Ureteropelvic junction obstruction in children. Unique considerations for open operative intervention

Use of retrograde pyelogram to plan for miniature open incision in pediatric pyeloplasty

INTRODUCTION

As robotic-assisted surgery becomes increasingly utilized for pediatric ureteropelvic junction (UPJ) obstruction, open surgeons have countered by using muscle-splitting, miniature (≤2 cm) incisions. To prepare for this type of incision during pyeloplasty, it is necessary to define the exact location of the UPJ. The use of retrograde pyelogram (RPG) at the time of pyeloplasty helps the surgeon to identify the exact location of UPJ, and thus be able to use a muscle-splitting, miniature incision for open pyeloplasty.

OBJECTIVE

We hypothesize that when performing a muscle-splitting, miniature incision open approach; preoperative RPG frequently changes the traditional pyeloplasty flank incision at the tip of the 11th or 12th rib.

MATERIALS & METHODS

A retrospective review of open pyeloplasties performed by a single surgeon at our institution from 7/1/2010 to 12/31/2018 was performed to determine rate of use of RPG, open pyeloplasty incision location and to determine what factors are predictive of incisional site.

RESULTS

114 of 122 (93.4%) patients with 115 renal units had pyeloplasties with preoperative RPG performed. Of the 8 procedures without RPG, two had a pelvic kidney diagnosed prior to surgery, two had narrow ureteric orifices that were difficult to cannulate, and four had associated reflux. In 31/115 (27%) pyeloplasties the incision was changed from a standard incision position at the 11th or 12th rib to an alternative incision (i.e. extended muscle-transecting incision at the tip of the 11th or 12th rib, or to an alternate incision site including Gibson, McBurney's incision, or low anterior abdominal incision). 84/115 (73.0%) had a miniature (<2 cm) incision at the tip of the 11th or 12th rib. Grade IV hydronephrosis was a significant predictor for changing the traditional incision site (p = 0.02). Preoperative nephrostomy tube insertion was also associated with an increased likelihood of having an alternate incision (p = 0.04). Incision site was not significantly affected by age of the patient at surgery, patient sex, size of the affected kidney, T1/2 times of <30 min, split function of <30%, kidney length differential, or laterality.

CONCLUSION

The consistent use of RPG prior to pyeloplasty helps surgeons to plan for a small muscle-splitting, miniature open incisions. In our experience, 27% of pyeloplasties required alternative incision sites based on the results of pre-operative RPG.

Minimally invasive open pyeloplasty in children: Long-term follow-up

OBJECTIVE

Our aim was to report the long-term follow-up for minimally invasive open pyeloplasty in children.

MATERIAL AND METHODS

A total of 213 children with a mean age 16.33 months underwent miniature open pyeloplasty for ureteropelvic junction obstruction between January 2010 and May 2016. Anderson-Hynes dismembered pyeloplasty was performed through a subcostal miniature incision. The intraoperative and postoperative parameters including surgical operative time, incision size, intraoperative blood loss volume, postoperative analgesic use, hospital stay, complications, and success rate were documented.

RESULTS

The mean surgery time was 65 min (50-85 min), and incision size was 16.99 mm (12-36 mm). None of the patients required blood transfusion or narcotic analgesics in the postoperative period. The mean hospital stay was 21.97 h (10-48 h). Minor side effects included urinary tract infection (3.8%) and urinary leakage in one case (0.004%). Major complications were not observed. The mean antero-posterior pelvic diameter before and after surgery was 28.69 ± 11.54 mm and 15.89 ± 9.29 mm, respectively with a mean difference of 12.78 mm, which shows a significant decrease (P value = 0.001). The success rate was 98.1% with a mean follow-up of 21.43 months (3-56 months). Two of the recurrences occurred in the first postoperative year, another one after 1.5 years, and the last one after 4 years.

CONCLUSION

Our study confirms minimally invasive open pyeloplasty in children as a safe and efficient procedure with the least complication and hospital stay rate in comparison with other minimally invasive techniques. Moreover, long-term follow-up is a requirement in pyeloplasty surgery.

Retroperitonoscopic pyelopexy for pelviureteral junction obstruction with crossing vessel in adolescents: Hellstrom principle revisited

OBJECTIVE

To present our new approach using a minimally invasive technique for the management of pelviureteral junction (PUJ) obstruction with a crossing vessel.

MATERIALS AND METHODS

In December 2009 to December 2011, out of 23 cases of retroperitoneoscopic laparoscopic pyeloplasty, four adolescents presenting with PUJ obstruction due to an aberrant crossing vessel, with intermittent attacks of renal colic and mild dilatation of the renal pelvis and calyces, were operated by retroperitoneoscopic pyelopexy. A retroperitoneoscopic approach was used in all patients using three trocars. After dissection of the PUJ from the anterior crossing vessel, and ensuring good funneling of the PUJ that proved to show mild dilatation, an interrupted 3/0 polyglycolic suture was used to fix the renal pelvis to the psoas muscle away from the crossing vessel (pyelopexy). A retrograde DJ stent was placed at the end of the procedure.

RESULTS

The four patients had a mean age of 18.25 years (16-20): 2 males and 2 females, two right sided and two left sided. Average operative time was 46 min (40-55). All patients were discharged on the same day. No intraoperative complications were encountered. The DJ stent was removed 6 weeks postoperatively. After a mean follow up of 2.125 years (6 months-3 years) no recurrences were observed.

CONCLUSION

Retroperitoneoscopic pyelopexy is shown to be a reliable, effective, safe and minimally invasive technique for the management of PUJ obstruction with a crossing vessel in selected cases. Long-term follow up is needed to assess any recurrence or development of complications.

Miniature pyeloplasty as a minimally invasive surgery with less than 1 day admission in infants

PURPOSE

Open dismembered pyeloplasty is usually performed through flank, anterior subcostal or posterior lumbotomy incisions. These incisions are cosmetically less acceptable and may produce significant postoperative pain. We present the smallest incision for open pyeloplasty, called a 'miniature pyeloplasty'. The aim of this study was to reduce hospital stay and postoperative pain, along with enhanced cosmetic results.

PATIENTS AND METHOD

373 infants (mean age 4 months) with hugely dilated pelvises underwent the miniature pyeloplasty. The exact site of incision was determined by intraoperative renal ultrasonography and palpation. A muscle-splitting incision was made in the most dependent part of the lower quadrant. After meticulous dissection of the ureteropelvic junction component, the affected section was pulled out and underwent classic dismembered pyeloplasty without renal pelvis reduction. All children had long-duration stented anastomoses. Surgical incision size, operative time, hospital stay, postoperative analgesic use and complication rate were recorded.

RESULTS

The operation was successful in all patients. The mean operative time was 53 min (range 43-75) and patients were discharged after 18 ± 3 (mean ± SD) h. Incision size ranged from 11 to 15 mm (mean 13). No narcotic analgesic was required postoperatively and there were no major complications during follow up.

CONCLUSIONS

Miniature pyeloplasty is a safe and successful technique for ureteropelvic junction obstruction that avoids long operative time with negligible postoperative pain compared to the classic open pyeloplasty in infants. The exact incision site must be reconfirmed intraoperatively by physical examination or renal ultrasonography.

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.

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.

Is visualising ureter before pyeloplasty necessary in adult patients?

In this study, we aimed to detect whether or not visualising ureter and ureteropelvic junction (UPJ) preoperatively is necessary in adult patients who have primer UPJ obstruction. Between January 1995 to June 1999, 46 renal units in 45 patients with primer UPJ obstruction were evaluated. The patients were separated into 2 groups. In group 1, intravenous pyelography (IVP) and renal scintigraphy were performed to 17 renal units preoperatively. In group 2, in addition to these methods, either retrograde pyelography (RGP) or antegrade pyelography (AGP) were performed to 29 renal units. Renal/bladder sonogram was used in patients with poor renal function in IVP or in renal scintigraphy. All the operations were performed through a flank incision. In group 2, additional information was gained for 8 (27.5%) of the renal units preoperatively. No additional information for this group found intraoperatively. In group 1, we found additional information in 4 (23.53%) of the units intraoperatively. All the pathologies in both groups were corrected intraoperatively. Double-J (D-J) stent was used in 6 (35.29%) of the units in group 1 and 8 (27.58%) of the units in group 2 intraoperatively (p > 0.05). In group 2, 4 (13.79%) preoperative complications were seen due to RGP and they were treated either medically or conservatively. In the early postoperative period, a complication observed in 1 (5.88%) of the patients in group 1 and 1 of the patients in group 2 (3.44%) (p > 0.05). The first patient was treated with inserting D-J and the latter one was treated conservatively. In the 3rd postoperative month, success rate was found to be 94.11% in group 1 and 96.55% in group 2 (p > 0.05). Additional pathologies in adult patients with primer UPJ obstruction can be corrected intraoperatively through a flank incision. Therefore, imaging of ureter and UPJ may not be necessary in these patients.

The role of endourology in ureteropelvic junction obstruction

Endopyelotomy has benefited from abundant confirmatory investigations, and significant progress in different technical modalities has occurred. Retrograde techniques, including the Acucise (Applied Medical, Laguna Hills, CA) cutting balloon and the ureteroscopic Holmium laser incision, are becoming preferred approaches while the other modalities retain their specific indications. Long-term results and potential complications have been carefully studied and reported. Better identification of risk factors has prompted precise preoperative investigations and allowed for careful patient selection, leading to improved results. These results approach those of open pyeloplasty, but with minimal morbidity.