1
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Högberg L, Värelä S, Anderberg M, Salö M. Sex differences in children operated with pyeloplasty for pelvoureteric junction obstruction. Pediatr Surg Int 2023; 39:270. [PMID: 37682361 PMCID: PMC10491548 DOI: 10.1007/s00383-023-05543-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Pelvoureteric junction obstruction (UPJO) is a common cause of hydronephrosis in children but no previous studies have evaluated differences between boys and girls operated with pyeloplasty. This study aimed to evaluate potential differences between sexes in children operated with pyeloplasty for PUJO in terms of presentation, surgery, and long-term results. METHODS Data was retrospectively collected from all children operated on with pyeloplasty between January 2002 and December 2020. Data contained several variables covering presentation, surgery, and long-term results. RESULTS In total, 194 patients were included of which 126 (64.9%) were boys. There were no significant differences in prenatal findings, pelvic dilation on ultrasound, function of the affected kidney, surgical method, obstruction type, resolution of hydronephrosis, or improvement of function. Boys presented with pain more often than girls (47.4 vs 25.0%, p < 0.01) while girls were more prone to infections preoperatively (17.2 vs 7.0%, p = 0.04). All nine patients requiring reoperation were boys (p = 0.03). CONCLUSION Girls with UPJO seem to experience infections as presenting symptoms more often than boys, while boys significantly more often present with pain. There is also a higher percentage of boys needing reoperation.
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Affiliation(s)
- Linnea Högberg
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Sanni Värelä
- Department of Clinical Sciences, Pediatrics, Lund University, Lasarettsgatan 48, 221 85, Lund, Sweden
- Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - Magnus Anderberg
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Pediatrics, Lund University, Lasarettsgatan 48, 221 85, Lund, Sweden
| | - Martin Salö
- Department of Pediatric Surgery, Skåne University Hospital, Lund, Sweden.
- Department of Clinical Sciences, Pediatrics, Lund University, Lasarettsgatan 48, 221 85, Lund, Sweden.
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2
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Kim JK, Keefe DT, Rickard M, Milford K, Lorenzo AJ, Chua ME. Vascular hitch for paediatric pelvi-ureteric junction obstruction with crossing vessels: institutional analysis and systematic review with meta-analysis. BJU Int 2021; 129:679-687. [PMID: 33463000 DOI: 10.1111/bju.15342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/05/2021] [Accepted: 01/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the outcomes for laparoscopic vascular hitch (VH) and dismembered pyeloplasty in patients with pelvi-ureteric junction obstruction (PUJO) secondary to crossing vessels (CV). PATIENTS AND METHODS Patients who underwent laparoscopic management of CV at our institution were identified between 2008 and 2020. Baseline characteristics and outcome measures were compared between those who underwent VH and those who underwent dismembered pyeloplasty. Those who underwent VH were selected intraoperatively by identifying CV in the absence of intrinsic obstruction by assessing resolution of hydronephrosis after cranially displacing the CV away from the PUJ, followed by intraoperative fluid bolus and diuretic test. In addition, a systematic search and meta-analysis were performed in June 2020 (International Prospective Register of Systematic Reviews [PROSPERO] ID CRD42020195833). RESULTS A total of 20 patients underwent VH and 74 dismembered pyeloplasty. On multivariate analysis, VH was associated with: shorter operative time (P = 0.001; odds ratio [OR] 0.455, 95% confidence interval [CI] 0.294-0.705) and length of stay (P = 0.012; OR 0.383, 95% CI 0.183-0.803), lower use of stents (P < 0.001; OR 0.024, 95% CI 0.004-0.141) and opioid administration (P = 0.005; OR 0.157, 95% CI 0.044-0.567). From our literature search, 194 records were identified and 18 records were included (three comparative and 16 non-comparative). Meta-analysis of the comparative studies and our institutional data showed similar success rates (relative risk [RR] 1.77, 95% CI 0.33-9.52) and complication rates (RR 0.75, 95% CI 0.20-2.82). VH was associated with shorter operative time (standardised mean difference [SMD] -1.65, 95% CI -2.58 to -0.72 h) and hospital stay (SMD -1.41, 95% CI -2.36 to -0.47 days). The VH success rates ranged from 87.5% to 100% in the identified studies. Failure of VH was associated with unrecognised concomitant intrinsic obstruction in addition to CV. CONCLUSIONS A VH, for well-selected patients with CV without concomitant intrinsic obstruction, offers a high success rate with shorter operative times.
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Affiliation(s)
- Jin K Kim
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Daniel T Keefe
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mandy Rickard
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Karen Milford
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Armando J Lorenzo
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael E Chua
- Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Urology, St. Luke's Medical Center, Quezon City, NCR, Phillipines
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3
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Kohno M, Ogawa T, Kojima Y, Sakoda A, Johnin K, Sugita Y, Nakane A, Noguchi M, Moriya K, Hattori M, Hayashi Y, Kubota M. Pediatric congenital hydronephrosis (ureteropelvic junction obstruction): Medical management guide. Int J Urol 2020; 27:369-376. [PMID: 32162424 DOI: 10.1111/iju.14207] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/27/2020] [Indexed: 02/07/2023]
Abstract
The prevalence of asymptomatic hydronephrosis, now detected by ultrasonography, has increased. However, definitive management guidelines for the management of congenital hydronephrosis have not been established. The Japanese Society of Pediatric Urology created a "medical management guide" based on new findings for physicians practicing pediatric urology. We developed a medical management guide focused on congenital hydronephrosis caused by ureteropelvic junction obstruction. This medical management guide consists of the definition, pathophysiology, epidemiology, diagnosis, classification, treatment using a clinical management algorithm of hydronephrosis and the long-term course of the disease. The aim of hydronephrosis management is to determine whether surgery should be carried out to avoid renal dysfunction, as there is a possibility for improvement without intervention. Ultrasonography is essential to make treatment decisions. Management is determined by a comprehensive assessment, including the degree of hydronephrosis, anterior-posterior diameter of the renal pelvis and, if necessary, a nuclear medicine evaluation of the status of urine drainage and renal function.
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Affiliation(s)
- Miyuki Kohno
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Tetsushi Ogawa
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatrics, Toranomon Hospital, Tokyo, Japan
| | - Yoshiyuki Kojima
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Akiko Sakoda
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazuyoshi Johnin
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yoshifumi Sugita
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Akihiro Nakane
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Nephro-Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Mitsuru Noguchi
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Saga Medical School Faculty of Medicine, Saga University, Saga, Japan
| | - Kimihiko Moriya
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Renal and Genitourinary Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Motoshi Hattori
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yutaro Hayashi
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric-Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Masayuki Kubota
- Committee for the Formulation of Medical Management Guide for Pediatric Congenital Hydronephrosis (ureteropelvic junction obstruction), Academic Committee, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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4
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Bilge I. Symptomatology and Clinic of Hydronephrosis Associated With Uretero Pelvic Junction Anomalies. Front Pediatr 2020; 8:520. [PMID: 33102401 PMCID: PMC7554633 DOI: 10.3389/fped.2020.00520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022] Open
Abstract
The most common cause of hydronephrosis in the pediatric age group is ureteropelvic junction-type hydronephrosis (UPJHN). Since the advent of widespread maternal ultrasound screening, clinical presentation of hydronephrosis associated with UPJ anomalies has changed dramatically. Today most cases are diagnosed in the prenatal period, and neonates present without signs or symptoms. For those who are not detected at birth, UPJHN eventually presents throughout childhood and even adulthood with various symptoms. Clinical picture of UPJHN highly depends on the presence and severity of obstruction, and whether it affects single or both kidneys. Abdominal or flank pain, abdominal mass, hematuria, kidney stones, urinary tract infections (UTI), and gastrointestinal discomfort are the main symptoms of UPJHN in childhood. Other less common findings in such patients are growth retardation, anemia, and hypertension. UTI is a relatively rare condition in UPJHN cases, but it may occur as pyelonephritis. Vesicoureteric reflux should be kept in mind as a concomitant pathology in pediatric UPJHN that develop febrile UTI. Although many UPJHN cases are known to improve over time, close clinical observation is critical in order to avoid irreversible kidney damage. The most appropriate approach is to follow-up the patients considering the presence of symptoms, the severity of hydronephrosis and the decrease in kidney function and, if necessary, to decide on early surgical intervention.
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Affiliation(s)
- Ilmay Bilge
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Koc University, Istanbul, Turkey
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5
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Gopal M, Peycelon M, Caldamone A, Chrzan R, El-Ghoneimi A, Olsen H, Leclair MD, Stillebroer A, MacDonald C, Tonnhofer U, Strasser C, Adam A, Spinoit AF, Haid B. Management of ureteropelvic junction obstruction in children-a roundtable discussion. J Pediatr Urol 2019; 15:322-329. [PMID: 31227314 DOI: 10.1016/j.jpurol.2019.05.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
The investigation, management and follow-up of paediatric ureteropelvic junction obstruction is not standardized. The Young Pediatric Urology Committee of the European Society of Pediatric Urology interviewed five experts in the field on various aspects of management and compared this with published literature.
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Affiliation(s)
- M Gopal
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle Upon Tyne, UK.
| | - M Peycelon
- Robert-Debré University Hospital (Assistance-Publique Hôpitaux de Paris), Department of Pediatric Surgery and Urology, Reference Center for Rare Diseases (CRMR), Malformations Rares des Voies Urinaires (MARVU), Université Paris Diderot, Sorbonne Paris CitéParis, France; Riley Hospital for Children, Indiana University and Purdue University in Indiana, Indianapolis, IN, USA
| | - A Caldamone
- Division of Pediatric Urology, Hasbro Children's Hospital, Warren Alpert School of Medicine at Brown University, Providence Rhode Island, USA
| | - R Chrzan
- Department of Paediatric Urology, Jagiellonian University Medical College, Krakow, Poland
| | - A El-Ghoneimi
- Robert-Debré University Hospital (Assistance-Publique Hôpitaux de Paris), Department of Pediatric Surgery and Urology, Reference Center for Rare Diseases (CRMR), Malformations Rares des Voies Urinaires (MARVU), Université Paris Diderot, Sorbonne Paris CitéParis, France
| | - H Olsen
- Department of Urology, Aarhus University Hospital, Arhus, Denmark
| | - M-D Leclair
- Department of Paediatric Surgery, Children University Hospital, NANTES, France
| | - A Stillebroer
- Department of Urology, University Medical Centre Groningen, Groningen, the Netherlands
| | - C MacDonald
- Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, UK
| | - U Tonnhofer
- Department of Pediatric Surgery, Medical University Vienna, Austria
| | - C Strasser
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria
| | - A Adam
- The Division of Urology, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - A-F Spinoit
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - B Haid
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria
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6
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Abstract
Urinary tract dilatation (UTD) is the most common congenital anomaly detected on prenatal ultrasonography (US), affecting 1% to 3% of all pregnancies. This article focuses on the prenatal detection of UTD and the postnatal evaluation and management based on the UTD grading system risk assessment. Prophylactic antibiotics and postnatal imaging are discussed. The recent management trend is for a more conservative approach to minimize unnecessary testing and exposures to the fetus and neonate while detecting those who may have clinically significant disorder. The renal bladder US remains a critical part of the evaluation and helps guide further investigations.
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Affiliation(s)
- Andrea Balthazar
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, VCU Medical Center, PO Box 980118, Richmond, VA 23298-0118, USA
| | - C D Anthony Herndon
- Pediatric Urology, Division of Urology, Department of Surgery, Children's Hospital of Richmond, Virginia Commonwealth University School of Medicine, VCU Medical Center, PO Box 980118, Richmond, VA 23298-0118, USA.
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7
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Chiarenza SF, Bleve C, Caione P, Escolino M, Nappo SG, Perretta R, La Manna A, Esposito C. Minimally Invasive Treatment of Pediatric Extrinsic Ureteropelvic Junction Obstruction by Crossing Polar Vessels: Is Vascular Hitching a Definitive Solution? Report of a Multicenter Survey. J Laparoendosc Adv Surg Tech A 2017; 27:965-971. [PMID: 28590826 DOI: 10.1089/lap.2016.0605] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This article aimed to evaluate the outcome of laparoscopic vascular hitch (VH) as an effective alternative to dismembered pyeloplasty in the treatment of children with extrinsic ureteropelvic junction obstruction (UPJO) by crossing vessels (CVs), by reporting the experience of three Italian centers of Pediatric Surgery. METHODS From 2006 to 2014, 54 children (18 girls and 36 boys, average age 10.7 years) affected by suspected extrinsic UPJO by CV were treated in three different institutions: 51 patients underwent laparoscopic VH, while 3 patients, in which a coexisting intrinsic etiology of UPJO was doubtful, underwent laparoscopic dismembered pyeloplasty. Preoperative diagnostic workup included: ultrasound (US)/Doppler scan, mercaptoacetyltriglycine (MAG3)-renal scan, and functional-magnetic-resonance-urography (fMRU). Symptoms at presentation were recurrent abdominal/flank pain and hematuria. All patients presented intermittent hydronephrosis (range 18-100 mm) on US and an obstructive pattern on MAG3 renogram. RESULTS Average operative time was 108 minutes, and average hospital stay was 1.8 days. As for complications, we reported a small abdominal wall hematoma and a high UPJ distortion without obstruction in 2 patients, not requiring reintervention (grade I Clavien-Dindo). At follow-up (range 12-96 months), all patients reported resolution of symptoms, decrease in the hydronephrosis grade, and improved drainage on MAG3 renogram. CONCLUSIONS Our results demonstrated the safety and efficacy of laparoscopic VH for treatment of extrinsic UPJO by CV, registering excellent outcomes in a very selected patient population. The careful selection of patients through intraoperative assessment of anatomical and functional aspects is a crucial step to confirm indications for VH and maintain a high success rate with the procedure. We believe that any concerns regarding the coexistence of intrinsic stenosis should certainly lead to opening the collecting system and to performing a classic dismembered pyeloplasty.
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Affiliation(s)
- Salvatore Fabio Chiarenza
- 1 Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital , Vicenza, Italy
| | - Cosimo Bleve
- 1 Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital , Vicenza, Italy
| | - Paolo Caione
- 2 Division of Pediatric Surgery, Department of Translational Medical Sciences, "Federico II" University of Naples School of Medicine , Naples, Italy
| | - Maria Escolino
- 3 Division of Pediatric Urology, Department of Nephrology and Urology "Bambino Gesù" Children's Hospital, Rome, Italy
| | - Simona Gerocarni Nappo
- 2 Division of Pediatric Surgery, Department of Translational Medical Sciences, "Federico II" University of Naples School of Medicine , Naples, Italy
| | - Rosa Perretta
- 1 Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital , Vicenza, Italy
| | - Angela La Manna
- 4 Department of Pediatrics, Second University of Naples , Naples, Italy
| | - Ciro Esposito
- 3 Division of Pediatric Urology, Department of Nephrology and Urology "Bambino Gesù" Children's Hospital, Rome, Italy
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8
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Parente A, Angulo JM, Romero R, Burgos L, Ortiz R. High-pressure balloon assessment of pelviureteric junction prior to laparoscopic "vascular hitch". Int Braz J Urol 2017; 42:154-9. [PMID: 27136482 PMCID: PMC4811241 DOI: 10.1590/s1677-5538.ibju.2015.0343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/26/2015] [Indexed: 12/11/2022] Open
Abstract
AIM To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). MATERIALS AND METHODS We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be presente where a 'waist' was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. RESULTS Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. CONCLUSION When no 'waist' is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels ('vascular hitch') may be a safe and reliable surgical technique.
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Affiliation(s)
- Alberto Parente
- Departamento de Urología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Jose-Maria Angulo
- Departamento de Urología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Rosa Romero
- Departamento de Urología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Laura Burgos
- Departamento de Urología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Ruben Ortiz
- Departamento de Urología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, España
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9
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Esposito C, Bleve C, Escolino M, Caione P, Gerocarni Nappo S, Farina A, Caprio MG, Cerulo M, La Manna A, Chiarenza SF. Laparoscopic transposition of lower pole crossing vessels (vascular hitch) in children with pelviureteric junction obstruction. Transl Pediatr 2016; 5:256-261. [PMID: 27867849 PMCID: PMC5107373 DOI: 10.21037/tp.2016.09.08] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Congenital hydronephrosis due to intrinsic or extrinsic uretero-pelvic-junction (UPJ) obstruction (UPJO) is a common problem in childhood UPJO may be caused by intrinsic disorganization or by extrinsic compression from crossing vessels (CV); extrinsic causes usually present symptomatically in older children. This report the large Italian experience in the treatment of children with extrinsic-UPJO by CV. METHODS We analyzed the data of 51 children (17 girls and 34 boys, median age 10, 7 years) affected by extrinsic-UPJO were treated in three Italian institutions with laparoscopic transposition of CV (Hellström Vascular Hitch modified by Chapman).The intraoperative diuretic-test was performed in all patients before and after the vessels transpositions confirming the extrinsic-UPJO. We included in the study only patients with suspicion of vascular extrinsic obstruction of the UPJ. Symptoms at presentation were recurrent abdominal/flank pain and haematuria. All patients presented intermittent ultrasound (US) detection of hydronephrosis (range, 18-100 mm). Preoperative diagnostic studies included: US/doppler scan, MAG3-renogram, functional-magnetic-resonance-urography (fMRU). RESULTS Median operative time was 108 minutes; median hospital stay: 3, 4 days. Unique complications: a small abdominal wall hematoma and higher junction-translocation without obstruction. During follow-up (range, 12-96 months) all patients reported resolution of their symptoms, a decrease in the hydronephrosis grade and improved drainage on diuretic renogram. CONCLUSIONS We believe that Vascular Hitch is less technically demanding than laparoscopic pyeloplasty, resulting in a lower complication rate and a significantly reduced hospitalization. The results of our study allow us to conclude that laparoscopic VH may be a safe, feasible, and attractive alternative to treat obstructed hydronephrosis due to CV presenting a useful alternative to AHDP in the management of symptomatic children where CV are deemed the sole aetiology. We recommend careful patient selection based on preoperative clinical and radiologic findings that are diagnostic of extrinsic-UPJO, combined with intraoperative-DT to confirm the appropriate selection of corrective procedure.
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Affiliation(s)
- Ciro Esposito
- Department of Pediatric Surgery "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Cosimo Bleve
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
| | - Maria Escolino
- Department of Pediatric Surgery "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Paolo Caione
- Division of Pediatric Urology, Department of Nephrology and Urology "Bambino Gesù" Children's Hospital, Rome, Italy
| | - Simona Gerocarni Nappo
- Division of Pediatric Urology, Department of Nephrology and Urology "Bambino Gesù" Children's Hospital, Rome, Italy
| | - Alessandra Farina
- Department of Pediatric Surgery "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Maria Grazia Caprio
- Department of Pediatric Surgery "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Mariapina Cerulo
- Department of Pediatric Surgery "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Angela La Manna
- Division of Pediatric Nephrology, Second University of Naples, Italy
| | - Salvatore Fabio Chiarenza
- Department of Pediatric Surgery and Pediatric Minimally Invasive Surgery and New Technologies, San Bortolo Hospital, Vicenza, Italy
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10
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Madec FX, Faraj S, Villemagne T, Fourcade L, Lardy H, Leclair MD. Laparoscopic transposition of lower-pole crossing vessels: Long-term follow-up of 33 patients at puberty. J Pediatr Urol 2016; 12:226.e1-6. [PMID: 27238751 DOI: 10.1016/j.jpurol.2016.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Laparoscopic transposition of lower-pole crossing vessels (LPCV) has been described as an effective alternative to dismembered pyeloplasty in selected indications of hydronephrosis, with purely extrinsic vascular PUJ obstruction. We hypothesized that the initial good results of laparoscopic transposition of LPCV in children presenting with pure extrinsic PUJO were sustained at puberty when these children go through statural growth, without inducing significant changes in systemic arterial blood pressure. Hence, we analysed the long-term follow-up of adolescents successfully treated with this technique during childhood, reviewed after they have reached puberty, focusing on the incidence of recurrent symptoms, renal dilatation, and systemic hypertension. PATIENTS AND METHODS Early 2015, among a cohort of 70 patients prospectively followed-up since they had undergone laparoscopic transposition of LPCV during childhood (2005-2012), we performed systematic clinical assessment of the 33 adolescent patients (16 years; range 12-22) who had reached puberty age. Assessment focused on clinical examination, arterial blood pressure measurements, and renal ultrasonography (Table). RESULTS The median delay since surgery was 67 months (31-113 months). Arterial blood pressure adjusted for age and height was within normal range in all patients. Three patients had occasional episodes of abdominal pain: two of them had normal US (including during pain episodes), one had persistent extra-renal dilated pelvis with no calyceal dilatation. None of them showed obvious clinical characteristics linking the pain to a renal origin. Renal US showed residual SFU grade 2 pelvicalyceal dilatation in 2/33 asymptomatic patients; SFU grade 1 extra-renal pelvis dilatation in 3, and was normal in the remaining. When Doppler analysis was performed, there was no evidence of lower-pole parenchyma perfusion defect. DISCUSSION In adolescents successfully treated during childhood with transposition of LPCV, there seemed to be no impact of this procedure on systemic arterial blood pressure in adolescents after puberty, nor any evidence of late recurrence of symptoms or hydronephrosis. The main limitation of the present study relies in its retrospective nature, the limited sample size, and the obvious difficulty in adequate selection of candidate patients to this technique. The present experience however reinforces the hypothesis that a vast majority of children can be definitely cured with transposition of LPCV when they represent the sole aetiology of obstruction. CONCLUSION In the long-term follow-up, most adolescents successfully treated during childhood by laparoscopic transposition of LCPV for PUJ extrinsic obstruction remain asymptomatic, with normal arterial blood pressure, and normal renal ultrasound when they reach puberty.
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Affiliation(s)
- François-Xavier Madec
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France
| | - Sébastien Faraj
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France
| | - Thierry Villemagne
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France; Paediatric Surgery Department, University Hospital, Tours, France
| | - Laurent Fourcade
- Paediatric Surgery Department, University Hospital, Limoges, France
| | - Hubert Lardy
- Paediatric Surgery Department, University Hospital, Tours, France
| | - Marc-David Leclair
- Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France.
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Ureteropelvic junction obstruction in children by polar vessels. Is laparoscopic vascular hitching procedure a good solution? Single center experience on 35 consecutive patients. J Pediatr Surg 2016; 51:310-4. [PMID: 26522896 DOI: 10.1016/j.jpedsurg.2015.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 10/05/2015] [Accepted: 10/06/2015] [Indexed: 11/23/2022]
Abstract
PURPOSE We report the results of laparoscopic vascular hitching (LVH) in a series of children with ureteropelvic junction obstruction (UPJO) owing to aberrant lower polar crossing vessels (CV). Our aim is to confirm if LVH associated with intraoperative diuretic test (DT) represents a good procedure to treat extrinsic-UPJO by CV. In order to confirm the relief of the obstruction we suggest performing an intraoperative DT. MATERIALS AND METHODS In our department from 2006 to 2014, 120 patients were treated for both extrinsic and intrinsic-UPJO. 85 (30 females, 55 males) presented an intrinsic obstruction and underwent dismembered pyeloplasty (AHDP), 61 open, 16 laparoscopic, 8 retroperitoneoscopic. 35 (23 males, 12 females) were studied for a suspected extrinsic-UPJO: 30 were treated with LVH (modified Hellström vascular hitch). Intraoperative-DT was performed in all patients before and after vessel transpositions confirming the UPJO and eventual relief after the procedure. We included in the study only patients with suspicion of vascular extrinsic-UPJO. Average age at surgery was 7.5years. Symptoms of presentation were recurrent abdominal/flank pain and hematuria. All patients presented ultrasound (US) detection of hydronephrosis. Preoperative diagnostic studies include: US/doppler scan, MAG3 renogram, urography, functional magnetic resonance urography (fMRU) and CT scan. RESULTS 28 out 35 patients had a correct preoperative diagnosis, and the remaining needed an intraoperative diagnosis confirmation. All 35 patients had an intraoperative-DT: 30 patients underwent LVH (positive-DT); 3 patients (negative-DT) underwent laparoscopic-AHDP for intrinsic-UPJO; two with positive-DT and nonobstructive CV, had no surgical treatment. Median operating time was 95min; mean hospital stay was 4days. At 12-84months follow-up 29 patients remained symptoms-free, one needed after two years a laparoscopic-AHDP. CONCLUSIONS According our experience, LVH associated with intraoperative-DT may be considered a safe procedure to treat extrinsic-UPJO by CV in carefully selected patients. In particular, the very low incidence of relapse suggest that in suspicion of extrinsic-UPJO, performing intraoperative-DT after CV transposition allows to exclude intrinsic-UPJO confirming that the LVH-procedure has relieved the pelvic obstruction, precluding the need for AHDP.
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MDCT and MR Urogram Spectrum of Congenital Anomalies of the Kidney and Urinary Tract Diagnosed in Adulthood. AJR Am J Roentgenol 2015; 205:W294-304. [PMID: 26295665 DOI: 10.2214/ajr.14.12867] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Congenital anomalies of the kidneys and urinary tract (CAKUT) encompass a spectrum of anomalies that result from genetic, epigenetic, environmental, and molecular signal aberrations at key stages of urinary tract development. CAKUT can be seen incidentally on cross-sectional imaging of the abdomen or can be a cause for adult-onset chronic kidney disease, posing new challenges for nephrologists, urologists, and radiologists. CONCLUSION Awareness of CAKUT and familiarity with their imaging findings permit optimal patient management and thorough workup to prevent hypertension and progression from CAKUT to renal failure. The purpose of this article is to review the cross-sectional imaging findings of CAKUT that may present in adulthood.
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Long-term results with the laparoscopic transposition of renal lower pole crossing vessels. J Pediatr Urol 2015; 11:174.e1-7. [PMID: 26139159 DOI: 10.1016/j.jpurol.2015.04.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND For the treatment of ureterovascular pelviureteric junction obstruction (PUJO), transposition of lower pole crossing vessels (LPCV) has been described as an alternative to dismembered pyeloplasty. PURPOSE To report on the long-term follow-up of children after laparoscopic transposition of LPCV. METHODS A retrospective analysis of 70 children consecutively treated by laparoscopic transposition of LPCV. Candidate patients were selected on the basis of clinical history, renal ultrasound (US), and pre-operative mercaptoacetyltriglycine (MAG-3) scan. Selection criteria included: presence of LPCV with SFU Grade 1-2 hydronephrosis, impaired drainage on MAG-3 and intraoperative normal pelviureteric junction (PUJ) and ureter peristalsis. Thinned parenchyma, impaired renal function, or history of prenatal hydronephrosis were not considered as exclusion criteria. Children were clinically followed up with US and MAG-3 scan. Success was defined by symptom resolution with improvement in hydronephrosis. RESULTS Seventy children, aged 8.3 years (range 2.75-16.0), were selected. Procedures were performed through transperitoneal laparoscopy (n = 42) or were robotic-assisted (n = 28). Operative time was 120 min and length of hospital stay was 2 days. The outcome was successful in 67/70 patients (96%), with a median follow-up of 52 months (range 13-114). There were three failures in children who eventually underwent dismembered pyeloplasty for a symptomatic, undiagnosed, intrinsic PUJ obstruction. Two of them had been postnatally followed for a resolving prenatally diagnosed hydronephrosis. Three children became free of symptoms, had improved hydronephrosis, but still showed impaired drainage on MAG-3 and are being closely followed up. DISCUSSION Although this procedure proves to have long-term efficiency in selected indications, the main challenge is to intraoperatively ascertain the absence of associated intrinsic stenosis. Objective criteria remain difficult to establish, but intraoperative findings, including dependent, funnel-shaped, normal-looking PUJ with decreasing hydronephrosis after pelvis and LPCV mobilisation, and efficient peristalsis across the PUJ under intraoperative diuretic test, represent a low likelihood of associated intrinsic stenosis. Ipsilateral impaired renal function doesn't seem to be associated with an adverse outcome. In contrast, a prenatal history of mild or self-resolving hydronephrosis in a patient later presenting with intermittent dilatation, raises the suspicion of associated intrinsic PUJ obstruction, as it is associated with a higher risk of failure. CONCLUSION With a long postoperative follow-up, the robotic-assisted or laparoscopic vascular hitch procedure has been successful in treating a selected group of children with obstructive LPCV, and represents a safe and reliable alternative to standard dismembered pyeloplasty in the absence of intrinsic PUJO suspected on prenatal US.
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Current radiological techniques used to evaluate unilateral partial ureteral obstruction: an experimental rabbit study. Int Urol Nephrol 2015; 47:1045-50. [PMID: 25943266 DOI: 10.1007/s11255-015-0998-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/20/2015] [Indexed: 10/23/2022]
Abstract
AIM The aim of this study was to evaluate functional and prognostic benefits of Doppler ultrasonography (DU), diuretic renal scintigraphy (DRS), and magnetic resonance urography (MRU) during diagnosis and follow-up of ureteropelvic junction obstruction (UPJO) and to examine apoptosis rates caused by UPJO in an experimental rabbit model. METHOD Twenty-four rabbits were divided randomly into two groups. The left kidneys of 15 rabbits from the first group underwent Ulm-Miller surgery to create UPJO, whereas the left kidneys of nine rabbits from the second group underwent sham surgery. A pressure flow study (Whitaker's test) was done during postoperative week 6. Based on the Whitaker test, the DU, DRS, and MRU findings were compared. The number of apoptotic renal cells was counted after death. RESULT The Whitaker test run during postoperative week 6 revealed obstructions in 15 rabbits from group 1; the nine rabbits of the sham group had no obstructions. Sensitivity and specificity of DRS were 93.3 and 88.8 %, respectively, and those of MRU were 93.3 and 88.8 %, respectively. The postoperative mean RI values were significantly higher than the preoperative values, associated with sensitivity of 86.6 % and specificity of 77.5 % for detecting UPJO. DRS, MRU, and RI could not predict UPJO in one (8 %), one (8 %), and two (16 %) kidneys, respectively. Likelihood ratio (LR) was 8.4 for MRU and scintigraphy, while for RI, LR was 3.9. Pathology specimens revealed that all kidneys with UPJO underwent apoptosis, and the number of apoptotic cells was significantly higher on the UPJO-created side than on the contralateral and in the sham group (p < 0.05). No test predicted all apoptosis related to UPJO. CONCLUSION The RI, DRS, and DMRU results correlated with the pressure flow results for detecting UPJO. No single radiological technique predicted all initial UPJO-created kidneys that concluded with apoptosis. Further studies are required to seek with better methods for diagnosing an obstruction or to define a combination of radiological techniques aiding in the management decision.
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Schneider A, Ferreira CG, Delay C, Lacreuse I, Moog R, Becmeur F. Lower pole vessels in children with pelviureteric junction obstruction: laparoscopic vascular hitch or dismembered pyeloplasty? J Pediatr Urol 2013; 9:419-23. [PMID: 22854387 DOI: 10.1016/j.jpurol.2012.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 07/04/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To choose between laparoscopic "vascular hitch" (VH) and dismembered pyeloplasty (DP) in treatment of aberrant lower pole crossing vessels potentially responsible for pelviureteric junction obstruction (PUJO) in older children. PATIENTS AND METHODS Retrospective study of 19 patients treated laparoscopically for PUJO. Based on videos of the procedures, we studied the anatomical relationship between the renal pelvis, the pelviureteric junction, and the aberrant vessels. RESULTS Eight patients had laparoscopic VH and 11 had DP. All patients with DP needed drainage. In the VH group, 7/8 patients were asymptomatic and had decreased pelvic dilation. Half of them accepted MAG3 scintigraphy, and in these patients the obstructive syndrome disappeared completely. The last patient in this group was lost to follow-up. We observed three anatomical variations in the location of polar vessels: type 1 (in front of the dilated pelvis), type 2 (in front of the pelviureteric junction), type 3 (under the pelviureteric junction, resulting in ureteral kinking). CONCLUSION Laparoscopic VH is a simple technique involving no urinary anastomosis or drainage, but we cannot guarantee that the crossing vessels are the sole etiology for PUJO. Following our experience, only patients with type 3 anatomical variations and with a normal pelviureteric junction should be proposed for VH.
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Affiliation(s)
- A Schneider
- University Hospital of Strasbourg, Faculty of Medicine of Strasbourg, Strasbourg, France.
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Merksz M, Sulya B, Polovitzer M, Héjj I, Molnár D, Szepesváry Z, Kiss A. [Intermittent hydronephrosis in childhood]. Orv Hetil 2013; 154:940-6. [PMID: 23752049 DOI: 10.1556/oh.2013.29639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intermittent pelviureteric junction obstruction, and its consequence,intermittent hydronephrosis is a difficult condition to identify. The renal collecting system is not dilated between the episodes of abdominal pain attacks and a prompt investigation is hard to carry out during the time of painful crisis. Therefore, most of the patients are initially misdiagnosed. AIM The aim of the study was to assess the occurrence and the clinical characteristics of this phenomenon in children operated in the Department of Urological Surgery, Heim Pál Children Hospital, Budapest, Hungary. PATIENTS AND METHODS Medical records of children operated for hydronephrosis between 2008 and 2012 were reviewed. The occurrence rate and clinical features of intermittent hydronephrosis were analyzed. RESULTS 76 children were operated for pelviureteric junction obstruction, of which 10 met the criteria of intermittent hydronephrosis. The average interval between the onset of symptoms and the final diagnosis was 2 years and 4 months. In 7 patients pyeloplasty, and in 3 patients nephrectomy were performed. CONCLUSIONS Intermittent hydronephrosis represents a well-defined proportion among cases operated for hydronephrosis. The delay in diagnosis led to the loss of the kidney in one third of the patients, and this finding urges for the awareness of health professionals for this phenomenon. In case of recurrent abdominal pain of unknown etiology one must suspect a urological origin, even if a previous abdominal ultrasound showed normal kidneys.
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Affiliation(s)
- Miklós Merksz
- Heim Pál Gyermekkórház, Urológiai Sebészeti Osztály, Budapest.
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Kim EH, Tanagho YS, Traxel EJ, Austin PF, Figenshau RS, Coplen DE. Endopyelotomy for pediatric ureteropelvic junction obstruction: a review of our 25-year experience. J Urol 2012; 188:1628-33. [PMID: 22906656 DOI: 10.1016/j.juro.2012.02.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Eric H Kim
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri, USA
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Sameh W, Elgebaly OF. Laparoscopic transposition pyelo-pyelostomy for repair of adult uretero-pelvic junction obstruction secondary to lower pole crossing vessels: a novel technique. J Endourol 2011; 26:377-80. [PMID: 22192105 DOI: 10.1089/end.2011.0441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION An aberrant crossing vessel(s) (CV) is considered an important cause of uretero-pelvic junction obstruction (UPJO) in adults. Intrinsic defect at the uretero-pelvic junction (UPJ) is not necessarily present and so, dismembered pyeloplasty would not be necessary. We introduce in the present study a novel technique, laparoscopic transposition pyelo-pyelostomy (LTP) to treat UPJO caused by aberrant CV in adults. PATIENTS AND METHODS From July 2004 to August 2010, 21 adult patients were diagnosed as having UPJO secondary to aberrant CV and were treated laparoscopically by transposition pyelo-pyelostomy. The main presentation was pain in 13 patients, while 3 patients presented with fever. Five patients were accidentally discovered as having hydronephrosis in ultrasound (U/S). Preoperative intravenous urography and U/S revealed grade III hydronephrosis in 11 patients and grade IV in 10 patients. Diagnosis of CV was suspected preoperatively in the IVU in 15 patients and was confirmed by computed tomography. The remaining six patients were diagnosed intra-operatively. RESULTS The operative time ranged from 75 to 125 minutes with a mean of 93 minutes. The mean time for anastomosis was 12 minutes. No intra-operative complication was reported. Drain was removed after 48 hours, and mean hospital stay was 3 days. Symptom improvement was encountered in all symptomatic patients. Postoperative US done at 3 months revealed resolution of the hydronephrosis in 10 patients, and 11 patients had a residual grade I hydronephrosis. Diuretic renography at 1 year postoperatively revealed normal T1/2 in 19 patients. CONCLUSION LTP is a simple procedure that spares the normal UPJ and provides a wide, stentless anastomosis which nullifies the risk of re-stenosis and failure.
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Affiliation(s)
- Wael Sameh
- Department of Urology, Faculty of Medicin, Alexandria University, 50 Omar Lotfy Street, Alexandria, Egypt.
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Singh RR, Govindarajan KK, Chandran H. Laparoscopic vascular relocation: alternative treatment for renovascular hydronephrosis in children. Pediatr Surg Int 2010; 26:717-20. [PMID: 20512343 DOI: 10.1007/s00383-010-2623-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2010] [Indexed: 10/19/2022]
Abstract
AIMS The standard treatment for pelviureteric junction obstruction (PUJO) has been dismembered pyeloplasty. The open surgical, Hellström procedure in which crossing polar vessels are relocated, has been an option in adult urological practice. We present our experience with laparoscopic vascular relocation in children. METHODS Data were retrospectively gathered on all patients who underwent laparoscopic relocation of lower pole vessels (LRLPV) at our institution between July 2004 and March 2008. Follow-up ultrasounds and MAG3 were obtained. RESULTS LRLPV was performed in 10 boys and 9 girls. Patients were between 5.8 and 15.25 years (median 9.9 years). They presented with recurrent abdominal pain (n = 17), urinary tract infections (n = 7) and haematuria (n = 3). On ultrasound, MAG3 and retrograde studies they had hydronephrosis, obstructed drainage and a normal calibre ureter with a sharp cut-off. They were further assessed at laparoscopy and were found to have aberrant lower pole crossing vessels. All underwent laparoscopic mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and relocating them superiorly onto the anterior wall of the pelvis. The median operating time was 120 min (range 60-240 min). The median hospital stay was 2 days (range 1-3 days). They were followed up for a median period of 12 months (range 6-36 months). All patients have remained asymptomatic. Ultrasound done at 6 months showed decreased hydronephrosis. MAG3 study showed improved drainage in 17, while 1 had poor drainage. This patient remains symptom free and is under regular follow up. CONCLUSION Laparoscopic vascular relocation is an unconventional technique in carefully selected patients with PUJO. It obviates disrupting an intrinsically normal PU junction and treats the cause rather than the effect. Our intermediate-term results are encouraging and further long-term assessment is needed.
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Affiliation(s)
- R R Singh
- Department of Paediatric Urology, Birmingham Children's Hospital, Birmingham, B4 6NH, UK.
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Further experience with the vascular hitch (laparoscopic transposition of lower pole crossing vessels): an alternate treatment for pediatric ureterovascular ureteropelvic junction obstruction. J Urol 2008; 180:1832-6; discussion 1836. [PMID: 18721979 DOI: 10.1016/j.juro.2008.05.055] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Indexed: 11/20/2022]
Abstract
PURPOSE Standard treatment for ureterovascular ureteropelvic junction obstruction has been dismembered pyeloplasty. We previously reported the alternative technique of laparoscopic transposition of lower pole vessels (the vascular hitch) in pediatric patients. This report is an update of this select group of pediatric patients with intermediate followup. MATERIALS AND METHODS Patients underwent diagnostic renal sonography and (99m)technetium-mercaptoacetyltriglycine diuretic renography with additional magnetic resonance angiography in candidate patients. Radiographic criteria included moderate hydronephrosis with no caliceal dilatation and a well preserved cortex, poor renal drainage with preserved split function and lower pole crossing vessels. Intraoperative criteria included a normal ureter and ureteropelvic junction with peristalsis. Postoperatively patients were followed clinically, and with renal sonography and (99m)technetium-mercaptoacetyltriglycine renography at 1 and 2 months, respectively. Success was defined as symptom resolution with radiographic improvement in hydronephrosis and drainage with preserved renal function. RESULTS Nine boys and 11 girls 7 to 16 years old (mean age 12.5) underwent laparoscopic transposition of crossing vessels, including 3 with da Vinci robot assistance. Mean operative time was 90 minutes (range 47 to 140). Median hospital stay was 24 hours. No ureteral stents or urethral catheters were placed intraoperatively. At a mean followup of 22 months (range 12 to 42) 19 of 20 patients (95%) had been successfully treated. One patient who had recurrent pain underwent successful laparoscopic pyeloplasty. CONCLUSIONS At intermediate followup the laparoscopic vascular hitch procedure has been successful in treating patients with ureterovascular ureteropelvic junction obstruction. In these select patients this technique offers a feasible and durable alternative to standard dismembered pyeloplasty. Ongoing evaluation continues to ensure that the promising results endure.
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Laparoscopic transposition of lower pole vessels--the 'vascular hitch': an alternative to dismembered pyeloplasty for pelvi-ureteric junction obstruction in children. J Pediatr Urol 2006; 2:285-9. [PMID: 18947622 DOI: 10.1016/j.jpurol.2005.11.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Accepted: 11/23/2005] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Dismembered pyeloplasty is the traditional technique in the management of ureterovascular pelvi-ureteric junction obstruction (PUJO) in children. Controversy remains regarding the role of lower pole vessels as the sole aetiology for PUJO. Endopyelotomy and concomitant laparoscopic transposition of lower pole vessels for PUJO has been described in adults. We describe our technique of laparoscopic transposition of lower pole vessels in children with PUJO, leaving the PUJ intact. PATIENTS AND METHODS Thirteen patients (seven boys and six girls) with a mean age of 10.2 years (range 7-16 years) underwent laparoscopic transposition of lower pole vessels. Surgery was indicated on the basis of intermittent pain and ultrasound/MAG3 appearance of obstruction with or without reduced function. The technique involved laparoscopic transperitoneal mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and transposing them superiorly onto the anterior wall of the pelvis. The main outcome measures were relief of pain and improvement in ultrasound appearance or drainage parameters on a postoperative MAG3 renogram performed within 4-6 weeks of surgery. RESULTS Median operating time was 92 min. All patients were discharged within 36 h of surgery. All patients remain pain free at a median of 6 months (range 3-18 months). Twelve patients showed good drainage on the postoperative MAG3 renogram and improvement in ultrasound appearance. One patient had recurrent symptoms requiring insertion of a JJ stent. She has undergone further laparoscopic exploration. The vessels were in their transposed position and there was a kink at the PUJ which was released. She had a vertical pyelotomy and transverse closure over the JJ stent with good results. CONCLUSION This technique is simple and requires less operating time. No anastomosis or temporary JJ stent is required. Our early results are very encouraging with no serious complications.
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Capello SA, Kogan BA, Giorgi LJ, Kaufman RP. PRENATAL ULTRASOUND HAS LED TO EARLIER DETECTION AND REPAIR OF URETEROPELVIC JUNCTION OBSTRUCTION. J Urol 2005; 174:1425-8. [PMID: 16145455 DOI: 10.1097/01.ju.0000173130.86238.39] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We hypothesized that the widespread adoption of prenatal ultrasound in the early 1980s has led to earlier and increased numbers of repairs for ureteropelvic junction (UPJ) obstruction. MATERIALS AND METHODS The New York State Department of Health database was used to identify all patients who underwent pyeloplasty between 1984 and 2002. RESULTS A total of 7,758 repairs were evaluated (6,725 pyeloplasties and 1,033 endopyelotomies). There was no substantial change in the rate of repair when adjusted for age specific population during the study period. The annual rate of repair in patients younger than 1 year increased from 94 to 156 per 100,000 live births between the periods 1984 to 1988 and 1989 to 2002. This same upward trend was seen in the children 1 to 9 years old. In contrast, there was a substantial decrease in the rate of repairs in patients 10 to 19 years old and in those 20 to 29 years old (from 10 to 9 per 100,000 and from 12 to 8 per 100,000 population, respectively). The male-to-female ratio of newborns in our series was approximately 3:1, which is consistent with previous reports. Among older patients males underwent fewer repairs such that the male-to-female ratio in patients older than 30 years was 1:2. CONCLUSIONS The overall rate of UPJ repair has not changed during the last 19 years, but there has been a substantial trend toward repair at an earlier age. This finding suggests that prenatal ultrasound has led to earlier diagnosis of UPJ obstruction, allowing earlier repair and obviating later repair. We also report the novel finding of a decreasing rate of pyeloplasty in males with age. This decrease was not observed in females.
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Affiliation(s)
- Seth A Capello
- Division of Urology, Albany Medical College, Albany, New York 12208, USA.
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Calisti A, Perrotta ML, Oriolo L, Patti G, Marrocco G, Miele V. Functional outcome after pyeloplasty in children: impact of the cause of obstruction and of the mode of presentation. Eur Urol 2003; 43:706-10. [PMID: 12767375 DOI: 10.1016/s0302-2838(03)00144-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare functional outcome after pyeloplasty in two groups of patients affected by hydronephrosis, which had different modalities of diagnosis. The first, asymptomatic, detected by prenatal ultrasonography and the second referred later because of clinical symptoms. PATIENTS AND METHODS 84 patients (54 prenatally detected and 30 symptomatic) among 339 observed with hydronephrosis, operated in a single centre for ureteropelvic junction obstruction, have been retrospectively studied. Seventeen cases with prenatal diagnosis had an early treatment and thirty-seven were operated on after an initial observation. Symptomatic cases were all operated on at diagnosis. Ultrasonographic and renographic assessment were made at diagnosis, before and after surgery. RESULTS Renal function of prenatally detected cases was not influenced by early or delayed surgery. Insignificant functional loss was recorded among some cases operated after conservative management. Improvement in differential renal function (p<0.05) was recorded in symptomatic patients after pyeloplasty. A high percentage of obstructions secondary to lower polar crossing vessel were found among symptomatic cases (12 out of 30). Intrinsic obstructions were predominant among cases with in utero diagnosis (48 out of 54). Whenever the cause of obstruction is considered, postoperative functional improvement was limited to crossing vessels cases. CONCLUSIONS Renal function among antenatally diagnosed obstructions is scarcely influenced by surgery; potential risk of further renal damage cannot be excluded when expectant management is decided. Later detected, symptomatic cases show a better functional response to surgery. This seems corresponding to distinct clinical entities based on different causes of hydronephrosis. A reversible renal damage seems to be associated to extrinsic obstructions from polar vessel, which are predominant among symptomatic, later detected cases. A congenital, irreversible loss of function accompanies intrinsic obstructions, typical of prenatally diagnosed cases.
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Affiliation(s)
- A Calisti
- Department of Pediatric Surgery, S Camillo-Forlanini Hospitals, Rome, Italy.
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MacKenzie RK, Mahomed AA. Symptomatic ureteropelvic junction obstruction in children. Urology 2001; 58:638. [PMID: 11597566 DOI: 10.1016/s0090-4295(01)01386-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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