Intermediate Term Outcomes Associated With the Surveillance of Ureteropelvic Junction Obstruction in Adults

Ureteropelvic junction obstruction and renal calculi: Simultaneous treatment by robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy. Technique description and early outcomes

BACKGROUND

Ureteropelvic junction obstruction (UPJO) and renal calculi are associated in 20 to 30% of cases and treatment is mandatory. The simultaneous surgical management is a therapeutic challenge that is still a source of controversy. We describe our technique combining robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy (fURS), assessing the feasibility of simultaneous treatment through an original technique.

METHODS

This single centre series reports our initial experience with 12 patients. From January 2014 to September 2018, 12 patients underwent robot-assisted laparoscopic pyeloplasty with simultaneous fURS for UPJO and renal calculi. Mean age was 46 years (24-68). 92% had multiple renal stones and the mean cumulative stone diameter was 31,3mm. Robot-assisted pyeloplasty was performed with peroperative transcutaneous retrograde fURS through a ureteral access sheath introduced in an incision on the bassinet through a subcostal trocar. Stone extraction was performed using a basket.

RESULTS

All patients underwent surgery successfully, achieving UPJ repair and complete stone extraction. Mean operating time was 92,5min (85-110). All reported Clavien-Dindo complications were grade 1. Non-contrast enhanced abdominal CT performed 1 month after surgery confirmed the absence of residual stones in all patients. Mean follow-up time was 10 months with no recurrence of UPJO.

CONCLUSION

This small series confirms the feasibility with good surgical results of concomitant robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde fURS stone extraction. No major complications were observed. This technique is easily reproducible but requires 2 experienced urologists to be achieved in a contained operative time.

The Utility of Radiologic and Symptomatic Surveillance After Minimally-invasive Adult Pyeloplasty

OBJECTIVE

To evaluate different types of failure after minimally-invasive pyeloplasty (MIP) when stratified by initial radiologic study and symptoms after ureteral stent removal.

METHODS

We retrospectively reviewed adults who underwent MIP (1996-2019) at a single academic center. Patients with at least 11 months of follow-up and patients who had a Mag3 scan as their initial postoperative imaging were included. Postprocedure, patients were categorized as having normal, equivocal, or obstructed imaging based on their initial radiologic test. Patients who were obstructed were excluded. Primary outcome was procedural failure, defined as the need for a procedure to treat recurrent obstruction. Secondary outcomes were radiologic failure and symptomatic failure. Groups were compared to assess for statistical significance (P <.05).

RESULTS

Overall, 122 patients met inclusion criteria. On initial postoperative imaging, 108 (89%) patients had no obstruction and 14 (11%) had equivocal findings. The procedural failure rate was 6.5% in the unobstructed group and 28.6% in the equivocal group (P = .023). Seven unobstructed patients (6.5%) and 2 equivocal patients (14.3%) eventually experienced radiologic failure (P = .275). Among patients who had no obstruction on initial imaging and remained asymptomatic, only one (0.9%) required a salvage procedure.

CONCLUSION

Recurrent obstruction after pyeloplasty varied based on the outcome of the initial radiologic study. These rates can be used to counsel patients and guide physicians' choice of surveillance schedules. The risk of future failure is very low in asymptomatic patients with normal initial imaging. The utility of routine radiologic surveillance in these patients may be limited.

Comments on a case of ureteropelvic junction obstruction with late progression in an adult female

INTRODUCTION

Ureteropelvic junction obstruction is a pathology typically diagnosed in childhood. Nevertheless, some clinically silent cases may be unnoticed until adulthood.

CASE DESCRIPTION

We report the case of a 53-year-old female with hydronephrosis due to ureteropelvic junction stenosis diagnosed in the adulthood, who subsequently developed obstruction with progressive worsening of renal function without symptoms.

CONCLUSION

The natural history of ureteropelvic junction obstruction is still obscure. Diuretic renogram is the gold standard for diagnosis and follow-up of ureteropelvic junction obstruction, but is weak in predicting the evolution of the disease, especially in patients with vague symptoms. Conservative treatment of adult patient with equivocal ureteropelvic junction obstruction seems reasonable, but requires a close clinical follow-up and strict patient compliance in order to promptly identify significant obstruction.

Risk Factors and Management Options for the Adult Failed Ureteropelvic Junction Obstruction Repair in the Era of Minimally Invasive and Robotic Approaches: A Comprehensive Literature Review

Guidelines for the management of pyeloplasty failure remain elusive given the rarity of this condition and the difficulty of integrating and analyzing reported outcomes given the varying definition of failures. In this article, we aim to review the existing literature on risk factors that may influence the surgical outcomes of reconstructive pyeloplasty for ureteropelvic junction obstruction. Furthermore, we discuss management options and review success outcomes of treatment options for patients with pyeloplasty failure.

Delayed renal tissue tracer transit in Tc-99m-DTPA renography correlates with postoperative renal function improvement in UPJO patients

OBJECTIVE

The aim of the study was to explore the potential parameters for evaluating the improvement in relative renal function (RRF) in patients with unilateral ureteropelvic junction obstruction (UPJO) who underwent surgery. In this regard we observed the RRF expressed as the obstructed kidney's percentage contribution to overall renal function in technetium-99m diethylenetriaminepentaacetic acid (Tc-99m-DTPA) diuretic renography.

MATERIALS AND METHODS

Data on 47 patients, who underwent Anderson-Hynes pyeloplasty for diagnosed unilateral UPJO during the period of February 2003 to October 2014, were retrospectively collected. Tc-99m-DTPA diuretic renography was performed on all patients before and after surgery, and no morphological or functional abnormalities were detected on the contralateral kidney. Several parameters, especially renal tissue tracer transit (TTT), the response to furosemide stimulation, and RRF, were evaluated. All data were analyzed with the statistical software SPSS, 17.0, and a value of P less than 0.05 was considered statistically significant.

RESULTS

Data on 42 patients were eventually retained for further analysis; five patients were excluded because of indeterminate TTT. All patients showed obstructive response to furosemide stimulation with a preoperative RRF of 41±12%. Postoperative RRF of the obstructed kidneys was 47±11%, significantly higher than the preoperative RRF (P<0.05). Postoperative RRF improvement (absolute increment≥5%) was seen in 18/42 (43%) patients, and 24/42 (57%) of them manifested with postoperative drainage improvement. After surgery, both the RRF increment and the percentage of patients with postoperative RRF improvement in the preoperative delayed TTT group were significantly higher than those in the normal TTT group (12±7 vs. 2±4%, and 81 vs. 19%, respectively; P<0.05), but no significant difference in postoperative drainage improvement was detected between the two groups (56 vs. 54%, P>0.05). None of the other factors, including the preoperative RRF, obstructed kidney location, surgical method, sex, and age, had a significant influence on postoperative RRF improvement (P>0.05).

CONCLUSION

Preoperatively delayed TTT of Tc-99m-DTPA diuretic renography was an independent factor that correlated with RRF improvement of unilaterally hydronephrotic kidneys, and might provide valuable information for surgical decisions pertaining to UPJO patients.