Ureteroscopic laser approach in recurrent ureteropelvic junction stenosis

Evaluation of the results of laser endopyelotomy with two different technique in ureteropelvic junction obstruction

INTRODUCTION

Failed pyeloplasty procedures are caused by large amounts of scarring, and peripelvic fibrosis. This finding has been associated with urinary extravasations to the operation, urosepsis or an excessive tissue reaction. The treatment options for secondary UPJO (Ureteropelvic Junction Obstruction) are the same with the options for primary procedures: in cases of very poor renal function, various pyeloplasty forms (open and laparoscopic), and ureterocalicostomy or sometimes nephrectomy may be considered in severe renal function loss. Whereas, endoscopic treatment can be considered in elective cases.

STUDY DESIGN

A total of 46 young patients who underwent endopyelotomy due to secondary ureteropelvic obstruction between January 2013 and September 2018 were included in the study. Patients underwent semirigid URS (Ureterorenoscopy) guided laser endopyelotomy until July 2015, and the patients had flexible URS guided laser endopyelotomy since July 2015.

RESULTS

The mean age of the patients was found as 17.7 ± 4.2 and 16.9 ± 5.7 years in the SURSLE (Semirigid Ureterorenoscopy Laser Endopyelotomy), and FURSLE (Flexible Ureterorenoscopy Laser Endopyelotomy) groups, respectively. Success of the procedure was confirmed in 20 (83%) patients in the SURSLE group, and 19 (86%) patients in the FURSLE group who had no obstructive symptoms based on USG, GFR and excretion curves on the renogram ordered in the 24th month. Four (16%) patients in the SURSLE group, and 3 (14%) patients in the FURSLE group were accepted as failed, their treatments were arranged for additional surgical procedures, and these patients were taken under the follow-up protocol.

DISCUSSION

This is one of the first studies comparing endopyelotomy with semirigid URS and flexible URS in patients with ureteropelvic stenosis. Long-term results with a large series of patients are not known, and our approach can be considered only as an individual method. There are different treatment options in UPJO. The use of fluoroscopy has advantages in endourologic operations. Therefore, lower radiation exposure can be a rational approach for protecting a person. Similarly, providing necessary protection also for physicians and operating room personnel is essential. In our study, shorter fluoroscopy time with SURSLE provided an advantage over FURSLE in terms of radiation exposure.

CONCLUSION

Of semirigid and flexible URS techniques that have no superiority over each other in terms of success, preferring semi-rigid URS guided laser endopyelotomy with lower ionizing radiation used, is more rational.

Concomitant management of renal calculi and recurrent ureteropelvic junction obstruction with percutaneous nephrolithotomy and antegrade balloon dilation

Objective

This study aimed to present our experience of concomitant management of renal calculi and recurrent ureteropelvic junction obstruction (UPJO) with percutaneous nephrolithotomy (PCNL) and antegrade balloon dilation.

Methods

We retrospectively reviewed 31 patients who underwent PCNL and antegrade balloon dilation for treatment of renal calculi and recurrent UPJO. The inclusion criterion was the presence of UPJO after failed pyeloplasty with ipsilateral renal calculi. Success was defined as achievement of both symptomatic and radiographic resolution of any stones and obstruction.

Results

All operations were successful without grade III or higher postoperative complications. A stone-free status was observed in all patients and the overall success rate of the procedure was 87.1% (27/31). The success rate of the procedure was significantly higher in patients with mild or moderate preoperative hydronephrosis (96%) than in those with high-grade preoperative hydronephrosis (50%). Moreover, the success rate of the procedure was lower in patients with poor preoperative renal function (0%) than in those with good or moderate renal function (93.1%).

Conclusion

Combined PCNL and antegrade balloon dilation management represents a safe and effective approach for patients with renal calculi and recurrent UPJO after failed pyeloplasty.

Retrograde intrarenal surgery: Past, present, and future

With the recent technological advancements in endourology, retrograde intrarenal surgery has become a more popular procedure for treatment of urolithiasis. Furthermore, since the introduction of new laser systems and advanced flexible ureteroscopy with miniaturized ureteroscopes, the treatment indications for retrograde intrarenal surgery have expanded to include not only larger renal stones of >2 cm but also upper urinary tract urothelial carcinoma, ureteral stricture, and idiopathic renal hematuria. Clinicians must keep up with these trends and make good use of these technologies in the rapidly changing field of endourology. Simultaneously, we must consider the risk of various complications including thermal injury due to laser use, ureteral injury caused by the ureteral access sheath, and radiation exposure during retrograde intrarenal surgery with fluoroscopic guidance. This review focuses on the past, present, and future of retrograde intrarenal surgery and provides many topics and clinical options for urologists to consider.

Factors affecting the effectiveness and success of retrograde holmium laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults

PURPOSE

To evaluate the factors affecting the effectiveness, safety, and success of retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults.

METHODS

Adult patients who underwent retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction between January 2012 and June 2016 at our clinic were retrospectively analyzed. Success was defined as the relief of symptoms and the resolution of obstruction, as assessed via radiography. Factors affecting success were analyzed, such as the clinical characteristics, procedural outcomes, complications, and the type of ureteroscopy used in the procedure.

RESULTS

Procedural success was achieved in 29 (74.4%) out of 39 patients, with a mean age of 38.3 ± 12.3 years during a median follow-up duration of 44 (33-65) months. Failure occurred at a median of 4.5 (3-22) months. It was detected that the presence of primary obstruction, ipsilateral kidney function being >30% of normal, and the length of obstruction being <1 cm positively affected procedural success (p = 0.009, p = 0.011, and p = 0.019, respectively). In the postoperative period, two Grade I and four Grade II complications were observed according to the Clavien-Dindo classification. There was a difference only in the operation time between semirigid (24) and flexible ureteroscopes (15), with the operation time being shorter with the use of a semirigid ureteroscope than with the use of a flexible uteroscope (p < 0.001).

CONCLUSION

Retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy is a minimally invasive method that can be used effectively and safely as the primary treatment of patients with ureteropelvic obstruction, when long-term results are also taken into consideration. The decision of performing laser endopyelotomy should be made after a detailed evaluation of the characteristics of the patient as well as of the obstruction.

Laser Endopyelotomy in the Management of Pelviureteric Junction Obstruction in Adults: A Systematic Review of the Literature

Laser endopyelotomy (LEP) is considered as an option for the treatment of pelviureteric junction obstruction in adults. A comprehensive systematic search of the published literature was performed to assess the success rate and perioperative complications of LEP in the treatment of primary and secondary pelviureteric junction obstruction and to identify the factors that may have an impact on the success of LEP. The evidence available has significant limitations in terms of the heterogeneous study design and the definitions of outcomes. The average overall success rate of the pooled data was 75% with a mean follow-up of 29 months. Complications were predominately minor with an average rate of 12.5%.

Laser endoureterotomy and endopyelotomy: an update

PURPOSE

Although minimally invasive approach is one of the first-line treatment choices for ureteral strictures, there are still controversies on the ideal method to treat this entity. The objective of this update was to define the level of evidence around endoscopic treatment of ureteropelvic junction (UPJ) and ureteral strictures.

METHODS

We reviewed the current available literature on the PubMed database from the last decade up to May 2014 on laser endoureterotomy and endopyelotomy.

RESULTS

The level of evidence for the endoscopic treatment of UPJ and ureteral strictures is low. Despite this, it appears that endoureterotomy and endopyelotomy performed mainly with Ho:YAG laser achieve good success rates with minimal perioperative morbidity.

CONCLUSIONS

Laser endoureterotomy and endopyelotomy should be considered a reasonable treatment option in selected patients.

[Transumbilical single-incision laparoscopic ureterolithotomy]

INTRODUCTION

laparoendoscopic single-site surgery (LESS) using transumbilical access and conventional laparoscopic instruments is a very attractive alternative to perform ureterolithotomy for ureteral stone with failed endourological management.

MATERIAL AND METHOD

a 29-year-old woman presented with chronic right lumbar pain and a 1.2 cm impacted calculus localized at transition of abdominal to pelvic ureter. Semi-rigid ureteroscopy had failed to fragment the stone and shockwave lithotripsy was not available. Double-J ureteral catheter had been inserted preoperatively. We performed a transumbilical single-incision laparoscopic ureterolithotomy. Three conventional trocars were inserted in a single semi-circular umbilical incision. Right colon was detached and the ureter was identified. Calculus was extracted and the ureteral incision was closed with intracorporal sutures.

RESULTS

ureterolithotomy was successfully completed, with all the operative steps performed transumbically. Operative time was 180 minutes. No single-port device or articulating and bent instruments were utilized. Estimated blood loss was less than 50 mL. No intraoperative, access-related and postoperative complications took place. The duration of hospitalization was 24 hours and scarless appearance was observed on postoperative day 15.

CONCLUSION

transumbilical single-incision laparoscopic ureterolithotomy is feasible and safe. This approach offers an inherent cosmetic advantage and few postoperative discomfort. Additional experience and continued investigation are warranted.

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.