Simultaneous repair of bilateral ureteropelvic junction obstruction

Predictive Factors of Contralateral Operation after Initial Pyeloplasty in Children with Antenatally Detected Bilateral Hydronephrosis Due to Ureteropelvic Junction Obstruction

OBJECTIVES

This study was performed to analyze the predictive factors of a contralateral operation after initial pyeloplasty in patients with antenatally detected bilateral ureteropelvic junction obstruction.

METHODS

Patients with prenatally diagnosed bilateral ureteropelvic junction obstruction who underwent initial pyeloplasty (aged <12 months at initial pyeloplasty) were offered to participate in the study. Patients were recruited from January 2012 to December 2015. The anteroposterior renal pelvic diameter, parenchymal thickness, and calyceal dilatation were evaluated. Predictive factors of contralateral pyeloplasty after initial unilateral pyeloplasty were also examined.

RESULTS

In total, 82 patients were included in the study (mean age, 2.8 months). Among all patients who underwent initial pyeloplasty, additional contralateral pyeloplasty was required in 11 patients (13.4%). The outcome of contralateral hydronephrosis was assessed as resolution, persistence, or surgery. The median anteroposterior renal pelvic diameter and calyceal dilatation were significantly different among the groups (p < 0.001). Calyceal dilatation of ≥10 mm and a calyceal dilatation/parenchymal thickness ratio of ≥5 strongly suggested the likelihood of a contralateral operation.

CONCLUSIONS

In most patients with bilateral ureteropelvic junction obstruction, improvement or resolution of contralateral hydronephrosis following initial unilateral pyeloplasty can be expected. Patients with contralateral calyceal dilatation >10 mm and the calyceal dilatation/parenchymal thickness ratio >5 are at higher risk of surgery.

Simultaneous bilateral robotic-assisted laparoscopic procedures in children

Our main objective is to report the feasibility of performing simultaneous robotic-assisted laparoscopic (RAL) heminephrectomy with contralateral ureteroureterostomy in children with bilateral duplicated systems. Three female children with bilateral congenital renal/ureteral anomalies underwent concurrent RAL simultaneous unilateral partial nephrectomy with ureterectomy and contralateral ureteroureterostomy with redundant ureterectomy using a four/five-port approach. Mean age at repair was 32.9 months (range 7-46 months) and mean weight was 13.7 kg (range 10.4-13.6 kg). The RAL heminephroureterectomy and contralateral ureteroureterostomy were performed via a four-port approach (five ports in one patient), and the patients were repositioned and draped when moving to the other side. Mean operative time was 446 min (range 356-503 min). Mean estimated blood loss was 23.3 cc (range 10-50 cc). Postoperative length of stay for two patients was 2 days and 1 day for one patient (mean = 1.7 days). Mean length of follow-up was 18.3 months (range 7-36 months). No significant intraoperative or postoperative complications occurred for any of the three patients. Two children had no hydronephrosis on postoperative imaging in follow-up, and one child had a small stable, residual pararenal fluid collection on the side of heminephrectomy. Two patients underwent postoperative ureteral stent removal under general anesthesia. In children with bilateral duplicated urinary tract with ureterocele, ectopic ureter, and/or vesicoureteral reflux, laparoscopic repair with robotic assistance can be accomplished safely in a single operative procedure with a short hospital stay.

Plasma rennin activity: Early indicator of renal injury in bilateral pelviureteric junction obstruction in children

OBJECTIVE

The objective of the present study is to analyze the early indicators of renal injury in children with bilateral pelviuretric junction obstruction.

MATERIALS AND METHODS

We investigated 23 children, 46 kidney units who were diagnosed with bilateral pelvi-ureteric junction obstruction (PUJO) and underwent unilateral or bilateral pyeloplasty between January 2001 and December 2011. Ipsilateral kidney biopsy was performed during pyeloplasty. Kidney biopsy results were divided into three categories. Pre-operative investigation included ultrasonography with the Society of Fetal Urology (SFU) grading, plasma rennin activity (PRA) and differential renal function (DRF).

RESULTS

Out of 23 children there were 17 (73.9%) boys while 6 (26.1%) girls. Median age at operation was 35.4 months (range: 9-60 months). Unilateral pyeloplasty was performed in 14 (60.8%), simultaneous bilateral pyeloplasty in 2 (8.6%) and sequential bilateral pyeloplasty in 7 (30.4%).

CONCLUSION

In bilateral PUJO where DRF and SFU grading of hydronephrosis did not correctly reflect renal injury, PRA showed a significant relationship with renal histopathologic grade and could be an early indicator of renal injury in bilateral PUJO.

Factors indicating renal injury in pediatric bilateral ureteropelvic-junction obstruction

OBJECTIVE

To analyze the factors indicating renal injury in patients with bilateral ureteropelvic-junction obstruction (UPJO).

METHODS

We investigated 26 patients, 35 kidney units (KUs), who were diagnosed with bilateral UPJO and underwent unilateral or bilateral pyeloplasty between January 2000 and December 2011. During pyeloplasty, ipsilateral kidney biopsy was performed. Kidney biopsy results were divided into 3 categories. Hydronephrosis was analyzed using both the Society of Fetal Urology (SFU) and Onen's grading system. We investigated factors related with the renal histopathologic results of 29 KUs. We additionally analyzed whether there were factors predicting contralateral pyeloplasty after initial unilateral pyeloplasty.

RESULTS

Ten KUs (34.5%) showed grade 1 histopathologic change, whereas 10 KUs (34.5%) and 9 KUs (31.0%) showed grade 2 and 3 change, respectively. Preoperative differential renal function (DRF) and serum creatinine levels were not different among groups (P = .697 and .516, respectively). Hydronephrosis grade was not different when graded by SFU system (P = .100) while significantly different by Onen's system (P <.001). Among 23 patients with initial unilateral pyeloplasty, additional contralateral pyeloplasty was required in 6 patients (26.1%). There were no significant preoperative factors predicting the need for additional operations.

CONCLUSION

In bilateral UPJO, DRF, and SFU grade of hydronephrosis did not correctly reflect renal injury. Onen's hydronephrosis grade showed a significant relationship with renal histopathologic grade and could be an indicator for renal injury in bilateral UPJO.

Laparoscopic simultaneous bilateral dismembered pediatric pyeloplasty applying three midline ports

OBJECTIVES

The objective of this study was to describe our experience with laparoscopic simultaneous bilateral dismembered pyeloplasty in two pediatric cases by using three midline ports.

METHODS

A 5-year-old boy and a 5-month-old male infant with bilateral ureteropelvic junction obstruction underwent bilateral laparoscopic transperitoneal dismembered pyeloplasty. A 10-mm trocar was placed through the umbilicus, and two 5-mm trocars were also placed in the midline superior and inferior to the umbilicus. On the left side, dismembered pyeloplasty was performed through a transmesocolic approach. Double-J ureteral stent was inserted through one of the trocars on both sides.

RESULTS

The postoperative period was uneventful. Patients were discharged on postoperative days 4 and 5. Oral feeding was tolerated on the first postoperative day. In a 6-month follow-up period, excretory urography and renal scan showed resolution of obstruction.

CONCLUSIONS

Laparoscopic dismembered pyeloplasty can be performed in a single session for pediatric patients with bilateral ureteropelvic junction obstruction. This can obviate the need for two sessions of anesthesia induction and intubation. However, more studies with large number of patients are needed to confirm this result.

Case Report: Simultaneous Bilateral Robot-Assisted Dismembered Pyeloplasties for Bilateral Ureteropelvic Junction Obstruction: Technique and Literature Review

BACKGROUND AND PURPOSE

Simultaneous bilateral laparoscopic renal operations are technically difficult and not often performed. We present our technique of bilateral simultaneous robot-assisted pyeloplasties for bilateral ureteropelvic junction (UPJ) obstruction, review the literature, and discuss the advantages of robot assistance in such cases.

METHODS

A 19-year-old man with bilateral congenital UPJ obstruction underwent bilateral simultaneous robotic pyeloplasties at our center. A transperitoneal approach was used with the patient in the lateral decubitus position and with repositioning and redraping between sides. A total of five ports was used: three in the midline, which were used for both sides, and an additional port in the iliac fossa on each side. Three arms of a four-arm da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) were used with four instruments. Antegrade 6F Double-J stents were placed on both sides.

RESULTS

The procedure was completed in a total surgical time of 305 minutes. This included 30 minutes for robot docking/instrument error and 145 and 130 minutes of operating time for the right and left sides, respectively. The blood loss was <30 mL. There were five adverse haptic events: two incorrect suture placements and three suture breakages during knot-tying. The patient developed subcutaneous emphysema on the chest wall that resolved in 6 hours. He was allowed oral intake 6 hours after surgery, ambulated after 14 hours, and was discharged after 38 hours.

CONCLUSIONS

Robotic assistance allows complex bilateral reconstructive laparoscopic operations to be performed in one session.

Survival in second trimester oligohydramnios secondary to bilateral pelviureteral junction obstruction

The extent and onset of obstruction in hydronephrosis determine the varying degrees of renal impairment. Bilateral hydronephrosis, especially in combination with oligohydramnios, is considered a negative predictor for pregnancy outcome. We describe a case of bilateral pelviureteral junction obstruction causing severe oligohydramnios between 25 and 29 weeks of gestation. The prenatal and postnatal findings and treatment are demonstrated. In the presence of bilateral renal impairment and oligohydramnios, our patient had an unfavorable prognosis. The respiratory and renal function, however, were better than expected. We show how urinary tract reconstruction and neonatal intensive therapy can result in an acceptable outcome.

Nonoperative management of neonatal moderate to severe bilateral hydronephrosis

PURPOSE

The natural history of prenatally diagnosed bilateral ureteropelvic junction hydronephrosis is unknown. No definite recommendations exist regarding management, and many authors recommend unilateral or bilateral pyeloplasty. We present the results of nonoperative management of bilateral hydronephrosis.

MATERIALS AND METHODS

A total of 16 patients (32 kidneys) with prenatally diagnosed moderate to severe bilateral hydronephrosis were followed nonoperatively. Pyeloplasty was performed only for evidence of deterioration of function and only unilateral surgery was performed when necessary.

RESULTS

Of the 32 kidneys 31 had moderate or severe hydronephrosis and 4 (12.5%) required pyeloplasty during a mean followup of 36 months. Hydronephrosis spontaneously resolved or improved in 78% of those observed nonoperatively. Of the 25 kidneys followed nonoperatively for at least 2 years 80% demonstrated improvement. While initial drainage half-time was more than 20 minutes in 55% of kidneys, 78% of unoperated kidneys had a final half-time of less than 20 minutes. Of the 10 kidneys with bilateral severe hydronephrosis 3 (30%) required pyeloplasty. All children had normal glomerular filtration rate for age at the latest followup. Only 1 child has persistent bilateral severe hydronephrosis at age 1 year.

CONCLUSIONS

Initial nonoperative observation appears to be safe in all cases of moderate to severe bilateral neonatal hydronephrosis. Spontaneous improvement can be expected in most kidneys by 2 years. Only a few children require unilateral pyeloplasty and bilateral operation can be avoided in most cases.

Outcome based comparison of surgical approaches for pediatric pyeloplasty: dorsal lumbar versus flank incision

PURPOSE

Dismembered pyeloplasty for the correction of ureteropelvic junction obstruction can be performed through a flank or dorsal lumbar incision. We compared the records of children who had undergone pyeloplasty by each approach to determine if 1 technique was more advantageous.

MATERIALS AND METHODS

We retrospectively reviewed the records of 33 consecutive children undergoing simple dismembered pyeloplasty by a single pediatric urologist from 1992 to 1996. The flank approach was used exclusively in the first group of patients who underwent repair in 1992 to 1993 and the dorsal lumbar incision was used exclusively in the second group after 1993. Data were obtained from hospital and clinic records, and both groups were compared with the 2-tailed t test.

RESULTS

Pyeloplasty was done by dorsal lumbar incision in 16 cases and via the flank approach in 17. One patient in each group had undergone simultaneous bilateral pyeloplasties. Although overall comparison of both groups revealed no differences in operative time, in children older than 1 year pyeloplasty through a dorsal lumbar incision (108.5 minutes) was statistically significantly faster than the flank approach (144.4 minutes). Hospital stay was approximately 2 days shorter in infants who had a dorsal lumbar (25.7 hours) versus a flank incision (73 hours), and this difference did reach statistical significance if the bilateral pyeloplasty patients were excluded. Hospital costs were less for the dorsal lumbar group but the difference was not statistically significant. Success and complication rates were similar between groups with 2 patients in each group requiring additional procedures. Review of other series of repair of ureteropelvic junction obstruction demonstrated that the dorsal lumbar repair had equivalent or shorter operative times and lengths of hospitalization compared to newer endoscopic methods, and the outcomes were superior.

CONCLUSIONS

The dorsal lumbar incision is a safe and efficacious approach to pyeloplasty and may be more cost-effective. In our series it was significantly faster in patients older than 1 year and resulted in shorter hospital stays in those younger than 1 year old.

Pyeloplasty in hydronephrosis: examination of surgical results from a morphologic point of view

BACKGROUND

Dilatation of the upper urinary tract is the most common congenital urogenital anomaly. Pyeloplasty is the therapy of choice in those patients with significant obstruction of the ureteropelvic junction. There are not many reports concerning the operative long-term results from a morphologic point of view. Furthermore, little information is available about children with giant hydronephrosis treated without resection of the dilated renal pelvis.

METHODS

Between 1973 and 1993, 231 children with 262 renal units (kidney, renal pelvis, ureter) were treated at our institution. Giant hydronephrosis was observed in 52 renal units. The clinical and follow-up data were obtained from the patients' records. The dilatation of the upper urinary tract, confirmed by means of intravenous pyelogram, was divided into 5 grades.

RESULTS

In 215 renal units, reconstructive surgery was performed without reduction of the renal pelvis. Revision of the pyeloplasty was necessary in 5 of the 215 renal units. The dilatation of the upper urinary tract improved or remained stable in 99.4% of the renal units during the follow-up period of 4.8 years (range, 1 month to 21 years).

CONCLUSION

Surgical reconstruction of the ureteropelvic junction obstruction is a safe and successful procedure. The excision of the dilated pelvis does not seem to be necessary, even in patients with giant hydronephrosis.