Pediatric pyeloplasty: outcome analysis based on patient age and surgical technique

Comparison between open and minimally invasive pyeloplasty in infants: A systematic review and meta-analysis

INTRODUCTION

Ureteropelvic junction obstruction (UPJO) is the most common cause of congenital hydronephrosis. Techniques such as laparoscopic pyeloplasty (LP) have gained in popularity over recent years. Although some retrospective studies have compared minimally invasive reconstructive techniques with open surgery for treatment of UPJO in infants, results remain controversial due to the small sample size in most of these studies.

OBJECTIVE

To verify whether the benefits of minimally invasive pyeloplasty (MIP) observed in adults and children over 2 years of age also apply to infants.

METHODS

A systematic review of the literature was performed according to PRISMA recommendations. We searched databases of MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials. We excluded studies in which patient cohorts were outside the age range between 1 and 23 months of age (infants). Studies should evaluate at least one of the following outcomes: average hospital stay, operative time, follow-up time, complications, post-surgical catheter use, success rate and reintervention rate. The quality of the evidence was assessed with the ROBINS-I tool.

RESULTS

In total, 13 studies were selected. 3494 patients were included in the meta-analysis, of whom 3054 underwent OP, while the remaining 440 were part of the group undergoing MIP. The mean difference in hospital days was -1.16 lower the MIP group (95 % CI; -1.78, -0.53; p = 0.0003). Also, our analysis showed a significantly shorter surgical time in the group who underwent OP, with a mean operative time of 119.92 min, compared to 137.63 min in the MIP group (95 % CI; -31.76, -6.27; p = 0.003). No statistically significant between-group differences were found respect to follow-up time, complications, post-surgical catheter use, success rate and reintervention rate.

CONCLUSION

This systematic review with meta-analysis has shown that laparoscopic/robotic pyeloplasty in infants is a safe technique with similar success rates to open surgery. Nonetheless, randomized clinical trials with longer follow-up are needed to consolidate these results with more robust scientific evidence.

Significant improvement in hydronephrosis with pyeloplasty prior to 3 months of age in patients with antenatal severe hydronephrosis

INTRODUCTION

Pyeloplasty is the definitive management of ureteropelvic junction obstruction (UPJO). One of the challenging questions is when to perform pyeloplasty. We studied if improvement post-pyeloplasty in the first 3 months of life could show greater improvement in hydronephrosis than surgery at an older age.

PATIENTS AND METHODS

Patients with postnatally diagnosed UPJO and underwent pyeloplasty in the first year of life were retrospectively reviewed. We excluded patients with concomitant vesicoureteral reflux, and patients who had pyeloplasty because of UTI or missed follow-up. Patients were divided into two groups, according to the age at pyeloplasty, before and after the age of 3 months. We collected patients' demographics, anteroposterior diameter of the renal pelvis (APD), SFU grade, renogram data, perioperative data (surgery duration, hospital stay, and ureteral stent duration) and postoperative ultrasound changes. The percentage of change of APD (Δ%APD) was calculatedusing the formula: Δ%APD = [ (initial APD-last APD)/initial APD] *100.

RESULTS

We included 90 patients (93 renal units). 36 patients had pyeloplasty during the first 3 months of life and 57 patients at 3 -12 months. Patients' characteristics were similar in both groups except APD which was higher when pyeloplasty was done < 3 months of age (p = 0.02). Both groups had comparable perioperative parameters. After almost similar follow-up period of both groups. The Δ%APD was 58% when pyeloplasty was done < 3 months compared to 33% when was performed > 3 months (p = 0.009). Using Kaplan-Meier analysis, APD significantly improved when pyeloplasty was performed before the age of 3 months (p = 0.001).

CONCLUSION

Early pyeloplasty, in the first 3 months of life, showed a significant improvement of APD postoperatively than those had surgery later. It is unclear if this will relate to less loss of renal function yet certainly this would be suspected and feel this finding provides some evidence for early intervention.

Comparative analysis of suturing technique in pediatric pyeloplasty on surgical outcomes

PURPOSE

Pyeloplasty for ureteropelvic junction obstruction is the gold standard for surgical repair. There are currently no reports outlining optimal suturing technique. This paper compares the effect of suturing technique in dismembered pediatric pyeloplasty (open and laparoscopic) on post-operative outcomes.

METHODS

A non-concurrent cohort study assessed different suturing techniques in both open and laparoscopic dismembered pyeloplasty performed two senior urologists at a tertiary referral pediatric center. Cases were stratified according to different suturing techniques for ureteropelvic anastomosis and subgroup analysis was performed according to open or laparoscopic approach.

RESULTS

A total of 185 renal units were evaluated. The overall comparative analysis of different anastomotic suturing techniques and clustered analysis according to open and laparoscopic approach showed no significant differences on post-operative complication rate, leakage, stenosis, redo-pyeloplasties, operative time and hospital stay. There was a significant difference between suturing techniques on stent duration, age and weight of the patient. There was no effect of suture type or size on post-operative complication rate, leakage, UPJ stenosis and redo pyeloplasty rates, however, sample sizes were small.

CONCLUSION

Suturing technique has no significant effect on the surgical outcomes assessed regardless of open or laparoscopic technique.

Comparative Outcomes of Double-J and Cutaneous Pyeloureteral Stents in Pediatric Robot-Assisted Laparoscopic Pyeloplasty

Background: Comparative outcome studies investigating internal Double-J (DJ) and externalized stents have primarily been performed for open and laparoscopic pyeloplasty, with a paucity of literature surrounding outcomes in robot-assisted laparoscopic pyeloplasty (RALP). Furthermore, outcomes of a modified external stent inserted into the renal pelvis, termed cutaneous pyeloureteral (CPU) stent, remain unexamined. This study investigates outcomes of DJ and CPU stents as methods of trans-anastomotic drainage. Materials and Methods: A retrospective analysis identified pediatric patients who underwent RALP between December 2007 and January 2020 at a single tertiary center, where CPU stents were introduced in June 2012. Operative success was defined as improved or stable hydronephrosis without subsequent redo pyeloplasty. Secondary outcomes included stent reinsertion, anesthesia requirements, opioid administration, urinary tract infection (UTI), and bladder spasms. Results: A total of 103 pediatric RALP procedures were analyzed (DJ = 70, CPU = 33). Operative success (DJ = 95.7%, CPU = 100%, p = 0.55), Society for Fetal Urology (SFU) grade improvement, and length of stay were comparable. Accidental stent expulsion was only seen with CPU stents (9%; p = 0.03). Intracorporeal stent migration also occurred more frequently in CPU stents (DJ = 3%, CPU = 15%, p = 0.03). Stent reinsertion, when needed, used a DJ stent with rates of 4% and 9% for DJ and CPU stents, respectively (p = 0.38). DJ stents were removed at a later postoperative day (DJ = 45.2 ± 25.0, CPU = 8.3 ± 4.2; p < 0.001) with increased general anesthesia (DJ = 99%, CPU = 3%; p < 0.001) and intravenous (IV) opioid (DJ = 27%, CPU = 9%; p = 0.04) requirements. Finally, DJ stents had nonsignificant increased rates of UTI (DJ = 17%, CPU = 3%, p = 0.06) and bladder spasms necessitating postoperative medication (DJ = 26%, CPU = 9%, p = 0.07). Conclusions: DJ and CPU stents display equivalent success rates in pediatric RALP and similar stent reinsertion rates. Appreciable differences can inform stent selection, including higher general anesthesia requirements and IV opioid administration among DJ stents and a higher incidence of accidental stent expulsion among CPU stents. In addition, DJ stents were associated with nonsignificant increased rates of UTI and bladder spasm necessitating medication.

Does the use of 5 mm instruments affect the outcomes of robot-assisted laparoscopic pyeloplasty in smaller working spaces? A comparative analysis of infants and older children

INTRODUCTION

Pediatric robot-assisted laparoscopic (RAL) pyeloplasty has become a viable minimally invasive surgical option for ureteropelvic junction obstruction (UPJO) based on its efficacy and safety. However, RAL pyeloplasty in infants can be a challenging procedure because of the smaller working spaces. The use of the larger 8 mm instruments for these patients instead of the 5 mm instruments is common because of the shorter wrist lengths.

OBJECTIVE

We hypothesized that the use of 5 mm instruments for RAL pyeloplasty in infants with smaller working spaces will have comparable perioperative parameters and surgical outcomes in comparison with older children with larger working spaces.

STUDY DESIGN

We compared the perioperative parameters and surgical outcomes of RAL pyeloplasties performed by a single surgeon in infants and non-infant pediatric patients over a 2 year period. All of the procedures were performed using an 8.5 mm camera and 5 mm robotic instruments. Patient demographics, operative times, perioperative complications, hospital pain medication usage, hospital length of stay, and treatment success rates were compared between the two groups.

RESULTS

A total of 65 pediatric RAL pyeloplasties were included in the study (16 infants and 49 non-infants, Table). There were no significant differences in gender, laterality, proportion of re-do pyeloplasty, or preoperative hydronephrosis grade between the two groups. All procedures were performed without conversion to open surgery or significant perioperative complications. There were no differences in segmental operative times (total operative time, console time, port placement time, time for dissection to UPJO, and anastomosis time), hospital pain medication usage, and hospital length of stay between the two groups (p > 0.05 for all comparisons). The treatment success rates were 93.8% (15/16) and 100% (49/49), respectively (p = 0.08).

DISCUSSION

We present the first comparative study of infant and non-infant pediatric RAL pyeloplasty using 5 mm robotic instruments. An advantage of the current study is the use of a single surgeon's experience to compare RAL pyeloplasty outcomes in infants with those of older children, a group in which RAL pyeloplasty has already been shown to be efficacious and safe. Operative tips for infant RAL pyeloplasty are also provided.

CONCLUSIONS

RAL pyeloplasty is a safe and effective surgical modality even in infants, with comparable perioperative parameters and outcomes as those in older children. The use of 5 mm instruments in infants does not affect outcomes and offers the potential for improved cosmesis.

A Randomized Control Trial Comparing Outcome after Stented and Nonstented Anderson-Hynes Dismembered Pyeloplasty

Aim

The aim of the study was to compare the efficacy and postoperative complications of stented and nonstented open pediatric dismembered pyeloplasty for ureteropelvic junction (UPJ) obstruction.

Settings and Design

A balanced, parallel group, prospective randomized controlled trial comparing stented and nonstented Anderson-Hynes Dismembered Pyeloplasty.

Subjects and Methods

It included 42 children who required Anderson-Hynes dismembered pyeloplasty for UPJ obstruction (UPJO). Patients were randomized into stented (double "J" [DJ] stent) and nonstented pyeloplasty groups. The intraoperative and postoperative course was compared. Both groups were analyzed for problems such as dysuria, frequency, pain, hematuria and urinary tract infection, and postoperative renal status.

Statistical Analysis

Mann-Whitney U-test, Fisher's exact test, Student's t-tests, and Chi-squared test were used.

Results

Surgical duration was significantly shorter for the nonstented group as compared to the stented group (60.4 ± 6.49 min vs. 78.9 ± 8.17 min). The intraoperative negotiation of DJ stent was troublesome in 21.7% patients belonging to the stented group. The hospital stay was comparable in both groups (4.67 ± 1.9 vs. 4.28 ± 0.67 days). Patients in stented group had experienced dysuria, loin pain, lower abdominal spasmodic pain, and frequency significantly higher than nonstented group. However, the other problems such as fever, hematuria, and urinary tract infections were more common in stented group, but the difference was not statistically significant. There was no difference in resolution of hydronephrosis in both groups.

Conclusions

There is no statistically significant difference in resolution of hydronephrosis following nonstented or stented dismembered pyeloplasty in children with UPJO. However, the patient is more symptomatic due to stent in the postoperative period.

Surgery versus non-surgical management for unilateral ureteric-pelvic junction obstruction in newborns and infants less than two years of age

BACKGROUND

Unilateral ureteric-pelvic junction obstruction (UPJO) is the most common cause of obstructive uropathy and may lead to renal impairment and loss of renal function. The current diagnostic approach with renal imaging cannot reliably determine which newborns and infants less than two years of age have a significant obstruction and are at risk for permanent kidney damage. There is therefore no consensus on optimal therapeutic management of unilateral UPJO.

OBJECTIVES

To assess the effects of surgical versus non-surgical treatment options for newborns and infants less than two years of age with unilateral UPJO.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2016), MEDLINE/Ovid, and EMBASE/Ovid databases from their inception to 13 June 2016. We searched the reference lists of potentially relevant studies without using any language restriction. We also searched the following trial registers for relevant registered studies: www.clinicaltrials.gov/; ISRCTN registry (controlled-trials.com/); www.trialscentral.org/; apps.who.int/trialsearch/; www.drks.de/; and www.anzctr.org.au/trialSearch.aspx.

SELECTION CRITERIA

We selected randomised and quasi-randomised controlled trials comparing surgical with non-surgical interventions for the treatment of unilateral UPJO.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and risk of bias of included studies and extracted data. In case of disagreements we consulted a third review author. The data reported in the two included studies did not allow us to perform a meta-analysis.

MAIN RESULTS

We found only two studies at high risk of bias that were eligible for inclusion in this review. The total sample size, including both trials, was small (n = 107 participants less than six months of age from the UK and USA), and not all prespecified outcome measures were assessed. Reported measures only accounted for the short-term follow-ups. The mean split renal function was not statistically different between the surgical and non-surgical group at the six-month or one-year time point (very low-quality evidence). The surgical group showed a significantly less obstructed drainage pattern and a lower urinary tract dilatation than the non-surgical group (very low-quality evidence). Transfer from the non-surgical group to the surgical group was reported for about one out of five participants. Split renal function after secondary surgical intervention was reported with variable results, but most of the participants reverted to pre-deteriorated values. The studies either provided no or insufficient data on the following outcome measures: postoperative complications, UPJO-associated clinical symptoms, costs of interventions, radiation exposure, quality of life, and adverse effects.

AUTHORS' CONCLUSIONS

We found limited evidence assessing the benefits and harms of surgical compared to non-surgical treatment options for newborns and infants less than two years of age with unilateral UPJO. The majority of participants in the non-surgical treatment group did not experience any significant deterioration of split renal function, and only about 20% of them underwent secondary surgical intervention, with minor risk of permanent deteriorated split renal function. The study follow-up period was too short to assess the long-term effects on split renal function in both treatment groups. We need further randomised controlled trials with sufficient statistical power and an adequate follow-up period to determine the optimal therapy for newborns and infants less than two years of age with unilateral UPJO.

Therapeutic approaches and long-term follow-up for prenatal hydronephrosis

Objective:

This study summarises the outcomes of 149 patients who underwent surgery for antenatally diagnosed unilateral hydronephrosis.

Methods:

The medical records of such patients over a 23-year period were reviewed retrospectively. Age at the time of operation, preoperative and postoperative mean pelvic diameter on ultrasound, split renal function, washout patterns on scintigraphy, and early and late complications were recorded.

Results:

The mean preoperative follow-up period was five months (range: 1–66 months). One patient was operated on after 12 months and two patients after five years of follow-up. Mean preoperative pelvic diameter and renal function were 30.8 mm and 38.6%, respectively; all patients had an obstructive wash-out pattern. In the postoperative period, the corresponding measurements were 11.7 mm and 39.2%, with 111 non-obstructive, 24 partially obstructive, and 14 obstructive wash-out patterns. Three patients with severe caliectasis and low renal function underwent surgery despite mild hydronephrosis. The mean postoperative follow-up period was six (range 4–11) years. Complications developed in 14 (9.3%) patients.

Conclusion:

Patients with antenatal hydronephrosis may need surgery even after a follow-up period of six years. Because of the potential late development of complications, postoperative follow-up should be continued for 10 years.

Mini incision open pyeloplasty - Improvement in patient outcome

PURPOSE

To assess the subjective and objective outcomes of mini-incision dismembered Anderson-Hynes pyeloplasty in the treatment of primary ureteropelvic junction obstruction (UPJO).

MATERIALS AND METHODS

Between January 2008 to January 2013, Anderson-Hynes pyeloplasty was performed in 71 patients diagnosed with primary UPJO. Small subcostal muscle splitting incision was used in all cases. Sixteen patients with renal calculi underwent concomitant pyelolithotomy. Subjective outcome was assessed using visual pain analogue score (VAS). For objective assessment, the improvement in differential renal function (DRF) and radio-tracer wash out time (T1/2) on Tc-99m DTPA scan and decrease in hydronephrosis (HDN) on renal ultrasound (USG) and urography (IVU) were assessed.

RESULTS

Mean incision length was 5.2 cm. The average operating time and postoperative hospital stay was 63 (52-124) minutes and 2.5 (2-6) days respectively. Concomitant renal calculi were successfully removed in all the patients. Overall complication rates were 8.4% and overall success rate was 98.6% at median follow-up of 16 months. There was significant improvement in pain score (p=0.0001) and significant decrease in HDN after the procedure. While preoperative mean T1/2 was 26.7±6.4 minutes, postoperative half-time decreased to 7.8±4.2 minutes at 6 months and to 6.7±3.3 minutes at 1 year. Mean pre-operative DRF was 26.45% and it was 31.38% and 33.19% at 6 months and 1 year respectively.

CONCLUSIONS

Mini-incision pyeloplasty is a safe and effective technique with combined advantage of high success rates of standard open pyeloplasty with decreased morbidity of laparoscopic approach. Excellent functional and objective outcomes can be achieved without extra technical difficulty.

Laparoscopic pyeloplasty in infants: single-surgeon experience

INTRODUCTION

Although laparoscopic pyeloplasty (LP) is popular in children, its role in infants is less well defined. It is presumed that infant LP is technically challenging, with a higher failure rate.

OBJECTIVE

To consider the hypothesis that LP can be safely and successfully performed in infants.

METHODS

The records of 111 infants that underwent LP from March 2009 to December 2013 with at least 1 year of follow-up, were retrospectively reviewed. The results of pre- and postoperative imaging studies (ultrasound (US) and diuretic renogram (DR)), operative details and complications were noted. Pre- and postoperative parameters were compared using statistical software.

RESULTS

The details are given in the Table. Laparoscopic pyleoplasty was successfully completed using three ports in all children without any open conversions. There were complications in 14 children (12%); 13 did not require a second intervention and the final outcome was not affected. One child (1%) had a re-obstruction with worsening hydronephrosis (HDN) 2 months after stent removal; she underwent successful redo LP. Median follow-up was 2 years; LP was successful in relieving the obstruction in 115 kidneys (99%); all had follow-up US, while 76 children had follow-up DR. The tests showed significant reduction in HDN (mean pre-operative anteroposterior diameter (APD) of renal pelvis, 34.4 mm (SD 13.4) versus mean post-operative APD 10.6 mm (SD 5.7), p < 0.001) and improved drainage in all kidneys. In unilateral cases, there was significant improvement in mean split renal function (SRF) of the operated kidneys (pre-operative 22.1% (SD 8.6) versus post-operative 35.6% (SD 11.4), p < 0.001).

DISCUSSION

Over the past 6 years, all pyeloplasties at our unit have been performed by laparoscopy, irrespective of the age or weight of the child. In this large retrospective series, it is demonstrated that infant LP is a safe and successful operation; pyeloplasty in this age group not only resulted in significant reduction of hydronephrosis, but also in significant functional improvement. The results are comparable to published series comparing open pyeloplasty to laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70 to 96%, and complication rates ranging from 0 to 24% for open pyeloplasty.

Factors associated with age at pyeloplasty in children with ureteropelvic junction obstruction

OBJECTIVES

Our objectives were to: (1) delineate factors associated with surgery at <1 year and (2) determine if early intervention was associated with increased risk of readmission.

METHODS

We conducted a retrospective review of children age 0-18 years with a diagnosis of UPJ obstruction who underwent pyeloplasty from 1/1/1999 to 9/1/2009 using the PHIS database. Data collected included patient factors (race, gender, insurance type, APR-DRG severity of illness) and hospital factors (annual case volume, census region, academic status). Outcomes assessed were: age at surgery and hospital readmission within 1 year of surgery. Data were analyzed using logistic regression and Cox PH for multivariate analyses.

RESULTS

4499 children met study criteria. Minority race (OR 1.55), male gender (OR 1.49), public insurance (OR 1.37), high severity of illness (OR 3.60), Southern region (OR 1.44), and low hospital volume (OR 1.37) were significant predictors of early surgery (p < 0.05). Only early surgery (HR 2.42; 95% CI 1.67-3.49 2.42) was associated with increased risk of readmission.

CONCLUSIONS

In children with UPJ obstruction, age at surgery is associated with patient demographic and hospital factors. Early surgery is associated with higher rates of readmission, suggesting that variations in age at surgery may be associated with significant differences in outcomes.

Laparoscopically Guided External Transanastomotic Stenting in Dismembered Pyeloplasty: A Safe Technique

OBJECTIVE

To describe a technique for insertion of external transanastomotic stents during laparoscopic dismembered pyeloplasty in children of all age-groups. To analyze stent-associated complications and changes in differential renal function (DRF).

PATIENTS AND METHODS

A retrospective study was performed of all patients up to 18 years of age undergoing laparoscopic pyeloplasty at our institution between March 2004 and December 2013. We analyzed patients in whom an external transanastomotic stent was placed using a specially constructed semicircular spear. Medical records were reviewed for stent-associated complications such as bleeding, stent dislocation, stent obstruction, and urinary tract infection. Additionally required secondary surgical procedures and changes in DRF were assessed.

RESULTS

A total of 150 patients (155 renal units [RU]) were included in the study, with a median patient age of 22 months (range, 1-214). Stents were removed after a median time of 7 days (range, 3-21). Stent-associated complications were observed in a total of 11 patients (12 RU), consisting of stent dislocations (6 RU), stent obstructions (3 RU), and persistent percutaneous leakage along the stent (1 RU) or after stent removal (2 RU). Stent-associated complications required a secondary surgical procedure in 4 RU. Neither significant blood loss nor urinary tract infection was associated with external transanastomotic stent placement. DRF did not change significantly after the procedure.

CONCLUSION

External transanastomotic stenting during laparoscopic dismembered pyeloplasty using a specially constructed semicircular spear is a safe technique associated with a low complication rate and only rarely requires secondary surgical procedures for stent-related complications. This technique makes an additional anesthesia for stent removal unnecessary, as it is required for internal urinary diversion.

Time course of hydronephrotic changes following unilateral pyeloplasty

OBJECTIVES

The temporal pattern of hydronephrotic change following pyeloplasty has not been well defined. To address this issue, 23 years of postpyeloplasty follow-up data from a single surgeon were analyzed.

PATIENTS AND METHODS

Records of dismembered pyeloplasty from 1986 to 2004 were retrospectively reviewed. Ultrasound follow-ups were conducted at 3-6-month intervals after surgery for up to 3 years, and were then extended to either annually or biannually until the completion of puberty. Overall outcome of hydronephrosis (HN), timing of initial improvement and normalization were determined. Factors associated with these changes were examined.

RESULTS

Of 215 patients who completed follow-up of at least 5 years, about 80% experienced either normalization or improvement. Once they had shown improvement of HN during follow-up, no recurrence was observed. The median time for recognition of initial improvement and normalization of HN was 8 months and 41 months after surgery, respectively. Multivariate analysis revealed that the presence of immediate postoperative obstruction was a negative factor for initial improvement. Symptomatic presentation and no initial improvement until 6 months after pyeloplasty turned out to be negative factors for normalization.

CONCLUSIONS

The results confirm the excellent long-term outcome of pyeloplasty, and highlight the importance of frequent ultrasound until initial improvement of HN, when subsequent ultrasound follow-ups may be safely omitted to focus on follow-up of renal function, proteinuria and hypertension.

Duration of urinary leakage after open non-stented dismembered pyeloplasty in pediatric patients

OBJECTIVE

We aimed to determine the duration and associated complications of postoperative urinary leakage in pediatric patients undergoing open, non-stented dismembered pyeloplasty for ureteropelvic junction obstruction.

METHODS

A retrospective review of 100 patients who underwent an open non-stented dismembered pyeloplasty between 2003 and 2008 was performed. Duration of urinary leakage and postoperative complications were tabulated. Patients were considered to have a dry anastomosis if the Penrose drain was removed within one week of surgery.

RESULTS

Duration of leakage ranged from 0 to 27 days. 86% had Penrose drain removal within 7 days of surgery and were considered dry.14 patients demonstrated a persistent urinary leakage (PUL) ranging from 7 to 27 days. Complications of any type were significantly more likely in the group with prolonged drainage (p = .0126). UTI and obstruction were not significantly more likely to occur in patients with PUL (p = .0931 and p = .2616 respectively). Only one patient with PUL required placement of a ureteral stent.

CONCLUSION

We demonstrate that stentless dismembered pyeloplasty is feasible with a low rate of urinary drainage beyond one week. The character and quality of the slightly increased complications in those that demonstrated PUL were not great and not bothersome enough to warrant routine stenting.

[Pyeloplasty without intrarenal stent in pediatric patients]

PURPOSE

In spite of advances in minimally invasive endoscopic surgery, open dismembered pyeloplasty continues to be used in many pediatric centers, especially in small children. The purpose of this work is to present our experience in the performance of this technique using a minimally invasive open pyeloplasty without intrarenal stents.

MATERIAL AND METHODS

A retrospective review was made of patients between July 1992 and July 2009. During this time, 348 patients underwent open dismembered pyeloplasty. A total of 310 patients (89%), 223 boys and 87 girls, underwent open pyeloplasty without intrarenal stent. The incision was from 2 to 2.5 cm in the flank. An extrarenal drain (3-5 days) and a bladder catheter (< 24 hs) were placed in all patients.

RESULTS

A total of 319 pyeloplasties were performed without intrarenal catheter in our Service. Of these, 174 (54.5%) were on the left side, 127 (39.8%) on the right side and 9 (5.6%) were bilateral. Age interval was 14 days to 18 years, 58% of the children being younger than 12 months at the time of surgery. With a mean follow-up of 6.7 years (17 years to 11 months), 312 pyeloplasties (97.8%) were successful, with persistence of the obstructive patient in 7 patients who required a new open pyeloplasty (2.2%). Other complications were: prolonged drainage (6), wound infection (1), and urinary infection (2). Mean stay was 22 hours.

CONCLUSIONS

Open dismembered pyeloplasty is a safe and effective treatment choice for pyeloureteral stenosis in children and can be done without intrarenal stents with no detriment to its success.

[Thickness of the renal pelvis smooth muscle indicates the postoperative course of ureteropelvic junction obstruction treatment]

OBJECTIVE

To investigate the relationship between the histopathologic findings and the postoperative course of children surgically treated for ureteropelvic junction (UPJ) obstruction.

MATERIAL AND METHODS

Twenty-eight patients operated for unilateral UPJ obstruction from 1998 to 2005 with adequate histopathologic specimens and postoperative follow up were retrospectively reviewed. Specimens were stained using elastic van Geisson to differentiate smooth muscle from collagen and elastin. Postoperative follow up included renal ultrasound (U/S) and diuretic renogram studies.

RESULTS

Twelve patients with mean renal pelvis smooth muscle thickness (mRPSMT) of 136.97 ± 34.17 improved on the 6(th) postoperative month. Nine patients that improved after 9 months postoperatively had mRPSMT=173.61 ± 33.91. The rest 7 patients that improved on the 12(th) postoperative month had mRPSMT=258.78 ± 96.09. Correlation between renal pelvis smooth muscle and time of postoperative improvement was extremely significant (r = 0.7928, p < 0.0001).

CONCLUSION

The thickness of the renal pelvis smooth muscle is significantly correlated to the postoperative course of patients with UPJ obstruction and can be used as a prognostic tool for the onset of their improvement.

Use of artificial neural networks in the management of antenatally diagnosed ureteropelvic junction obstruction

BACKGROUND

In this study, an artificial neural network (ANN) based system has been developed specifically to help in the management of antenatally diagnosed uretero-pelvic junction (UPJ) obstruction.

METHODS

A total of 53 infants with antenatally detected hydronephrosis caused by UPJ obstruction were included in this study. A neural network was developed with the help of a commercially available software package. The patients' age and sex, renal pelvic diameter, laterality, split renal function and presence of renal scar on radionuclide scan, follow-up times, urine culture results and the presence of symptomatic infections were used as variables. These data were also entered into a statistical software package and linear regression analysis was done.

RESULTS

During the follow-up period, 36 children were observed, and the remaining 17 renal units underwent pyeloplasty. The average sensitivity of the ANN model in predicting the outcome was found to be 92% in the training group and 75% in the validation and test groups. In linear regression, none of the predictors were found to be statistically significant.

INTERPRETATION

In this study, we have demonstrated that the use of ANNs in antenatally diagnosed UPJ obstruction can help the clinician in making treatment decisions, and thus can be useful in daily clinical practice.

The significance of fetal renal pelvic dilatation as a predictor of postnatal outcome

OBJECTIVES

To define the clinical outcome of fetal renal pelvic dilatation (FRPD) in cohort of infants in United Arab Emirates.

STUDY DESIGN

Data were collected from all fetuses having FRPD from January 2005 to February 2008. FRPD was graded as normal (<5 mm), mild (5-9 mm), moderate (10-15 mm), and severe (>15 mm).

RESULTS

Data from 80 fetuses with 120 kidneys were studied. Nine resolved antenatally and seven were lost to follow up. Of the remaining 89 FPRD (64 patients), 36% had normal postnatal ultrasound, 22.5% significant uropathy, and 41.5% had isolated hydronephrosis. Pelvi-ureteric junction obstruction was the commonest identified underlying abnormality. Severe FRPD predicted significant postnatal uropathy with a sensitivity of 65% and a specificity of 98.6%. Moderate FRPD increased the sensitivity to 95% but decreased the specificity to 60.9%, mild FPRD was seldom (4%) associated with significant postnatal pathology. Postnatal resolution was significantly (p = 0.01) higher in mild RPD than in the moderate or severe group.

CONCLUSION

Severe FRPD need comprehensive postnatal assessment. Although moderate FRPD had a high prevalence of uropathy, they rarely needed surgical intervention. Parents could be reassured that RPD of less than 10 mm in the third trimester is unlikely to be associated with significant uropathology.

Ureteric stents in pyeloplasty: a help or a hindrance?

OBJECTIVE

To examine whether routine ureteric stenting influences outcome of pyeloplasty for pelvi-ureteric junction obstruction (PUJO).

PATIENTS AND METHODS

A 10-year review was conducted of 105 consecutive open Anderson-Hynes dismembered pyeloplasties performed for PUJO, covering two periods: (1) pyeloplasties performed without ureteric stents (1994-1998) and (2) pyeloplasties performed with ureteric stents (1999-2003). Outcomes (expressed as means+/-SEM) of unstented patients (UPs; n=47) and stented patients (SPs; n=58) were compared and results analysed using ANOVA and chi-square tests.

RESULTS

Fifty-five patients (53.9%) presented with antenatal hydronephrosis, whilst 47 (46.1%) presented postnatally (at mean age 88.4+/-7.1 months) with one or more of the following: pain (n=30, 63.8%), urinary tract infection (n=16; 34.0%), haematuria (n=3, 6.4%), abdominal mass (n=3, 6.4%), acute renal failure (n=2, 4.3%), incidental finding (n=4, 8.5%). Pyeloplasty was performed (at mean age 58.9+/-5.3 months) for one or more of the following: pain (n=40, 38.1%), haematuria (n=6, 5.7%), urinary tract infection (n=18, 17.1%), poor initial or deteriorating function (n=29, 27.6%), severe or deteriorating hydronephrosis (n=41, 39.0%), calculus (n=1, 0.95%). Recognised complications of surgery were significantly higher in UPs (5 of 47; 10.6%) than SPs (0 of 58); P=0.016. These were leakage (n=4, 8.5%) and obstruction by blood clot (n=1, 2.1%). Nine SPs (15.5%) developed stent-related complications, including stent migration (n=5, 8.6%), infection (n=3, 5.2%) and calculus (n=1, 1.7%). SPs had significantly shorter hospital stay (2.71+/-0.25 days) than UPs (4.30+/-0.38 days); P<0.01. Preoperative renal pelvis antero-posterior diameter in SPs (3.24+/-0.25 cm) and UPs (3.21+/-0.28 cm) was comparable (P=0.80). Following pyeloplasty, a significant improvement from these preoperative baselines occurred earlier in SPs (at 3.10+/-0.46 months) than UPs (at 15.71+/-3.05 months); P<0.01.

CONCLUSION

Stented pyeloplasty significantly reduces complications from surgery, particularly leakage, and results in shorter hospital stay and earlier resolution of hydronephrosis, but at the expense of stent-related complications which could be avoided in future by the use of external stents.

Management of fetal hydronephrosis

Prenatally detected hydronephrosis has become a common diagnosis for both pediatric nephrologists and urologists. Hydronephrosis is most commonly assessed by the Society for Fetal Urology grading system or anterior-posterior diameter of the renal pelvis in the transverse plane. Some cases of bilateral obstruction, most commonly from posterior urethral valves, can be life-threatening and require close monitoring or, occasionally, fetal intervention. The majority are unilateral and of no threat to the growing fetus. The crux of postnatal management is the separation of the minority of patients whose renal function is at risk from the majority who will suffer no renal consequences. This management involves a regimen of ultrasounds, voiding cystourethrograms, and nuclear renograms for diagnosis and surveillance. Recent literature has been aimed at the timing and necessity of these studies in order to minimize extraneous studies without compromising renal function.

The minimally invasive open pyeloplasty

BACKGROUND

The dismembered pyeloplasty is the operation of choice for ureteropelvic junction obstruction (UPJO). Recently, with the advent of improved minimally invasive techniques and equipment, laparoscopic dismembered pyeloplasty has gained popularity. We present our experience with a minimally invasive open pyeloplasty.

MATERIALS AND METHODS

A retrospective review of the last 5 years of consecutive open pyeloplasties was performed with regard to age, surgical operative time, length of hospital stay, need for postoperative narcotics and surgical success.

RESULTS

Seventy-four patients had a dismembered pyeloplasty using an open flank incision: 34 patients (<1 year), 13 (1-5 years), 7 (5-10 years) and 20 (>10 years). Mean surgical time for patients according to age was: <1 year, 109.4+/-36.4 min; 1-5 years, 105.5+/-37.4 min; 5-10 years, 131.1+/-76.4 min; >10 years, 134+/-37.8 min. Mean incision sizes for the respective groups were 2.01+/-0.50 cm, 1.93+/-0.73 cm, 2.71+/-1.55 cm and 3.5+/-1.58 cm. The last 20 patients under 1 year of age had incisions of 1-1.5 cm. The majority of incisions were via a posterior subcostal muscle splitting approach. All patients received postoperative ketorolac and acetaminophen. Supplemental narcotics were not required in any patient less than 10 years old. All patients were discharged in <23 h. Radiologic and/or symptomatic improvement was seen in 70/74 (95%) patients after surgery.

CONCLUSION

The minimally invasive approach to open pyeloplasty is a safe and effective treatment choice for UPJO. In small children our technique can be easily performed through a small incision without excessive postoperative pain allowing for early discharge. Our results with a refined open surgical technique challenge the current trend in the literature that laparoscopic pyeloplasty techniques are superior with regard to cosmesis, length of stay and postoperative narcotic use.

Is one-day hospitalization after open pyeloplasty possible and safe?

OBJECTIVES

A critical pathway was developed to determine whether open pyeloplasty could be performed in preadolescent and adolescent children with ureteropelvic junction (UPJ) obstruction with patients safely discharged after a 1-day hospitalization.

METHODS

Twenty-six consecutive children who underwent open dismembered pyeloplasty for the treatment of UPJ obstruction and followed a critical pathway for preoperative education, operative management, and postoperative care were evaluated. The patients received a caudal anesthetic for preventive analgesia unless not technically possible and postoperative ketorolac (Toradol) unless contraindicated. A child was required to fulfill five strict criteria to be discharged from the hospital.

RESULTS

The 26 patients with UPJ obstruction consisted of 18 boys and 8 girls (age range 2.4 months to 16.7 years). Of the 26 patients, 24 (92%) were discharged on the first postoperative day, with a mean length of hospitalization of 1.1 days (range 1 to 3). All patients younger than 6 years of age (19 patients) were discharged on the first postoperative day. Of the 25 patients who received a caudal block, 24 (96%) were discharged on the first postoperative day. All patients tolerated the procedure well without major complications.

CONCLUSIONS

This is the first study, to our knowledge, to describe a detailed critical pathway for open pyeloplasty to treat UPJ obstruction. This enabled all children younger than 6 years of age and more than 90% of all patients to be discharged uniformly on the first postoperative day.

Dismembered pyeloplasty in children: A review of 5 years single center experience

AIM

Dismembered pyeloplasty is the treatment of choice for significant ureteropelvic junction obstruction in children. In the present study, we review our experience in 103 pediatric patients and present the clinical characteristics, the surgical treatment and its complications and the long term results.

METHODS

We have reviewed the medical charts of 103 consecutive patients who underwent dismembered pyeloplasty in a 5-year period, from 1997 to 2002. Preoperative data, short- and long-term complications and outcome were recorded. Imaging studies included urinary tract sonography and dynamic renal scans, the results of which were compared pre- and postoperatively.

RESULTS

Most of our patients were boys (81%), diagnosed prenatally (78%). We had no major complications and acceptable incidence of minor complications. Postoperative outcome was excellent, with decreased hydronephrosis (81%), improved renal drainage (87%) and preserved or improved renal function (89%).

CONCLUSION

Dismembered pyeloplasty can be performed with a low incidence of minor complications, no major complications and excellent long-term outcome.

Endopyelotomy in Childhood: Our Experience with 37 Patients

PURPOSE

To evaluate our experience and results with endopyelotomy in the pediatric population.

PATIENTS AND METHODS

Between 1990 and 2002, we performed percutaneous antegrade endopyelotomy under general anesthesia in 37 children because of ureteropelvic junction (UPJ) stricture. The youngest patient was 4.5 years and the oldest 17 years at the time of the procedure (mean age 11.5 years). One patient had bilateral stenosis; the two sides were operated on separately. After insertion of a 4F ureteral catheter and filling the collecting system with colored contrast material, a middle calix was punctured under fluoroscopic control. The tunnel was dilated to 26F by telescopic metal dilators. After insertion of a 0.035-inch gidewire through the UPJ, all its layers were cut by a cold knife in the dorsolateral direction so that the periureteral fatty tissue could be seen. Finally, the ureteral wound was stented by a 6F to 12F transrenal drain or a double-J catheter, which was removed after 6 weeks.

RESULTS

Among the 37 patients, the procedure had to be repeated in 1 because the transrenal drain stenting the UPJ slid back to the renal pelvis. We had to perform open pyeloplasty or nephrectomy in two patients because of bleeding or failed procedure. The average postoperative hospital stay was 6 days. Comparison of the preoperative intravenous urograms with studies performed 1 year after endopyelotomy showed an overall success rate of 89%. All patients are without complaints at the moment.

CONCLUSIONS

In experienced hands, endopyelotomy is a safe and effective method for the treatment of UPJ stricture, not only in the adult, but also in the pediatric, population.

Stented versus nonstented pediatric pyeloplasty: a modern series and review of the literature

PURPOSE

Dismembered pyeloplasty remains the principal surgical therapy for pediatric ureteropelvic junction obstruction, although the method of postoperative drainage continues to be debated. We compared stented versus nonstented repairs in a modern series.

MATERIALS AND METHODS

We evaluated 117 pediatric dismembered pyeloplasties performed by 3 pediatric urologists at 2 institutions from 1991 to 2000. Hospital stay, success rate and complication rate were reviewed. Results were compared with 833 evaluable cases in the literature.

RESULTS

Of the 52 stented repairs urological complications developed in 6 (12%), including symptomatic urinary tract infection in 3 and temporary obstruction in 3. Of the 65 nonstented repairs urological complications developed in 10 (15%), including prolonged leakage in 3, urinoma in 3, obstruction in 3 and urinary tract infection in 1. Mean hospitalization plus or minus standard error was shorter in the stented group (2.1 +/- 0.89 versus 2.6 +/- 1.1 days, p <0.02). We identified 9 previous studies comparing a total of 339 stented with 494 nonstented repairs. Overall the number of complications was almost equal (12% versus 14%) but the stented group had more infections, whereas more leaks occurred in the nonstented group. The nonstented group required more secondary procedures (12 of 339 versus 45 of 494, p = 0.003). Hospital stay was 12 days for stented and 5 days for nonstented repair in these earlier series.

CONCLUSIONS

In children the outcome of stented pyeloplasty is similar to that of nonstented repair. In contrast to previous reports, using a stent for drainage should not necessitate a longer hospital stay.

Successful early pyeloplasty in infants

BACKGROUND

Early pyeloplasty for the treatment of congenital ureteropelvic junction obstruction to maximize nephron salvage is justified only if potential hazards of operating on small infants are avoided.

METHODS

The records were analyzed of all infants who underwent pyeloplasty over a 5-year period. Open pyeloplasty was performed if collecting systems had deteriorated or were demonstrated to be obstructed; it was also performed for severe cases of hydronephrosis. Outcome of surgery in the younger infant (patients <2 months of age) was compared with the older infant group (patients >2 months of age). Preoperative evaluation in case of mild or moderate hydronephrosis was directed toward ruling out a non-obstructed collection system and included voiding cystourethrography, and serial ultrasonography and/or dual isotope diuretic renography. Postoperative assessment consisted of serial ultrasonography and/or nuclear imaging to confirm decompression and relief of obstruction.

RESULTS

A total of 24 pyeloplasties were performed on 22 patients in the younger infant group (two bilateral) and 30 were performed on 27 infants in the older infant group (three bilateral). The only significant differences between the groups were as follows: patients in the younger infant group were likely to present in utero (75%, p = 2.69), whereas those in the older infant group were more likely to present with a urinary tract infection (48%, p = 4.12). During follow-up examination, 23 renal units in the younger infant group and 24 in the older infant group were judged to be stable or improved. Four kidneys were not salvaged after pyeloplasty, one in the younger infant group and three in the older infant group.

CONCLUSIONS

Good results of pyeloplasties performed in the infants in this series support early correction of ureteropelvic junction obstruction in infants.

A transperitoneal laparoscopic approach to endourology

Although endoscopic methods have become the preferred means of management for many diseases facing the genitourinary surgeon, a laparoscopic approach might be considered comparable or advantageous in select circumstances. In the literature, laparoscopists reporting their work have favored the transperitoneal approach; however, there are clear advantages and disadvantages to both transperitoneal and retroperitoneal laparoscopy. Intracorporeal suturing remains the most time-consuming aspect of reconstructive surgery, and research emphasis has been on suturing devices and novel anastomotic techniques. Laparoscopic pyeloplasty is efficacious and should be considered, particularly in the case of a capacious renal pelvis, crossing vessel, or failed previous endopyelotomy. Laparoscopic pyelolithotomy is uniquely suitable for patients with aberrant anatomy, such as a horseshoe kidney, and may be performed concurrently with pyeloplasty for ureteropelvic junction obstruction. The use of laparoscopic extravesical ureteral reimplantation awaits further development in both open and subtrigonal injection techniques. Its use in colposuspension is undetermined and requires further study as suturing technology improves. During laparoscopic exploration, it is possible to address intraoperative injuries to the ureter and bladder laparoscopically. In summary, laparoscopic surgery of the urinary tract is a "work in progress," but it offers promise for some of the most challenging of circumstances. As the technology advances and the clinical experience widens, the indications and contraindications for these techniques will be better established.

Nephrostomy tube drainage with pyeloplasty: is it necessarily a bad choice?

PURPOSE

Despite continued controversy regarding the optimal method of urinary diversion after dismembered pyeloplasty in children, we have treated the majority of our patients with postoperative nephrostomy tubes and no stents. We report our experience.

MATERIALS AND METHODS

The records of all patients who underwent surgery for ureteropelvic junction obstruction from August 1985 to October 1998 and were treated only with a nephrostomy tube after pyeloplasty were reviewed for hospital course, complications and postoperative followup. All patients had a perinephric Penrose drain as well as a Foley catheter placed for bladder drainage.

RESULTS

A total of 137 pyeloplasties were performed in 132 patients, including 5 with bilateral ureteropelvic junction obstruction, using only nephrostomy tube drainage with an average followup of 2.1 years. Initial nephrostograms demonstrated good drainage across the repair with no extravasation in 91% of patients. Subsequent nephrostograms revealed a widely patent anastomosis in the remaining cases. No patient had postoperative obstruction, or required secondary pyeloplasty or nephrectomy. Urinary tract infection developed in 2 patients (1.5%). Mean hospitalization was 4.4 days. There was a significant difference in length of stay in the last 5 years compared to that in previous years (3.4 versus 5.8 days, p <0.05) and hospital stay continues to decrease.

CONCLUSIONS

Use of only a nephrostomy tube after pyeloplasty resulted in few complications and an open anastomosis in 100% of cases. Nephrostomy drainage not only serves as a protective mechanism, but also allows easy access for radiographic studies before removal of the tube. In addition, nephrostomy tube drainage does not prolong hospitalization and the tube may be easily removed on an outpatient basis without further anesthesia.