The role of endourological techniques in the treatment of the pediatric ureteropelvic junction

Endopyelotomy versus redo pyeoloplasty for management of failed pyeloplasty in children: A single center experience

PURPOSE

We compared endopyelotomy to redo pyeloplasty for the treatment of failed pyeloplasty in children to identify factors that may have an impact on outcome and favor one procedure over the other.

METHODS

Of 43 patients with recurrent UPJO, EP was performed in 27 and RP was performed in 16. Age, gender, side, presentation of secondary UPJO, hospital stay, complications and success rates were compared. Success was defined as radiographic relief of obstruction as determined by ultrasound or diuretic renography at latest follow-up.

RESULTS

Mean (Range) patient age was 7.2 years (range 6 months to 17 years) in EP (group 1) while 7.4 (range 6 months to 17 years) in RP (group 2). EP technique consisted of retrograde cold-knife in 17 patients, retrograde holmium laser in 8 and antegrade cold-knife in 2. RP was performed in 16 patients. All the patients with failed EP had a stricture greater than 15 mm. Mean length of the narrowed ureteral segment was 17.8 mm in the failed EP group vs 10 mm in the successful group (p < 0.001). Mean Hospital stay was 1 day for the EP group and 5 days for the RP group (p < 0.001). Mean follow-up was 17 months (range 12 to 43) after EP and 21 months (12 to 51) after RP. There was no statistical significance between both groups regarding the postoperative degree of hydronephrosis, parenchymal thickness, split renal functions and renal drainage. The overall success was (86%); the success was nonsignificantly higher in RP (93.8%) vs (81.5%) in EP.

CONCLUSION

In selected children, retrograde endopyelotomy is safe and may give comparable short-term outcomes as open redo pyeloplasty for correction of secondary UPJO after failed pyeloplasty. Narrowed ureteral segment greater than 15 mm and preoperative grade 4 hydronephrosis were factors significantly associated with a poor outcome after EP.

A LEVEL-OF-EVIDENCE RATING FOR CLASSIFYING STUDY QUALITY

LEVEL III Retrospective comparative study.

Endopyelotomy for pediatric ureteropelvic junction obstruction: a review of our 25-year experience

PURPOSE

We elucidate the role of endopyelotomy as a primary and secondary intervention for ureteropelvic junction obstruction in children.

MATERIALS AND METHODS

We retrospectively identified 79 pediatric patients who underwent endopyelotomy for ureteropelvic junction obstruction between 1986 and 2011. Eleven patients were lost to followup and were excluded from analysis. Patient demographics, operative information, complications and success rates were reviewed for the remaining 68 patients. Treatment success was defined as the absence of symptom recurrence and improved radiographic features on ultrasound, computerized tomography, diuretic renogram or excretory urogram at most recent followup.

RESULTS

Primary endopyelotomy data were analyzed in 37 patients with a median age of 11.1 years. The success rate was 65% at a median followup of 34 months (range 1.5 to 242). Treatment failure occurred in 13 patients with a median time to failure of 8 months (range 1.5 to 131). There were 8 cases of failure during 12 months of surgery. Secondary endopyelotomy data were analyzed in 31 patients with a median age of 6.5 years. The success rate was 94% at a median followup of 61 months (range 1 to 204). Treatment failure occurred in 2 patients at 1 and 6 months. Approximately two-thirds of all procedures used an antegrade approach.

CONCLUSIONS

Primary endopyelotomy is significantly less successful than pyeloplasty in the treatment of ureteropelvic junction obstruction in pediatric patients. However, secondary endopyelotomy following failed pyeloplasty represents a viable alternative to redo pyeloplasty.

Reconstructive surgery of the upper urinary tract

This paper reviews the major publications over the past year regarding upper urinary tract reconstruction. Controversies in the diagnosis of ureteropelvic junction obstruction and in the surgical repair of the obstructed upper urinary tract are discussed. Special emphasis is placed on issues surrounding minimally invasive techniques.

Pediatric ureteroscopy

Endoscopic evaluation and management of the diverse conditions involving the upper urinary tract of children is now feasible and has been shown to be safe and efficacious. This modality should be considered an essential part of the armamentarium of any urologist involved in the care of children. Continued technological advances will allow the indications for pediatric ureteroscopy to evolve. The benefits of minimally invasive surgery that have been proved in adult patients can now be offered to pediatric patients. A thorough knowledge of available equipment and the anatomic and physiologic differences of pediatric patients will ensure a successful outcome with minimal morbidity.

Long-term followup of pediatric dismembered pyeloplasty: how long is long enough?

PURPOSE

We determined followup for pediatric patients after pyeloplasty based on the risk of late complications and the likelihood of return if discharged early from followup.

MATERIALS AND METHODS

We retrospectively reviewed the charts of all patients who underwent dismembered pyeloplasty at a single center between 1986 and 1996. Data regarding recurrent ureteropelvic junction obstruction and symptoms suggesting possibly recurrent obstruction were assessed.

RESULTS

During the select period 123 pyeloplasties were performed. A total of 77 renal units were followed greater than 5 years. At 1 year postoperatively diuretic renograms showed normal drainage in 87% of the cases and prolonged or incomplete drainage in 13%. Obstruction recurred 8 years postoperatively in only 1 renal unit (0.8% overall, 1.3% of those followed greater than 5 years). Symptoms suggestive of recurrent obstruction developed in 18% of the patients but represented true recurrence in only 1. If one were to consider early followup discharge for these patients, the probability of repeat referral due to such symptoms was significantly higher in year 1 than in year 3. Most symptoms were initially assessed with ultrasound.

CONCLUSIONS

Recurrent ureteropelvic junction obstruction is unlikely after unobstructed postoperative diuretic renogram and does not warrant long term followup. Ideal followup would extend to 2 years, covering the period when an initial symptom of recurrence is most likely to present and enabling baseline unobstructed renal ultrasound to be performed.

Strategies for managing upper tract calculi in young children

PURPOSE

Pediatric urolithiasis is relatively uncommon and there is little information on the application of modern surgical procedures in young children. We present a single center experience with the surgical management of upper tract calculi in this age group.

MATERIALS AND METHODS

We reviewed presentation, co-morbidity, treatment, outcome and complications in all prepubertal patients who required surgical treatment for ureteral or renal calculi during a 4-year period. The series consists of 24 girls and 17 boys 17 months to 14 years old (mean age 7.5 years). A total of 26 children were anatomically normal, and 4 had myelomeningocele, 4 had ureteropelvic junction obstruction (in a pelvic kidney in 1), 2 had cloacal anomalies, 2 had vesicoureteral reflux, and 1 each had nonrefluxing megaureter, orthotopic ureterocele and a functioning renal transplant.

RESULTS

Extracorporeal shock wave lithotripsy was performed in 24 patients. Stents or nephrostomy tubes were only used in the 4 patients who presented with pyonephrosis. Of the 41 cases 17 were rendered stone-free, 3 had a decreased stone burden and 4 were failures. Ureteroscopic extraction of distal ureteral calculi was successful in 11 of 12 children, of whom the youngest was 2.5 years old. No child had postoperative infection or evidence of ureteral obstruction. Stent placement facilitated stone passage or dissolution in 2 patients, a renal calculus was percutaneously extracted in 2 and 7 required open surgery, mostly for correcting simultaneous anatomical abnormalities or after minimally invasive surgery failed. Some metabolic abnormality was detected in 80% of the children tested.

CONCLUSIONS

The surgical management of upper urinary tract calculi in young children parallels that in adults. Minimally invasive surgical methods may be safely used even in young infants. Most children do not need elective stenting before lithotripsy. Open procedures are still required in 17% of cases. The majority of children have definable metabolic abnormalities.

Strategies for managing upper tract calculi in young children

PURPOSE

Pediatric urolithiasis is relatively uncommon and there is little information on the application of modern surgical procedures in young children. We present a single center experience with the surgical management of upper tract calculi in this age group.

MATERIALS AND METHODS

We reviewed presentation, co-morbidity, treatment, outcome and complications in all prepubertal patients who required surgical treatment for ureteral or renal calculi during a 4-year period. The series consists of 24 girls and 17 boys 17 months to 14 years old (mean age 7.5 years). A total of 26 children were anatomically normal, and 4 had myelomeningocele, 4 had ureteropelvic junction obstruction (in a pelvic kidney in 1), 2 had cloacal anomalies, 2 had vesicoureteral reflux, and 1 each had nonrefluxing megaureter, orthotopic ureterocele and a functioning renal transplant.

RESULTS

Extracorporeal shock wave lithotripsy was performed in 24 patients. Stents or nephrostomy tubes were only used in the 4 patients who presented with pyonephrosis. Of the 41 cases 17 were rendered stone-free, 3 had a decreased stone burden and 4 were failures. Ureteroscopic extraction of distal ureteral calculi was successful in 11 of 12 children, of whom the youngest was 2.5 years old. No child had postoperative infection or evidence of ureteral obstruction. Stent placement facilitated stone passage or dissolution in 2 patients, a renal calculus was percutaneously extracted in 2 and 7 required open surgery, mostly for correcting simultaneous anatomical abnormalities or after minimally invasive surgery failed. Some metabolic abnormality was detected in 80% of the children tested.

CONCLUSIONS

The surgical management of upper urinary tract calculi in young children parallels that in adults. Minimally invasive surgical methods may be safely used even in young infants. Most children do not need elective stenting before lithotripsy. Open procedures are still required in 17% of cases. The majority of children have definable metabolic abnormalities.