Retrograde ureteroscopic endopyelotomy

Technology Based Treatment for UreteroPelvic Junction Obstruction

Surgical management of ureteropelvic junction obstruction (UPJO) has historically been performed with open pyeloplasty. With the advent of endourology, laparoscopy, and robotics, minimally-invasive techniques have been described and accepted as alternatives to open surgery. Each of these approaches has its own advantages and disadvantages, equipment needs, degree of invasiveness, and experience of the treating urologist. Advocates and critics have their own say as to their preferred technique. In this article, we review the chronological evolution of these techniques and discuss their current role in the management of UPJO.

Retrograde Endopyelotomy with Cutting Balloon™ for Treatment of Ureteropelvic Junction Obstruction in Infants

PURPOSE

The aim of this study is to analyze results of retrograde endopyelotomy with cutting balloon for treatment of ureteropelvic junction obstruction (UPJO) in infants.

METHODS

We routinely treat patients with UPJO under 18 months of age with retrograde high-pressure balloon dilatation of the pelviureteric junction (PUJ). During the procedure, in these cases where narrowing at the PUJ persists, endopyelotomy with cutting balloon is performed. Endopyelotomy is performed over guidewire with 5-mm Cutting Balloon™ under fluoroscopic control. Double-J stents is left in situ for 4 weeks. We retrospectively analyzed the postoperative, clinical, and radiological outcome infants treated with cutting balloon endopyelotomy between 2007 and 2015.

RESULTS

Sixteen patients required cutting balloon endopyelotomy to achieve complete resolution of narrowing of the waist observed during high-pressure balloon dilatation of the PUJ. Mean operative time was 35 ± 21 min (mean ± SD) and hospital stay was <24 h in all patients. Complete resolution of the narrowing at the PUJ under fluoroscopy was achieved in all cases, with no perioperative complications. One patient presented with urinary tract infection, postoperatively (Clavien grade II). Preoperatively, all cases had grade IV SFU hydronephrosis with parenchymal thinning. During follow-up, resolution of the hydronephrosis was observed in 11 patients (grade I SFU). In four infants, there was an improvement of the hydronephrosis (grade II SFU) and the renogram curve. In one case, an open pyeloplasty was required due to persistent hydronephrosis and obstructive curve.

CONCLUSION

We believe that endopyelotomy with cutting balloon could be a valid and safe option in minimally invasive management of UPJO in infants.

Ureteropelvic junction obstruction: which is the best treatment today?

The aim of this review is to critically compare the different procedures performed for the treatment of ureteropelvic junction obstruction (UPJO) in order to identify, currently, the best treatment that a urologist should propose to patients with this condition. Three different types of procedures were assessed: open pyeloplasty (OP), endopyelotomy, and laparoscopic pyeloplasty (LP). Regarding efficacy, success rates of 94.1, 62-83, and 95.9-97.2% were reported for OP, endopyelotomy, and LP, respectively. Concerning operative time and length of hospital stay, no extensive data are available in the literature, although endopyelotomy seems to provide shorter times with respect to those reported after OP and LP. Regarding the complication rate, it was very similar after the different techniques and due to the respective approaches. Overall, our data support the conclusion that LP provided a balance between the highly successful technique reported by OP and the quick postoperative recovery provided by the endoscopic approach. Anyway, in spite of these clear advantages, the reproducibility of LP is still strongly limited by the challenge of the learning curve. The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA), providing an extraordinary vision and precision of surgical movement, appears to be changing this scenario, allowing naïve surgeons to achieve very good results after few procedures. In this setting, robot-assisted pyeloplasty seems to be emerging as the new standard of care in the patients with UPJO, which will further take place over the other techniques once its costs decrease.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Treatment of ureteropelvic junction obstruction using a detachable inflatable stent: initial experience

OBJECTIVE

We describe a new method for treating ureteropelvic junction (UPJ) obstruction using a detachable inflatable stent positioned via a cystoscopic transvesicular approach.

CONCLUSION

Eleven patients with UPJ obstruction were treated using a detachable inflatable stent, 64% of whom experienced complete pain relief. In 82% of patients, no obstruction was seen on renograms obtained after the procedure. The initial results achieved in the treatment of UPJ obstruction with a detachable inflatable balloon are promising, but further research in a larger patient population is required.

Pathophysiology and treatment of ureteropelvic junction obstruction

This paper reviews the current literature on both the pathophysiology and treatment options for ureteropelvic junction obstruction (UPJO). A medical literature search using Pubmed/Medline that addressed both the pathophysiology of UPJO and the different treatment options for the adult and pediatric population with UPJO was performed. The pathophysiology of UPJO is still unknown but appears to be multifactorial. Perhaps future molecular studies will give us an answer to the etiology and also a pathway in preventing UPJO. Treatment options have been studied in-depth, and the gold standard is open pyeloplasty. In both the pediatric and adult population, laparoscopic or robotic pyeloplasty has similar success rates to open pyeloplasty with the benefits of minimally invasive surgery. In the pediatric population, however, further studies need to be done. Endopyelotomy also has a role in the treatment of UPJO but should have strict selection criteria.

Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results

OBJECTIVES

To analyse the indications and long-term results of endoscopic and minimal access approaches for the treatment of ureteropelvic junction (UPJ) obstruction and to compare them to open surgery.

METHODS

A review of the literature from 1950 to January 2007 was conducted using the Ovid Medline database.

RESULTS

A lack of standardisation of techniques used to diagnose UPJ obstruction and to follow up treated patients introduces a degree of inaccuracy in interpreting the success rates of the various modalities of treatment. However, there is no indication that any one of these techniques is affected by this to a greater or lesser extent than another. Open pyeloplasty achieves very good (90-100% success) results, endopyelotomy and balloon disruption of the UPJ fail to match these results by 15-20%, and minimal access pyeloplasty produces results that are at least as good as those of open surgery but with the advantages of a minimal access approach.

CONCLUSIONS

Minimal access pyeloplasty is likely to gradually replace endopyelotomy and balloon disruption of the UPJ for the treatment of UPJ obstruction. The much higher cost of robotic pyeloplasty and greater availability of laparoscopic expertise in teaching centres are likely to limit the dissemination of robotic pyeloplasty.

Retrograde endopyelotomy: a comparison between laser and Acucise balloon cutting catheter

Endopyelotomy and laparoscopic pyeloplasty are the preferred modalities for treatment of ureteropelvic junction obstruction because of their minimally invasive nature. There are continuous efforts for improving endopyelotomy techniques and outcome. Retrograde access represents the natural evolution of endopyelotomy. The Acucise cutting balloon catheter (Applied Medical Resources Corp., Laguna Hills, CA) and ureteroscopic endopyelotomy using holmium laser are the most widely accepted techniques. The Acucise catheter was developed to simplify retrograde endopyelotomy and made it possible for all urologists, regardless of their endourologic skills. The Acucise catheter depends on incision and dilatation of the ureteropelvic junction under fluoroscopic guidance, whereas ureteroscopy allows visual control of the site, depth, and extent of the incision; the holmium laser is a perfect method for a clean precise incision. Review of the English literature showed that the Acucise technique was more widely performed, though laser had better (but not statistically significant) safety and efficacy profiles.

Ureteroscopic laser approach in recurrent ureteropelvic junction stenosis

OBJECTIVES

Endourological procedures are widely used for treating ureteropelvic junction (UPJ) obstruction. Our aim was to establish the value of using laser retrograde endopyelotomy (REP) in cases with recurrence.

MATERIALS AND METHODS

Between November 2000 and June 2005 we performed 30 REPs in recurrent UPJ obstruction with grades 3 and 4 hydronephrosis (failed pyeloplasty, 17 cases; failed endopyelotomy, 13 cases). Our series was characterized by absence of renal calculi, stenosis length<2 cm, and absence of massive hydronephrosis. We used semirigid and flexible endoscopic equipment (Wolf and Storz) and holmium:YAG laser. In 11 cases, an indwelling double J was placed for 2 wk. An indwelling pyelostent 8/12 F was postoperatively placed for 8 wk.

RESULTS

All cases were evaluated at 6, 12, and 18 mo. Ultrasonography and urography were the main follow-up investigations. At 6 mo, we found normal UPJ and pyelocaliceal system in 9 cases (30%); a reduction of the hydronephrosis degree with normal UPJ in 4 cases (13.3%); and no changes of the hydronephrosis degree in 17 cases (56.6%), but with large UPJ passage in 13 of the 17 cases (76.5%). REP success did not correlate with the degree of hydronephrosis. The success rate after 18 mo was 83.3%. Patients experienced minor complications. The mean follow-up period was 31 mo (range: 18-52 mo).

CONCLUSIONS

REP may represent an efficient minimally invasive technique in recurrent UPJ stenosis, with a reduced rate of complications, short period of hospitalization, and good anatomical and functional results.