Cost-effective treatment for ureteropelvic junction obstruction: a decision tree analysis

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.

Surgical approaches for treatment of ureteropelvic junction obstruction - a systematic review and network meta-analysis

Background

Multiple surgical treatment options are available for the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study is to compare the most frequently used technics in a comprehensive network approach.

Methods

A systematic literature search of the EMBASE, MEDLINE and COCHRANE libraries was conducted in January 2018. Publications were included that evaluated at least two of the following surgical techniques: open pyeloplasty (OP), endopyelotomy (EP), laparoscopic (LP) and robot assisted pyeloplasty (RP). Main outcomes were operative success, complications, urinary leakage, re-operation, transfusion rate, operating time, and length of stay. Network meta-analyses with random effects models simultaneously assessed effectiveness of all surgical techniques.

Results

A total of 26 studies including 3143 patients were analyzed. Compared with RP, EP and LP showed lower operative success rates (EP: OR = 0.09, 95%CI:0.05–0.19; p < 0.001; LP: OR = 0.51, 95%CI:0.31–0.84; p = 0.008). Compared with OP, LP and RP had lower risk for complications (LP: OR = 0.62; 95%CI:0.41–0.95; p = 0.027; RP: OR = 0.41; 95%CI:0.22–0.79; p = 0.007). Compared with RP, no significant differences were detected for urinary leakage or re-operation, transfusion rates. Compared with EP, RP yielded longer operating time (mean = 102.87 min, 95%CI:41.79 min–163.95 min, p = < 0.001). Further significant differences in operating times were detected when comparing LP to EP (mean = 115.13 min, 95%CI:65.63 min–164.63 min, p = < 0.001) and OP to EP (mean = 91.96 min, 95%CI:32.33 min–151.58 min, p = 0.003).

Conclusions

Multiple surgical techniques are available for treatment of UPJO. RP has the highest rates of operative success and as well as LP lower complication rates than OP. Although surgical outcomes are worse for EP, its operating time is shorter than OP, RP, and LP. Surgeons should consider these findings when selecting the optimal treatment method for individual patients.

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%.

[Pyeloplasty: pro laparoscopic]

With increasing experience and availability of the da Vinci® robotic surgery system there has been an extension of the indications from initially exclusively ablative interventions, such as nephrectomy and radical prostatectomy to reconstructive interventions, such as pyeloplasty, bladder augmentation and urinary diversion. Laparocopic pyeloplasty has been established for both adults and children, with results comparable to the open procedure. In comparison the conventional laparoscopic procedure is little cost-intensive and therefore widely used. The available literature has to be analysed to find advantages for the cost-intensive, robot-assisted laparoscopic pyeloplasty from which patients can profit.

Retrograde ureteroscopic holmium laser endopyelotomy in a selected population of patients with ureteropelvic junction obstruction

OBJECTIVE

Significant controversy remains concerning the best way to treat ureteropelvic junction obstruction (UPJO). This study evaluates subjective and objective outcomes of retrograde holmium laser endopyelotomy in a selected population with UPJO.

MATERIAL AND METHODS

Forty-seven patients with UPJO were referred to retrograde endopyelotomy between April 2004 and March 2007. Patients with a very large pelvis, a high insertion of the ureter, a renal split function below 20% or a long (>2 cm) stenosed ureteropelvic segment, and patients younger than 18 years were not selected for endopyelotomy, but subjected to laparoscopic pyeloplasty. Renal function was estimated on renal diuretic scan before and after surgery with a mean renographic follow-up of 35 weeks. Subjective results were based on questionnaires which were returned from 44 patients with primary (n=37) or secondary (n=7) obstruction (mean follow-up 110 weeks). Success criteria were defined as symptom relief and improved or preserved renal function.

RESULTS

Twenty-nine patients (66%) experienced complete symptom resolution and 10 patients (23%) had significant symptom improvement (i.e. no need for pain-killing medication). Five patients (11%) had unchanged symptoms. No difference in postoperative renal function was observed between these three groups of patients. The differences between preoperative and postoperative renal function were non-significant in each group. No major complications were observed. Five patients (11%) were referred to retreatment owing to unchanged symptoms.

CONCLUSION

Retrograde ureteroscopic endopyelotomy is a safe and effective treatment option in patients with primary and secondary UPJO when selected properly.

Comparison of surgical approaches to ureteropelvic junction obstruction: Endopyeloplasty versus endopyelotomy versus laparoscopic pyeloplasty

Several minimally invasive approaches to treatment of ureteropelvic junction obstruction are now in the urologist's armamentarium. This review provides in-depth analysis of endopyelotomy, endopyeloplasty, and laparoscopic pyeloplasty and suggests a treatment algorithm for proper patient selection to improve efficacy and minimize morbidity.

The use of the acucise technique for ureteropelvic junction obstruction: A trade-off between efficacy and invasiveness?

Open pyeloplasty is traditionally the recommended treatment for ureteropelvic junction obstruction. In the past decades, several less invasive procedures emerged with the advantages of lower morbidity and better patient tolerance. In 1993, an electrosurgical cutting balloon device called the Acucise (Applied Medical Resources Corp., Laguna Hills, CA) was introduced. It was presented as a straightforward, safe procedure that can be performed in a complete retrograde fashion under fluoroscopic guidance. Despite these advantages; however, it is not yet a generally excepted procedure. This is mainly due to the fact that specific patient selection is needed, and success rates are comparable with other already established endoscopic procedures. Considering the large variety of minimally invasive procedures available, treatment of choice must be based on several factors such as success rate, morbidity, cost, and surgeon's experience. Acucise is considered a good alternative for the treatment of ureteropelvic junction obstruction in selected patients. However, the efficacy is significantly lower than the reference standard.

FlexGuard: a new laser insertion sheath: functional aspects in ureterorenoscopy (URS)

The evolution of flexible ureteroscopes led to a widespread use for the management of upper urinary tract abnormalities. The cost of purchase, maintenance and the durability of these instruments has become a major issue. This work describes a new device to avoid damages due to incorrect use of the Holmium laser during insertion of the laser fibre. A laser fibre with an optical core of 271 and 430 muicrom outside diameter was slid inside the FlexGuard laser fibre insertion sheath (LISA laser products, Germany). The outside diameter of the sheath measures 2.7 F (0.9 mm) and 2.1 F (0.7 mm) luminal diameter. The distal fibre tip was brought up to a position app. 2 mm inside the distal end of the sheath. The loaded sheath was pushed through the working channel of various ureteroscopes which were in maximum deflection. With the insertion sheath protruding about 2 mm from the distal tip of the URS the fibre was effortless forwarded out of the sheath to approach the stone. Once the laser fibre was in position, the sheath was removed, to increase the volume of irrigation fluid during laser lithotripsy. The radius of curvature (ROC) of the URS in maximum deflection and the integrity of the working channel was investigated. Using the insertion sheath the laser fibre reached the working position without any recognition of scratching or resistance. The integrity of the ureterorenoscopes was checked thoroughly be manually operated manometry. No damage of the inner surface of the working channel occurred. The ROC of the instrument did not change significantly during this procedure. After removal of the sheath the ROC remained stable. With the extended use of ureteroscopy, durability and repair costs are of concern. Damage resulting from incorrect use of laser fibres is a major issue in this respect. FlexGuard proved to avoid this damage in all flexible ureteroscopes investigated without limiting their mobility.

Ureteropelvic Junction Obstruction

PURPOSE

We quantified the burden of ureteropelvic junction obstruction in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

Inpatient hospitalization rates were highest in children younger than 3 years. Most patients were male and hospitalizations occurred almost exclusively at urban centers. Patients with a primary diagnosis of ureteropelvic junction obstruction between 1994 and 2000 had an overall decrease in the age adjusted rate of inpatient hospitalization from 1.1/100,000 to 0.8/100,000. Physician office visits by Medicare beneficiaries with ureteropelvic junction obstruction as the primary diagnosis showed stable overall age adjusted rates during the reported years. Between 1999 and 2003 mean inpatient length of stay and cost per child hospitalized with the primary diagnosis of ureteropelvic junction obstruction was 2.9 days and $7,728, respectively. Average length of stay decreased more for children than for adults but total inpatient spending remained stable at about $12 million.

CONCLUSIONS

The majority of ureteropelvic junction obstructions are diagnosed in the perinatal period. Surgical intervention for pediatric patients has decreased with time, while there has been an increasing trend toward the conservative management of this condition.

Antegrade versus Retrograde Endopyelotomy for Pelvi-Ureteric Junction (PUJ) Obstruction

OBJECTIVES

To compare complication and success rates of antegrade and retrograde endopyelotomy performed over 10 years and to define possible risk factors associated with treatment failure.

METHODS

From 1994 to 2004, 61 patients underwent a total of 68 endoscopic treatments: 19 antegrade and 49 retrograde endopyelotomy procedures. Antegrade endopyelotomy was always performed using diathermy. In the first 18 procedures retrograde endopyelotomy was performed using diathermy. In the most recent 30 procedures the incision was made using holmium laser. Endoluminal ultrasound was used in 78% of retrograde endopyelotomy and in 5% of antegrade endopyelotomy.

RESULTS

The retrograde endopyelotomy patients demonstrated significantly lower complication rates (12.5% vs. 42%) and shorter hospital stay (1.5 vs. 7 days) than the antegrade endopyelotomy patients. The mean follow up of the patients who remained free from disease recurrence during the study period was 46 and 24 months for the antegrade and retrograde endopyelotomy group, respectively. The overall success rate (mean time to failure) of antegrade and retrograde endopyelotomy was 56% (31 months) and 70% (17 months), respectively. There was no statistically significant increase in the overall success rate of retrograde endopyelotomy using endoluminal ultrasound per se. Stratifying retrograde endopyelotomy by the type of energy used for the incision, the overall success rate (mean time to failure) was 80% (10 months) and 53% (21 months) for Holmium laser and diathermy, respectively (p = 0.0626).

CONCLUSIONS

The overall success of antegrade and retrograde endopyelotomy in this series appears to be largely a factor of lead-time bias and is similar enough to recommend retrograde endopyelotomy with holmium laser on the basis of its relative safety and shorter hospital stay.

Laparoscopic pyeloplasty: current status

OBJECTIVE

To review current publications and report our results and long-term follow-up of laparoscopic transperitoneal pyeloplasty for pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

In all, 147 laparoscopic transperitoneal pyeloplasties were performed between August 1993 and November 2000 (mean patient age 35.7 years, range 10-85). All patients were diagnosed with PUJ obstruction by symptoms and intravenous urography, radionuclide diuretic renography or ultrasonography. An Anderson-Hynes dismembered pyeloplasty (106), Y-V plasty (28), Fenger plasty (11) and others (two) were used, according to the intraoperative findings. Twenty-five patients had secondary obstruction, having had previous surgery to the PUJ. The mean (range) follow-up was 24 (3-84) months; all patients were followed clinically and radiologically.

RESULTS

The mean operative duration time was 246 (100-480) min and estimated blood loss was 158 mL. Crossing vessels were identified in 80 cases. The success rate for all, primary and secondary patients was 95%, 98% and 84%, respectively. With one exception, all failures occurred within 6 months. Twenty-one patients (22 renal units) had simultaneous laparoscopic pyeloplasty and lithotomy; they were treated successfully and all have an intact PUJ, and 20 renal units (90%) were stone-free. The overall complication rate was 8.8%.

CONCLUSIONS

This series has comparable success rates to those of open pyeloplasty and the morbidity was minimal. Laparoscopic pyeloplasty may soon become the standard operation for PUJ obstruction, especially with crossing vessels.

Cost analysis of flexible ureterorenoscopy

OBJECTIVE

To assess the costs of flexible ureterorenoscopy.

MATERIALS AND METHODS

Data were collected prospectively for 100 cases using a new flexible ureteroscope (DUR8, Circon ACMI, Stamford, USA), including the indications for flexible ureterorenoscopy, use of laser probes, disposable instrumentation, and the cost and timing of ureteroscope repair.

RESULTS

Of the 100 procedures 68 were for stone disease, 21 for known or suspected transitional cell carcinoma (TCC), six were diagnostic only and five were for pelvi-ureteric junction obstruction. The ureteroscope was repaired after the 29th and 88th cases. The ability of the ureteroscope to deflect was maintained throughout. At the time of purchase the ureteroscope was listed at pound 15 000 and each repair/exchange currently costs pound 4200, thus the total expenditure on the ureteroscope was pound 23 400. Total expenditure on ancillary equipment was pound 28 727, of which pound 22 927 was on disposables and pound 5800 on 10 laser probes.

CONCLUSION

In this series the costs of the ancillary equipment exceeded the purchase and maintenance of the ureteroscope, and we expect this trend to continue in the long term. The advent of more durable ureteroscopes may ultimately reduce the frequency of costly repairs. The cost of disposables should be considered in planning the budget.

Ureteropelvic junction obstruction repair: when, how, what?

PURPOSE OF REVIEW

To review factors that affect the success of ureteropelvic junction obstruction repair and recent developments in minimally invasive procedures for the repair of ureteropelvic junction obstruction.

RECENT FINDINGS

Recent reports and studies further confirm earlier findings that the success rate of endopyelotomy is decreased when a crossing vessel is the primary cause of ureteropelvic junction obstruction, poor renal function and significant hydronephrosis. Various minimally invasive procedures have emerged recently for the treatment of ureteropelvic junction obstruction. These include laparoscopic pyeloplasty, robotically assisted laparoscopic procedures, and percutaneous endopyeloplasty. These procedures offer potential advantages over conventional endopyelotomy, including better success rates in the presence of crossing vessels, wider caliber reconstruction of the ureteropelvic junction, and full-thickness healing with primary intent.

SUMMARY

With such a large variety of minimally invasive procedures for the treatment of ureteropelvic junction obstruction available, the treatment choice for ureteropelvic junction obstruction must be based on several factors, including the success and morbidity of the procedures, the surgeon's experience, the cost of the procedure, and the patient's choice.

Acucise™ endopyelotomy in a porcine model: procedure standardization and analysis of safety and immediate efficacy

PURPOSE

The study here presented was done to test the technical reliability and immediate efficacy of the Acucise device using a standardized technique.

MATERIALS AND METHODS

56 Acucise procedures were performed in pigs by a single surgeon who used a standardized technique: insert 5F angiographic catheter bilaterally up to the midureter, perform retrograde pyelogram, Amplatz super-stiff guidewire is advanced up to the level of the renal pelvis, angiographic catheters are removed, Acucise catheter balloon is advanced to the ureteropelvic junction (UPJ) level, the super-stiff guide-wire is removed and the contrast medium in the renal pelvis is aspirated and replaced with distilled water, activate Acucise at 75 watts of pure cutting current, keep the balloon fully inflated for 10 minutes, perform retrograde ureteropyelogram to document extravasation, remove Acucise catheter and pass an ureteral stent and remove guide-wire.

RESULTS

In no case did the Acucise device present malfunction. The electrocautery activation time was 2.2 seconds (ranging from 2 to 4 seconds). The extravasation of contrast medium, visible by fluoroscopy, occurred in 53 of the 56 cases (94.6%). In no case there was any evidence of intraoperative hemorrhage.

CONCLUSIONS

This study revealed that performing Acucise endopyelotomy routinely in a standardized manner could largely preclude intraoperative device malfunction and eliminate complications while achieving a successful incision in the UPJ. With the guidelines that were used in this study, we believe that Acucise endopyelotomy can be completed successfully and safely in the majority of selected patients with UPJ obstruction.

Cost-effective laparoscopic pyeloplasty: Single center experience

OBJECTIVE

Laparoscopic pyeloplasty (LPP) is a minimally invasive treatment option for ureteropelvic junction (UPJ) obstruction. We report here our experience of performing cost-effective LPP on 24 patients at a single center.

METHODS

Between October 1999 and March 2002, LPP was performed in 24 patients (17 male, seven female; age range 8-51 years) including two patients who had failed previous endourologic treatments. In two patients with concomitant renal stones, laparoscopic pyelolithotomy was also performed. LPP was conducted in a cost-reductive manner by both transperitoneal (n = 12) and retroperitoneal (n = 12) access. To reduce the cost, an indigenous balloon to create the retroperitoneal space, reusable ports, ordinary polyglactin suture and intracorporeal free-hand suturing were employed. To reduce operative time, antegrade stenting was also performed in some cases.

RESULTS

Laparoscopic Anderson-Hynes pyeloplasty was performed in 16, Foley Y-V pyeloplasty in five and Fenger pyeloplasty in three patients. One patient required conversion to open surgery due to tension at the anastomosis site during Anderson-Hynes pyeloplasty. The mean operating time, blood loss, analgesic (pethidine) requirement, duration of drain and hospital stay for the retroperitoneal and transperitoneal groups were 170.3 and 187.6 min, 102.2 and 145.9 mL, 125 and 136.4 mg, 2.1 and 2.5 days, and 3.4 and 4.3 days, respectively. No significant complications were encountered apart from prolonged ileus in three patients in the transperitoneal group. The mean follow-up period was 10.8 months with a range of 2-24 months. Postoperative renal scan was performed at 3 months in 21 patients, and 1 year in 11 patients. There was evidence of equivocal obstruction in one patient, but there were no obstructions in the remaining patients.

CONCLUSION

Although LPP is technically demanding, it is emerging as a viable, minimally invasive alternative to open pyeloplasty for UPJ obstruction with a success rate similar to that of open pyeloplasty. It allows the duplication of open surgery steps (unlike endoscopic procedures), thereby providing durable and sustained results. LPP can also be performed safely, effectively and efficiently in a cost-efficient manner.