stenting in 27, and ureteral stenting alone in 6 patients. Ureteral strictures were divided into strictures with intact or with compromised vascular supply.

RESULTS

Balloon dilation was successful in short ureteral strictures with intact vascular supply in 33 of 37 (89.2%), but only in 3 of 8 (37.5%) long ureteral strictures and in 1 of 2 (50%) recurrent ureteropelvic junction strictures. Balloon dilation was less successful when the vascular supply was compromised in 2 (40%) of 5 short strictures, 1 (16.7%) of 6 long strictures, and 2 (33.3%) of 6 recurrent ureteropelvic junction strictures. Endopyelotomy/ureterotomy was successful in 17 (89.5%) of 19 strictures with compromised vascular supply.

CONCLUSIONS

Balloon dilation is recommended for management of short strictures with intact vascular supply. Endoureterotomy with stenting is recommended for all long ureteral strictures, for ureteropelvic junction stenoses, and for short ureteral strictures with compromised vascular supply and benign underlying etiology.

Endopyelotomy for horseshoe and ectopic kidneys

PURPOSE

We report our experience with endopyelotomy for horseshoe and ectopic kidneys in the largest series to date to our knowledge, and discuss the technical modifications adopted to perform successfully percutaneous antegrade endopyelotomy.

MATERIALS AND METHODS

From September 1987 to April 1996, 4 patients with horseshoe and 5 with ectopic kidney underwent percutaneous antegrade endopyelotomy for symptomatic ureteropelvic junction obstruction. The percutaneous puncture was made more posteromedial and the ureteropelvic junction was incised lateral. A retrograde percutaneous access tract was created under laparoscopic guidance in pelvic kidneys.

RESULTS

The operative procedure was performed uneventfully in all patients with no major bleeding, pleural effusion or visceral perforation. The stents were removed at 6 weeks, and an excretory urogram was performed at 2 weeks, 6 months and yearly thereafter. In 2 patients (22%) with severe hydronephrosis, poor renal function and a long ureteral stricture surgical treatment failed immediately. The remaining 7 patients (78%) had long lasting clinical and radiographic success with a mean followup of 62 months.

CONCLUSIONS

Percutaneous antegrade endopyelotomy, with a few technical modifications, is a safe and effective treatment for ureteropelvic junction obstruction associated with horseshoe and ectopic kidneys.

Endopyelotomy after failed pyeloplasty: the long-term results

PURPOSE

Endopyelotomy has been proposed as a technique to treat ureteropelvic junction obstruction after failed open pyeloplasty. However, to our knowledge no long-term results of this treatment have been reported. We report the long-term followup of a cohort of patients in whom pyeloplasty failed and who subsequently were treated with endopyelotomy.

MATERIALS AND METHODS

From January 1985 to February 1996, 72 patients in whom open surgical pyeloplasty failed were treated with percutaneous endopyelotomy. Mean patient age was 35 years (range 5 to 82). The interval between pyeloplasty and subsequent failure ranged from 2 months to 30 years (mean 57 months). The major presenting symptoms were pain in 82% of cases, fever and urinary tract infections in 37.5%, stone formation in 25% and gross hematuria in 21%.

RESULTS

Antegrade endopyelotomy using a hooked knife was performed in all patients with no unusual difficulty and minimal complications. A total of 63 patients (87.5%) had long lasting clinical and radiographic treatment success after a mean followup of 88.5 months. Of the 9 endopyelotomy failures (12.5%) 7 (77.8%) were detected immediately after stent removal at 6 weeks, 1 (11.1%) at 6 months and 1 (11.1%) at 10 months postoperatively (mean failure interval 3.3 months). The failures were corrected with repeat endopyelotomy in 1 patient, pyeloplasty in 3, ileal interposition in 1 and nephrectomy in 4.

CONCLUSIONS

Endopyelotomy is the treatment of choice for recurrent ureteropelvic junction obstruction after failed pyeloplasty, with a high and sustained long-term success rate and no reported new failures after 1-year followup. Furthermore, endopyelotomy is technically easier with less morbidity than repeat open pyeloplasty.

Endopyelotomy for horseshoe and ectopic kidneys

PURPOSE

We report our experience with endopyelotomy for horseshoe and ectopic kidneys in the largest series to date to our knowledge, and discuss the technical modifications adopted to perform successfully percutaneous antegrade endopyelotomy.

MATERIALS AND METHODS

From September 1987 to April 1996, 4 patients with horseshoe and 5 with ectopic kidney underwent percutaneous antegrade endopyelotomy for symptomatic ureteropelvic junction obstruction. The percutaneous puncture was made more posteromedial and the ureteropelvic junction was incised lateral. A retrograde percutaneous access tract was created under laparoscopic guidance in pelvic kidneys.

RESULTS

The operative procedure was performed uneventfully in all patients with no major bleeding, pleural effusion or visceral perforation. The stents were removed at 6 weeks, and an excretory urogram was performed at 2 weeks, 6 months and yearly thereafter. In 2 patients (22%) with severe hydronephrosis, poor renal function and a long ureteral stricture surgical treatment failed immediately. The remaining 7 patients (78%) had long lasting clinical and radiographic success with a mean followup of 62 months.

CONCLUSIONS

Percutaneous antegrade endopyelotomy, with a few technical modifications, is a safe and effective treatment for ureteropelvic junction obstruction associated with horseshoe and ectopic kidneys.

Endostent: new device for ureteral strictures

The results with the new Korth Endostent (manufactured by Rüsch), which was placed in 71 ureters after endopyelotomy, were compared with the results of conventional stenting in 183 ureters. Good or excellent results were seen in 79% of the Endostented ureters v 73% of the conventionally stented ureters. With conventional stents, results were better in primary than in secondary stenoses, whereas the reverse was true with the Endostent. The Endostent provided superior results in patients with third-degree hydronephrosis and in those with long scars. There was a striking reduction in the risk of infection (fever) in patients having an Endostent inserted (7% v 44%). The Endostent may also be indicated for permanent implantation in patients with strictures of ureterovesical anastomoses involving neobladders or allograft kidneys.

Percutaneous endopyelotomy and results: Korth technique

Endoscopic incision of ureteral strictures has become an important component of the urologic armamentarium. Despite different techniques and stenting times applied for the procedures, the rates of long-term favorable outcomes have proved to range consistently from 72% to 89% for both secondary and primary hydronephrosis. Cold-knife incision combined with 3 weeks of stenting has been utilized at our institution from the beginning. The results have been as favorable as those from other groups. However, stenting times are the subject of controversy. In a prospective trial, a newly designed stent for internal reflux-free drainage and subcutaneous fixation was applied in 53 patients and left indwelling for 6 months. Whereas such long-term stenting using the Endostent seemed to produce less favorable overall results, stenting for 3 weeks proved sufficient in lower-grade hydronephrosis secondary to small stenotic ureteral segments. Although stenoses recurred in 12% of our cases, 90% of these recurrences could be treated endoscopically. All but two recurrences became evident within the first 6 months after stent removal. After a mean follow-up of 20.2 +/- 19.6 months, the outcomes have remained unchanged even on late reexamination.

Comparison of open and endourologic approaches to the obstructed ureteropelvic junction

OBJECTIVES

To compare open pyeloplasty with three minimally invasive modalities: antegrade endopyelotomy, Acucise endopyelotomy (Applied Medical, Laguna Hills, Calif), and laparoscopic pyeloplasty.

METHODS

Forty-five adult patients with ureteropelvic junction obstruction were managed by one of the above four techniques. Success rates, analgesic use, length of hospital stay, recovery time, and complications were compared between each of the four groups.

RESULTS

Successful relief of obstruction was achieved in 100% of patients undergoing open and laparoscopic dismembered pyeloplasty, 78% undergoing Acucise endopyelotomy, and 77% undergoing antegrade percutaneous endopyelotomy. Acucise endopyelotomy results in shorter convalescence (1 week) than antegrade endopyelotomy (4.7 weeks), laparoscopic pyeloplasty (2.3 weeks) or open pyeloplasty (10.3 weeks). Complication rates appear to be similar among all groups.

CONCLUSIONS

Our limited data imply that Acucise endopyelotomy offers low morbidity with success rates comparable to antegrade pyeloplasty, whereas laparoscopic pyeloplasty is as effective as open pyeloplasty with diminished morbidity.

Endopyelotomy: patient selection, results, and complications

The popularity of minimally invasive surgical techniques, such as endopyelotomy, has increased markedly among urologists in recent years. While it was initially thought that this procedure was best utilized in patients with secondary UPJ obstruction, recent evidence suggests that endopyelotomy should be considered in the majority of cases. The primary contraindication to endoscopic incision of the UPJ is a long stricture, although a large redundant renal pelvis and the presence of crossing lower pole vessels are considered by some to be relative contraindications as well. Although the majority of surgeons have used a percutaneous, antegrade approach to endopyelotomy, successful results also have been reported with a ureteroscopic, retrograde technique. With the development of modified ureterotomes and balloon-cutting devices, the retrograde approach eventually may become the preferred method since no skin incision or external drainage are needed. The role of endopyelotomy in children remains undefined. While successful results have been reported in infants, the relative morbidity and long-term success of open pyeloplasty in this age group are excellent, thus limiting the relative advantage of an endoscopic approach. However, there may be a role for endopyelotomy in older children and in those patients with secondary obstruction who have failed open surgery. From a technical standpoint, there are several minor variations in surgical technique and postoperative management that are important. The success rate of endopyelotomy using a cold knife or small electrocautery probe appears to be comparable, and the use of cautery may allow for precise control of minor bleeding thus decreasing the risk of complications. However, larger electrodes may induce greater tissue reaction leading to fibrosis and should be avoided. Postoperatively, most authors prefer a tapered double-pigtail stent which allows for adequate internal drainage while avoiding excessive pressure within the distal ureter. While successful results have been reported with stenting intervals of only four days, it is generally recommended that the stent be left in place for a minimum of six weeks following endoscopic incision of the UPJ. Overall, endopyelotomy is associated with shortened hospitalization, more rapid return to normal activity levels, and decreased morbidity compared with open pyeloplasty. The success rates reported with endopyelotomy approach those achieved with open surgery, and it is likely that an endoscopic approach to UPJ obstruction will assume an increasingly greater role in the future.

Occlusive effect of metallic stents on canine ureters

A three-part study, with successive modifications based on preceding results, was conducted to evaluate ureteral placement of metallic stents. Gianturco self-expanding (10 mm and 4 mm diameter) and balloon-expanded (4 mm diameter) metallic stents were placed in normal and stenotic canine ureters. No migration or ureteral perforation occurred during the follow-up of 10 mm stents. Varying degrees of hydronephrosis and hydroureter were found on all 1-week pyelograms. At 4 weeks, complete occlusion of the stented ureter was noted in all cases because of mucosal hyperplasia around the stent wires. To prevent this reaction, 4 mm self-expanding stents constructed of smaller wire that was uncoated or coated with either Teflon or poly-urethane were tested in five dogs. In all cases, results were similar to those obtained with the larger prostheses. Finally, 4 mm balloon-expanded stents were placed in a normal ureter of three dogs. In one dog, the stent migrated out of the ureter. No migration or ureteral perforation occurred in the two remaining dogs. In these animals, mucosal hyperplasia and complete ureteral occlusion occurred 6 and 8 weeks after placement. Therefore, ureteral placement of Gianturco self-expanding as well as balloon-expanded metallic stents leads to occlusion of the ureter instead of maintaining its patency. Stents, therefore, may be useful as ureteral occlusion devices.

Percutaneous pyeloplasty (endopyelotomy) for congenital ureteropelvic junction obstruction

Endopyelotomy was performed in 30 patients with congenital primary ureteropelvic junction obstruction; 4 patients had high insertion of the ureter and 8 patients had caliceal stones. Clinical and radiologic success was achieved in 25 patients. There were five failures, all of whom subsequently had successful open pyeloplasty. The theoretical and experimental foundations of the procedure and fine points of the operative technique are presented. Endopyelotomy appears to be valuable for primary ureteropelvic junction obstruction just as it is for secondary obstruction.

Endopyeloureterotomy via a transpelvic extraureteral approach

Endopyeloureterotomy has been accepted as a procedure to relieve obstruction of the ureteropelvic junction and upper ureteral stenosis. However, in patients with a long stenotic segment poor results are often obtained with the conventional technique. To resolve this problem we developed a new technique using a 22F urethrotome and a transpelvic extraureteral approach. In this technique the renal pelvis was incised for 1 to 1.5 cm. from the ureteropelvic junction in the direction of the parenchyma using the cold knife of the urethrotome under direct vision. For upper ureteral stenosis the dilated pelvic and ureteral posterolateral walls were incised 1 to 1.5 cm. from the stenotic segment toward the ureteropelvic junction. Then, the stenotic segment was treated with the urethrotome after it was advanced into the retroperitoneal space through the incision in the renal pelvis. We treated 21 patients with the new technique between August 1988 and August 1990. Our series included 3 patients with the high insertion type of ureteropelvic junction obstruction and 4 with a long stenotic segment. The success rate was 95% without any severe complication. These results indicate that our new technique could become a useful procedure for endopyeloureterotomy.

Endopyelotomy: review of results and complications

Percutaneous endopyelotomy augmented by balloon dilation was performed on 27 of 40 patients for the treatment of symptomatic, primary ureteropelvic junction obstruction. Percutaneous ultrasonic lithotripsy was performed simultaneously on 12 of 27 patients (44%) for associated calculi. After endopyelotomy 24 of 27 patients became asymptomatic (clinical success rate 89%). Three clinically improved patients demonstrated only radiographic stability, while radiographic improvement was documented in 21 of 27 (radiographic success rate 78%). Adjuvant percutaneous ultrasonic lithotripsy was successful from the standpoint of stone removal in all patients and no increased morbidity could be identified. Of 27 patients 3 (11%) suffered major complications and are considered failures. Reasons for failure varied and are discussed. Included is a patient who at nephrostography and stent capping became septic and subsequently died. To decrease the risk of sepsis perioperative antibiotics to include at the time of nephrostomy tube capping are recommended. Angiography was performed in 19 of 40 patients to rule out an accessory crossing vessel at the ureteropelvic junction, and such a vessel was found in 6. From analysis of presenting excretory urograms (IVPs) we conclude that a crossing vessel cannot predictably be identified on an IVP.