Vascular anatomy at the ureteropelvic junction

Percutaneous retropelvic endopyelotomy for treatment of ureteropelvic junction obstruction

Purpose:

A new minimally invasive approach for endopyelotomy for the treatment of ureteropelvic junction obstruction (UPJO) is described. The results are compared with those of other lines of treatment.

Materials and Methods:

A total of 39 patients with UPJO underwent percutaneous retropelvic endopyelotomy. Retrograde percutaneous renal access, using the Lawson catheter and deflecting guidewire, was done for creation of the nephrostomy tract. Using holmium laser through a 28-Fr nephroscope, a small window was made in the posterolateral surface of the renal pelvis. The nephroscope was advanced from the renal pelvis to the retropelvic space through that window. Crossing vessels were easily detected and were either coagulated or avoided. The window incision was extended distally, and the narrow ureteropelvic junction (UPJ) was incised using holmium laser.

Results:

The entire procedure was done in the supine position within 1 h. The presence of secondary stones, hugely dilated renal pelvis, high insertion of the UPJ, and whether UPJO was primary or secondary, did not alter the results. The only factor that affected the results was split function of the obstructed renal unit. The success rate was 100% when the split function exceeded 35%. When the split function was <35%, the success rate dropped to 56%.

Conclusion:

Percutaneous retropelvic endopyelotomy is a promising approach for the treatment of UPJO that gave favorable results. The use of the nephroscope provided a wide visual field. The wide-field facilitated detection of crossing blood vessels with no incident of vascular injury. It also facilitated endopyelotomy with high precision. Ureteral injury was not a risk factor.

Laparoscopic pyeloplasty with cephalad translocation of the crossing vessel - a new approach to the Hellström technique

Introduction

It is believed that lower pole crossing vessels may play an important role in the etiology of ureteropelvic junction obstruction (UPJO). A conventional operative technique, which seems to be widely used in patients with UPJO, is Anderson-Hynes (A-H) plasty with dorsal transposition of the vessel. An attractive alternative to dorsal transposition of the vessel might be its cephalad translocation.

Aim

To assess the effectiveness of cephalad translocation of the crossing vessel in patients who underwent laparoscopic A-H or Y-V pyeloplasty.

Material and methods

Eighty-five patients were included in the study. To assess the effectiveness of cephalad translocation of the crossing vessel in patients who underwent laparoscopic pyeloplasty, the results of the procedure were compared to the results of laparoscopic pyeloplasties performed in patients without crossing vessels (control group). Success was defined as the following factors taken collectively: 80% or greater pain relief according to VAS, no sign of obstruction on intravenous urography (patent UPJ), decreasing excretion curve with T1/2 < 12 min, and improved or stable differential renal function on diuretic renography.

Results

The mean follow-up was 53.7 months. There was no statistically significant difference in the success rate between the compared groups (group 1 – cases with cephalad translocation of the crossing artery, and group 2 – cases without crossing vessels) in patients who underwent A-H plasty or Y-V plasty.

Conclusions

The analysis of our data seems to indicate that cephalad translocation of the anterior crossing vessel gives good therapeutic results in patients who undergo laparoscopic pyeloplasty.

Laparoscopic Anderson-Hynes pyeloplasty without symphysiotomy for hydronephrosis with horseshoe kidney

INTRODUCTION

The objective of this study is to clarify whether symphysiotomy is an essential procedure combined with the laparoscopic pyeloplasty for the surgical treatment of ureteropelvic junction obstruction related to horseshoe kidney.

METHODS

We retrospectively reviewed five horseshoe kidney patients with symptomatic hydronephrosis who underwent laparoscopic transperitoneal Anderson-Hynes pyeloplasty without symphysiotomy between July 2002 and October 2011.

RESULTS

All procedures were completed successfully without open conversion. Mean operative time and estimated blood loss were 209 min and 40 mL, respectively. Anterior crossing vessels were observed in all cases, and four of them were defined as a principle cause of the obstruction. In the remaining case, intrinsic stenosis of the ureteropelvic junction was noted. Crossing vessels were transposed behind the ureter with ureteropelvic anastomosis at the anterior aspect of these structures. Preoperative symptoms were absent postoperatively in all cases. Diuretic renogram showed that renal function of the side with hydronephrosis was unchanged, but diuretic excretion half-time was diminished in all cases.

CONCLUSION

The present data suggest that symphysiotomy can be avoided in many, if not all, cases of hydronephrosis related to horseshoe kidney. Laparoscopic Anderson-Hynes pyeloplasty with transposition of anterior crossing vessels seems effective, especially if aberrant vessels are strongly suspected to be present from the preoperative imaging examination.

Is the pelviureteric junction an anatomical entity?

OBJECTIVE

The concept of the pelviureteric junction has existed for more than a century and yet there is no clear anatomical definition of this junction. This systematic review addresses the question of whether the human pelviureteric junction is a discrete anatomical entity.

METHODS

A systematic literature review was undertaken to investigate the normal gross and microscopic anatomy of the pelviureteric junction using the electronic databases MEDLINE, PubMed, Cochrane Library and Google Scholar.

RESULTS

In most individuals there is a gradual transition between the renal pelvis and ureter with no external features indicating the presence of a discrete pelviureteric 'junction'. Internally, however, luminal mucosal folds are prominent in this region. There is no consensus on the arrangement of muscle fibers at the pelviureteric junction (which may be age-dependent) although some studies suggest a focal thickening in the muscle wall consistent with physiological observations suggesting a high pressure zone capable of regulating urine flow. Studies of innervation have shown no evidence of specialization at this site.

CONCLUSIONS

There is some evidence that a pelviureteric region can be delineated anatomically and physiologically. However, although it may be a useful clinical concept, there is no sound anatomical basis for an actual pelviureteric junction.

Laparoscopic transposition pyelo-pyelostomy for repair of adult uretero-pelvic junction obstruction secondary to lower pole crossing vessels: a novel technique

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.

[A case report of ureteropelvic junction obstruction and multiple renal stones associated with nutcracker syndrome]

A 20 year-old man presented to emergency room with severe left-sided flank pain. Urinalysis showed hematuria and he was referred to the urology department. KUB, DIP and retrograde pyelography (RP) revealed multiple renal stones, left hydronephrosis (grade 2) and ureteropelvic junction obstruction (UPJO). Abdominal CT revealed shortened nutcracker distance and renal angiography showed left renal vein hypertension. From these findings, diagnosis of nutcracker syndrome was made. Transposition of the left renal vein, dismembered pyeloplasty and left pyelolithotomy were performed simultaneously. 2 months after the procedure, his symptom and hematuria disappeared. 3 months after the procedure, DIP revealed improvement of hydronephrosis (grade 1) and CT showed elongation of nutcracker distance. In 12 months follow-up, there was no recurrence of symptom and hydonephrosis. To the best our knowledge, there has been no report of UPJO associated with nutcracker syndrome and the simultaneous treatment for the both diseases.

Percutaneous nephroscopic surgery

With the development of techniques for percutaneous access and equipment to disintegrate calculi, percutaneous nephroscopic surgery is currently used by many urologists and is the procedure of choice for the removal of large renal calculi and the management of diverticula, intrarenal strictures, and urothelial cancer. Although it is more invasive than shock wave lithotripsy and retrograde ureteroscopic surgery, percutaneous nephroscopic surgery has been successfully performed with high efficiency and low morbidity in difficult renal anatomies and patient conditions. These advantages of minimal invasiveness were rapidly perceived and applied to the management of ureteropelvic junction obstruction, calyceal diverticulum, infundibular stenosis, and urothelial cancer. The basic principle of endopyelotomy is a full-thickness incision of the narrow segment followed by prolonged stenting and drainage to allow regeneration of an adequate caliber ureter. The preferred technique for a calyceal diverticulum continues to be debated. Excellent long-term success has been reported with percutaneous, ureteroscopic, and laparoscopic techniques. Each approach is based on the location and size of the diverticulum. So far, percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique. Infundibular stenosis is an acquired condition usually associated with inflammation or stones. Reported series of percutaneously treated infundibular stenosis are few. In contrast with a calyceal diverticulum, infundibular stenosis is a more difficult entity to treat with only a 50-76% success rate by percutaneous techniques. Currently, percutaneous nephroscopic resection of transitional cell carcinoma in the renal calyx can be applied in indicated cases.

Accessory or additional renal arteries show no relevant effects on the width of the upper urinary tract: a 64-slice multidetector CT study in 1072 patients with 2132 kidneys

OBJECTIVE

The aim of this study was to find out on an unselected patient group whether crossing vessels have an influence on the width of the renal pelvis and what independent predictors of these target variables exist.

METHODS

In this cross-sectional study, 1072 patients with arterially contrasted CT scans were included. The 2132 kidneys were supplied by 2736 arteries.

RESULTS

On the right side, there were 293 additional and accessory arteries in 286 patients, and on the left side there were 304 in 271 patients. 154 renal pelves were more than 15 mm wide. The greatest independent factor for hydronephrosis on one side was hydronephrosis on the contralateral side (p<0.0001 each). Independent predictors for the width of the renal pelvis on the right side were the width of the renal pelvis on the left, female gender, increasing age and height; for the left side, predictors were the width of the renal pelvis on the right, concrements, parapelvic cysts and great rotation of the upper pole of the kidney to dorsal. Crossing vessels had no influence on the development of hydronephrosis. Only anterior crossing vessels on the right side are associated with widening of the renal pelvis by 1 mm, without making it possible to identify the vessel as an independent factor in multivariate regression models.

CONCLUSION

The width of the renal pelvis on the contralateral side is the strongest independent predictor for hydronephrosis and the width of the renal pelvis. There is no link between crossing vessels and the width of the renal pelvis.

Ureteropelvic junction obstruction secondary to crossing vessels-to transpose or not? The robotic experience

PURPOSE

We compared the surgical outcomes of robot assisted laparoscopic dismembered pyeloplasty in patients presenting with anterior crossing vessels with and without transposition of the crossing vessel.

MATERIALS AND METHODS

A total of 107 patients with ureteropelvic junction obstruction underwent robot assisted laparoscopic dismembered pyeloplasty. Evaluation of surgical success was based on validated pain scores, diuretic renography and imaging results, including excretory urography, computerized tomography or ultrasound.

RESULTS

Anterior crossing vessels were identified in 48 patients (44.9%) and vessels were transposed in 18 (37.5%) (group 1). No transposition was performed in 30 patients (62.5%) (group 2). Mean radiological followup was 52.9 weeks in group 1 and 65.3 weeks in group 2 (p = 0.181). Mean pain score on a scale of 10 was 0.82 in group 1 and 0.74 in group 2 (p = 0.917). A Whitaker test performed in 3 patients with persistent pain was negative. Preoperatively mean differential function on the affected side was 35.1% in group 1 and 36.9% in group 2 (p = 0.133). Half-time was calculated as a mean of 46.3 minutes in group 1 and 49.4 minutes in group 2 (p = 0.541). In groups 1 and 2 mean postoperative differential function improved to 41.1% and 40.9%, and mean half-time improved to 7.43 and 8.03 minutes, respectively (p = 0.491). A comparison of preoperative and postoperative differential function, and half-time in each group showed a statistically significant difference. The radiographic and symptomatic success rate was 100% with no open conversion and recurrence.

CONCLUSIONS

Comparison of robot assisted laparoscopic dismembered pyeloplasty outcomes revealed similar success rates in terms of the change in symptoms and renal function in patients with or without anterior crossing vessel transposition. Transposition of crossing vessel should only be performed when the anatomical relation dictates and it should be an intraoperative decision.

Pathologic findings in patients with ureteropelvic junction obstruction and crossing vessels

OBJECTIVES

To define the role of crossing vessels in the pathophysiology of ureteropelvic junction (UPJ) obstruction, we analyzed the relationship between the presence of crossing vessels and UPJ pathologic findings in patients undergoing laparoscopic pyeloplasty. The significance of crossing renal vessels in patients with UPJ obstruction is unclear.

METHODS

We performed a retrospective analysis of 155 consecutive patients undergoing laparoscopic pyeloplasty. Pathologic specimens from the UPJ were evaluated in 95 patients. The presence or absence of crossing vessels was documented intraoperatively. The histopathologic findings allowed for categorization into 5 groups: group 1, normal ureteral tissue; group 2, chronic inflammation; group 3, smooth muscle hypertrophy, group 4, fibrosis; and group 5, smooth muscle atrophy. The pathologic findings between patients with and without crossing vessels were compared.

RESULTS

Overall, crossing vessels were identified in 98 patients (63.2%). Of the 95 cases with specimens retrieved for histologic analysis, 65 had crossing vessels and 30 did not. The most common UPJ histologic finding in patients with crossing vessels was no intrinsic abnormality (43%). In contrast, this was seen in only 10% of patients without a crossing vessel. In the group without crossing vessels, chronic inflammation (40%) was the predominant histologic findings. Patients with a crossing vessel were less likely to have intrinsic histologic pathologic findings (P < .0003).

CONCLUSIONS

Patients with crossing vessels and UPJ obstruction had no histologic abnormalities identified in 43% of cases. This finding implicates crossing vessels in the pathogenesis of select cases of UPJ obstruction and direct mechanical compression as the etiology of obstruction in these individuals.

Two Stage Complex Embolization of an Arteriovenous Fistula between the Right Common Iliac Artery and the Inferior Vena Cava

We present an interesting case of a symptomatic high flow AV fistula between the right common iliac artery (CIA) and the inferior vena cava (IVC), successfully treated by endovascular coil embolization. The patient was found to have a right lower polar renal artery crossing the ipsilateral ureter arising from the CIA, causing pelvi-ureteric junction (PUJ) obstruction and recurrent pyelonephritis. It is hypothesized that this fistula arising from the lower polar renal artery and entering the IVC, may have occurred as a result of trauma during a previous pyeloplasty, or a pathologically induced process of angiogenesis stemming from recurrent pyelonephritis.

First Prize (tie): Hemorrhage following percutaneous renal surgery: characterization of angiographic findings

PURPOSE

Percutaneous surgery is an established approach to a spectrum of renal pathology, and hemorrhage is the most concerning complication of this technique. We determined the frequency of postoperative hemorrhage requiring selective angioembolization (sae), the efficacy of this approach, and characterized the angiographic findings.

METHODS

We reviewed our database of 4695 patients who underwent percutaneous renal surgery and identified patients requiring SAE for postoperative hemorrhage. Angiographic findings were recorded and efficacy of SAE documented.

RESULTS

Patients undergoing percutaneous stone extraction (PSE; 3685), percutaneous antegrade endopyelotomy (PAE; 850), and upper-tract transitional cell carcinoma (UTTCC) resection (160) were reviewed. We identified 57 patients requiring SAE (1.2%) who underwent 44 PSEs (77.2%), 7 PAEs (12.3%), and 6 UTTCC resections (10.5%). This represented 1.2%, 0.8%, and 3.2% of all PSE, PAE, and UTTCC resections, respectively. Angiography revealed treatable lesions in 94.7% of patients. Overall, 64 angiographic findings were encountered including 30 pseudoaneurysms (53% of patients, 47% of findings), 14 arteriovenous fistulas (AVFs) (25% of patients, 22% of findings), and 14 instances of contrast extravasation (25% of patients, 22% of findings). Two arterial dissections and one instance each of a hypervascular area, a vascular "cut-off" sign, and a fistula between an artery and the percutaneous tract were identified. One bleeding vessel identified at the base of a UTTCC resection was not amenable to embolization. Ten patients (17.5%) had >or=1 angiographic finding. Three patients (5.3%) had no angiographic findings to account for hemorrhage. No angioembolization-related complications occurred. Complete resolution of bleeding was observed in 54 patients (95%).

CONCLUSIONS

Major hemorrhage requiring intervention after percutaneous renal surgery is uncommon. The most common angiographic finding is arterial pseudoaneurysm, followed by arteriovenous fistula, and contrast extravasation. In 95% of cases angiography reveals a demonstrable and treatable etiology. This strongly supports the first-line use of angiography for intractable bleeding in this setting.

The retroperitoneal laparoscopic Hellström technique for pelvi-ureteric junction obstruction from a crossing vessel

OBJECTIVE

To report our experience with the treatment of pelvi-ureteric junction obstruction (PUJO) using the retroperitoneal laparoscopic Hellström (RLH) technique to relocate the crossing vessel.

PATIENTS AND METHODS

We used the RLH technique selectively in eight patients with PUJO from an aberrant crossing vessel, according to observations during surgery. The crossing vessel was mobilized and embedded in the generous pelvic wall with 4-0 polyglactin sutures to relieve the PUJO. Follow-up studies included intravenous urography, ultrasonography and renal functional scintigraphy at 1 month after surgery and every 3 months thereafter.

RESULTS

The mean (range) operative duration was 45 (40-60) min; the blood loss was negligible. Crossing vessels were identified to be anterior to the renal pelvis in two patients and posterior in six. The hospital stay after surgery was 5 (4-7) days. No paregoric was required after surgery. The collecting systems were intact and no JJ stent was required in any patient. The mean (range) follow-up was 13.6 (12-15) months. In all patients the obstruction was resolved or significantly improved, and there were no complications, e.g. urine leakage and infection. A long-term follow-up is mandatory.

CONCLUSIONS

The RLH technique is a minimally invasive alternative for patients with PUJO caused by a crossing vessel. Embedding the crossing vessels in the pelvic wall is feasible and safe for such patients; empirical judgement during surgery is prudent for success.

Laparoscopic Pyeloplasty: Status and Review of Literature

The ideal treatment for ureteropelvic junction (UPJ) obstruction should have the highest success rate, enable treatment of all types of obstruction, allow removal coexisting renal stones, and be minimally invasive. Open pyeloplasty offers all these features except the last (minimal invasiveness), whereas endourology techniques guarantee only the last one. Different techniques of pyeloplasty can be applied laparoscopically, although the best results are seen with dismembered pyeloplasty (Anderson-Hynes technique). Various methods of tissue approximation have been devised to avoid the difficult-to-master, time-consuming conventional suturing technique. Laparoscopic (antegrade) stenting is preferred by some surgeons, but we consider retrograde stenting is superior, as this rules out the presence of associated distal-ureteral obstruction. The transperitoneal approach has the advantages of a larger working space and readily identifiable anatomic landmarks. However, access to the renal pelvis requires considerable mobilization and retraction of the overlying loops of bowel. The retroperitoneal approach has the perceived disadvantage of a somewhat limited working space and absence of readily identifiable intra-abdominal anatomic structures such as the liver and spleen. However, the retroperitoneal approach has the advantage of greater familiarity, better detection of crossing vessels, direct and rapid access to the UPJ, and less risk of ileus. The robot-assisted technique has made suturing easier and may allow expansion of advanced laparoscopic procedures to surgeons without expertise in advanced laparoscopic surgery. The optimal length of follow-up after pyeloplasty is still unclear. Although most failures occur within the first 2 years, failures continue to appear after 5 and 10 years.

Lasers in the upper urinary tract for non-stone disease

Though the most common use for lasers in the genitourinary tract is for urolithiasis, a number of other urologic conditions can be treated with lasers because of their unique ablative, destructive and hemostatic properties. This paper reviews the advantages and disadvantages of laser technology for a number of non-stone indications.

Laparoscopic Transperitoneal Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction

PURPOSE

To review the outcome of transperitoneal laparoscopic dismembered pyeloplasty (LDP) in our institution.

PATIENTS AND METHODS

From April 2001 to April 2005, 36 men and 34 women underwent LDP for symptomatic and radiologically proved ureteropelvic junction (UPJ) obstruction. A successful outcome was defined clinically by improvement in symptoms and objectively by improvement in the diuretic renography study performed at 3 and 12 months after reconstruction.

RESULTS

The mean operative time was 160.5 +/- 45 minutes with a mean blood loss of 77.8 +/- 52.8 mL. There were no conversions to open surgery. Lower-pole vessels were observed in 38 patients (54.3%). In all cases, the ureter was transposed anteriorly. The mean hospital stay was 3.3 +/- 2.1 days. Postoperative complications were recorded in 4 patients (5.7%). One patient developed an anastomotic stricture. A successful outcome was achieved in 68 of the 70 patients (97.1%) at a mean follow-up of 27.6 +/- 13.2 months.

CONCLUSION

Our results further strengthen the evidence that LDP has a reliable medium-term outcome with the added benefit of being minimally invasive.

Minimally Invasive Treatment of Ureteropelvic Junction Obstruction: Optimizing Outcomes with Concomitant Cost Reduction

With the seemingly exponential increase in the use of minimally invasive techniques in urology, cost-benefit comparisons will continue to play a major part in establishing services and in improving those that already exist. The management of ureteropelvic junction obstruction is a focus of significant attention. An effective way of optimizing the economy of management is to understand the implications in terms of the success of each mode of treatment. Subsequently, costing models should be developed and applied in large-scale multicenter studies with the aid of health economists. The long-term benefits can then be assessed by also including patient's perceived quality of life. Economic assessment will not be enough to promote cost-effective practices. The take-up of any techniques will always be influenced not only by patient preference and surgeon expertise but also, perhaps ironically, by the way hospitals and surgeons are remunerated. In addition, the impact of the time taken to train a surgeon to carry out laparoscopic dismembered pyeloplasty competently may play a significant role. Until these issues are resolved, definitive recommendation for the treatment of ureteropelvic junction obstruction will continue to be made on an individual basis.

The incidence of crossing vessels in patients with normal ureteropelvic junction examined with endoluminal ultrasound

PURPOSE

We estimated the incidence of a crossing vessel at the normal ureteropelvic junction (UPJ) in patients undergoing ureteroscopy and endoluminal ultrasonography for indications other than UPJ obstruction.

MATERIALS AND METHODS

Endoluminal ultrasonography was performed in 141 patients undergoing upper tract endoscopy for various indications excluding UPJ obstruction. A detailed description of the anatomy of the UPJ as well as the location and size of crossing vessels was included in the operative note. Charts were reviewed to determine the precise anatomy of the UPJ.

RESULTS

The overall incidence of crossing vessels at the unobstructed UPJ was 19.2%. Endoluminal ultrasonography demonstrated a crossing vessel in 13.2% of patients with ureteral narrowing or stricture, 31.3% of those with tumors or filling defects, 10.5% of those with submucosal calculi and 16.7% of patients with ureteral diverticula. In cases where the position of a crossing vessel was ascertained, 41% were anterior to the ureter, 28% anterolateral, 24% anteromedial and 7% posterior. There was a statistically significant difference in the frequency of vessels at the UPJ in patients with and without obstruction examined with endoluminal ultrasound (p <0.0001).

CONCLUSIONS

A crossing vessel at the UPJ is seen with endoluminal ultrasound in 19.2% of patients with a normal UPJ. This incidence is lower than that seen in patients with obstructed UPJ. Many of these vessels are related to the lateral surface of the UPJ and there was no area that was always free of vessels.

Laparoscopic pyeloplasty: Evolution of a new gold standard

OBJECTIVES

To report our series of laparoscopic dismembered pyeloplasty for the treatment of primary and secondary ureteropelvic junction obstruction and to review the current status of this procedure.

METHODS

A total of 170 consecutive cases of laparoscopic pyeloplasty (156 for primary and 14 for secondary ureteropelvic junction obstruction) were performed or supervised by a single surgeon (C.G.E). A four-port extraperitoneal approach was used in all but 3 cases, which were performed transperitoneally.

RESULTS

The median operative time was 140 minutes. The complication rate was 7.1%, and the conversion rate was 0.6%, with no conversion in the last 161 cases. The median postoperative hospital stay was 3 nights. Crossing vessels were encountered in 42% of cases, and in 11 patients, coexisting renal calculi were successfully removed. At a median follow-up of 12 months, the success rate was 96.2%.

CONCLUSIONS

Laparoscopic dismembered pyeloplasty produces functional results comparable to that of open surgery with the advantages of a minimally invasive procedure. Our results are consistent with previous series and support the view that laparoscopic pyeloplasty is moving rapidly toward replacing open surgery as the gold standard in the treatment of ureteropelvic junction obstruction.

The use of endoluminal ultrasonography for preventing significant bleeding during endopyelotomy: evaluation of helical computed tomography vs endoluminal ultrasonography for detecting crossing vessels

OBJECTIVE

To evaluate, in a prospective study, the efficiency of helical computed tomography (CT) and endoluminal ultrasonography (ELUS) for detecting significant crossing vessels, a major cause of bleeding complications when treating patients with pelvi-ureteric junction (PUJ) obstruction, and to compare our results using ELUS with those of an earlier multicentre study (not using ELUS), to see whether the complication rate decreased.

PATIENTS AND METHODS

The study included 27 patients with a PUJ who had isotope renography, intravenous urography, helical CT and ELUS before surgery. Depending on the findings of ELUS, patients were treated with a pure lateral Acucise incision (Applied Medical, Irvine, CA, USA) an Acucise with changed cutting direction, or (later) a laparoscopic pyeloplasty.

RESULTS

ELUS detected 15% more crossing vessels than helical CT; 16 patients had Acucise (seven lateral, nine other cutting direction), eight were treated with a laparoscopic pyeloplasty and three with other procedures. By contrast with earlier reports and as a consequence of using ELUS, there was no bleeding, vs 16% in the study not using ELUS. The success rate of 73% of the endourological approach is comparable with previous reports.

CONCLUSION

ELUS is more sensitive in detecting relevant crossing vessels than helical CT and therefore the use of ELUS can better prevent bleeding complications. ELUS can also improve the success rate by helping in selecting the correct treatment. Because it is minimally invasive and safe, ELUS combined with Acucise (or other possible endourological techniques, like holmium laser incision) should be the first choice of treatment for PUJ stenosis.

Dynamic Contrast-Enhanced MR Urography in the Evaluation of Pediatric Hydronephrosis: Part 2, Anatomic and Functional Assessment of Uteropelvic Junction Obstruction

OBJECTIVE

The purpose of our study was to retrospectively review our experience using MR urography in the diagnosis of ureteropelvic junction (UPJ) obstruction in children.

MATERIALS AND METHODS

Sixty-one studies were performed in 50 children with hydronephrosis but without hydroureter. Anatomic criteria assessed included degree of hydronephrosis, morphology of the renal pelvis, atrophy of medulla, swirling contrast material, fluid levels, and the presence of fetal folds and crossing vessels. Functional criteria included renal transit time, differential renal function, and time-intensity curves when available.

RESULTS

Thirty-one kidneys were classified as obstructed, 15 as equivocal, and 15 as nonobstructed. Obstructed systems had more marked hydronephrosis, more extensive medullary atrophy, more fluid levels, and more swirling contrast material. Fetal folds were seen in only the equivocal and nonobstructed groups. Crossing vessels were seen in all groups. Obstructed systems also showed greater functional derangement, decreased split renal function, and abnormal time-intensity curves.

CONCLUSION

MR urography provides both excellent anatomic and functional information in children with UPJ obstruction in a single test that does not use ionizing radiation. MR urography may lead to greater understanding of the pathophysiology of UPJ obstruction.

Laparoscopic pyeloplasty versus antegrade endopyelotomy: Comparison in 100 patients and a new algorithm for the minimally invasive treatment of ureteropelvic junction obstruction

The aim of this article is to assess the treatment efficacy of percutaneous endopyelotomy and laparoscopic pyeloplasty to establish a new algorithm in the minimally invasive treatment of ureteropelvic junction obstruction (UPJO). Hospital records, office charts, and radiographic studies of patients with UPJO treated either endoscopically (n = 50), laparoscopically (n = 50), or by endopyeloplasty (n = 5) were reviewed. All percutaneous endopyelotomies were performed with a cold hook-knife technique, and all laparoscopic pyeloplasties were performed transperitoneally using an Anderson-Hynes dismembered anastomosis. Successful outcomes were defined as relief of obstruction as quantified by diuretic renal scans and/or relief of obstructive symptoms. All patients were followed for an average of 16.0 months (range, 2 to 42 months). In the endoscopically treated group, the average age was 44.6 +/- 15.6 years, estimated blood loss (EBL) was 152.1 +/- 112.8 mL, and the hospital stay was 2.5 +/- 1.0 days. There was no significant change from preoperative to postoperative creatinine (1.2 +/- 0.7 mg/dL to 1.2 +/- 0.7 [106 +/- 62 micromol/L +/- 106 +/- 62 micromol/L]). Success rates included 92% (35 of 38) for primary percutaneous antegrade endopyelotomy and 58% (7 of 12) for secondary percutaneous antegrade endopyelotomy. All of the primary percutaneous antegrade endopyelotomy failures (n = 3) had either grade 3 or grade 4 hydronephrosis. In the laparoscopic pyeloplasty group the average age was 37.9 +/- 14.8 years, EBL was 108.3 +/- 109.4 mL, and the average hospital stay was 2.6 +/- 0.9 days. There was no significant change from preoperative to postoperative creatinine (1.1 +/- 0.4 mg/dL to 1.0 +/- 0.4 mg/dL [97 +/- 35 micromol/L to 97 +/- 35 micromol/L]). Success rates included 100% (29 of 29) for primary repair and 95.2% (20 of 21) for secondary repair. There was no statistical difference in preoperative patient parameters or objective outcomes when comparing primary endopyelotomy and primary laparoscopic pyeloplasty. In skilled hands, highly successful outcomes can be expected when either antegrade endopyelotomy or laparoscopic pyeloplasty is used to treat a primary UPJO. In the instance of a UPJO associated with a high degree of hydronephrosis, patients may be better served with a laparoscopic pyeloplasty. To maximize an efficacious outcome, minimally invasive UPJO treatment decisions should be based on patient and surgeon preference, as directed by the presented algorithm.

Acucise endopyelotomy: A technique with limited efficacy for primary ureteropelvic junction obstruction in adults

AIM

To retrospectively evaluate the ef fi cacy of Acucise endopyelotomy in a series of patients with primary ureteropelvic junction obstruction (UPJO).

METHODS

Twenty-four patients with a symptomatic primary UPJO underwent Acucise endopyelotomy. Patients with high-grade hydronephrosis and/or poor renal function were excluded. Patients were followed by ultrasound imaging, intravenous urography, diuretic renography, and clinical review.

RESULTS

The overall success rate was 58% (14/24 patients), with a median follow up of 32 months. Of the ten patients in whom Acucise endopyelotomy failed, seven underwent open pyeloplasty, one required nephrectomy, and two received a permanent ureteral stent. A poor outcome was noted in patients without perioperative extravasation.

CONCLUSIONS

Our experience with Acucise endopyelotomy indicates that the success rate is lower than initially reported. Larger studies are needed to clarify the role of Acucise endopyelotomy in comparison with other techniques.

Correlation of preoperative three-dimensional magnetic resonance angiography with intraoperative findings in laparoscopic renal surgery

BACKGROUND AND PURPOSE

Contrast-enhanced three-dimensional magnetic resonance angiography (3D-MRA) with image reconstruction has important applications in laparoscopic urologic surgery. We now use 3D-MRA as part of our preoperative evaluation in selected patients undergoing laparoscopic donor nephrectomy, pyeloplasty, radical nephrectomy, and partial nephrectomy.

PATIENTS AND METHODS

From June 2001 to December 2002, 50 patients underwent preoperative 3D-MRA at 1.5 T prior to laparoscopic renal surgery. In general, preoperative 3D-MRA was obtained for donor nephrectomies and pyeloplasties and for cases where prior imaging suggested a possible vascular anomaly. Patients who underwent preoperative imaging included those having donor nephrectomy (N = 28), pyeloplasty (N = 12), radical nephrectomy (N = 5), partial nephrectomy (N = 3), and other laparoscopic renal procedures (N = 2). The 3D-MRA studies were interpreted by one radiologist, and all laparoscopic cases were performed by one of two surgeons. The findings of 3D-MRA were correlated with the intraoperative findings with special attention to aberrant vasculature, including duplicated renal arteries or veins, accessory vessels, or crossing vessels.

RESULTS

Among patients undergoing laparoscopic donor nephrectomy, 3D-MRA correctly predicted the number of renal vessels in 27 of 28 cases (96%), including all 3 cases of left retroaortic renal vein. Also, 3DMRA correctly predicted the presence or absence of a crossing vessel in 10 of 12 cases (83%) of laparoscopic pyeloplasty. The imaging study also correctly predicted the number of hilar vessels in all five cases of radical nephrectomy, all three cases of partial nephrectomy, and both cases of other renal operations. Overall, 3D-MRA correctly defined the renal hilar anatomy in 48 of 50 patients, for an overall accuracy of 96%.

CONCLUSIONS

Three-dimensional MRA findings correlate well (96%) with intraoperative findings in laparoscopic renal surgery. The imaging study provides exquisite vascular detail and is highly accurate, making it sufficient imaging prior to laparoscopic donor nephrectomy and useful for pyeloplasty and other complex renal operations.

Ureteropelvic junction obstruction: endourologic relocation of laterally inserting ureters

PURPOSE

To describe a technique of endourologic management for ureteropelvic junction (UPJ) obstruction associated with lateral insertion of the ureter.

PATIENTS AND METHODS

Among 57 patients with primary UPJ obstruction selected to undergo retrograde endopyelotomy, 2 patients (3.5%) demonstrated a nondilated ureter inserting laterally along a hydronephrotic renal pelvis on retrograde pyelography. Using the hot-wire balloon catheter in one and a holmium laser inserted ureteroscopically in one, retrograde endopyelotomy was performed with the incision directed medially in order to marsupialize the ureter into the renal pelvis and to relocate the UPJ to the dependent portion of the medial aspect of the renal pelvis.

RESULTS

The hospital stay for both patients was 1 night, and there were no complications. The stent was removed 4 or 6 weeks postoperatively. Intravenous urography 6 weeks thereafter demonstrated relocation of the UPJ to a medial and dependent position, associated with prompt drainage of contrast medium and decreased pelvocaliectasis compared with preoperative studies. Both patients are asymptomatic.

CONCLUSIONS

In cases of primary UPJ obstruction associated with lateral insertion of the ureter, the UPJ can be relocated to the medial and dependent portion of the renal pelvis using minimally invasive endourologic techniques. The dictum of performing a endopyelotomy incision laterally does not hold true in all patients and may compromise functional outcomes in cases where the ureteral insertion is nondependent and laterally positioned.

Adult Ureteropelvic Junction Obstruction: Insights with Three-dimensional Multi–Detector Row CT

Ureteropelvic junction obstruction (UPJO) is a benign, congenital condition that remains an enigma in terms of both diagnosis and therapy. On the basis of a series of cases that were referred to the authors in their clinical practice, they found that the unprecedented quality and novel perspectives of multi-detector row computed tomography (CT) with two- and three-dimensional postprocessing allow a comprehensive, single-study assessment of the ureterovascular relationships in UPJO. This topic is important because the causative role of crossing vessels may be questioned on the basis of such studies, and the therapeutic approach may be altered by using precise anatomic images customized to the pathologic features of the individual patient. Although CT images can provide only circumstantial or supportive evidence of the pathophysiology of UPJO, they greatly facilitate therapeutic intervention when it is clinically indicated and may eliminate the need for it in select cases. Careful attention to the postprocessing of CT images may show that the crossing vasculature has no direct relationship to the transition point of the UPJO in many cases.

Detection of crossing vessels as the cause of ureteropelvic junction obstruction: the role of antegrade pyelography prior to endopyelotomy

PURPOSE

To review the utility of antegrade pyelography in detecting crossing vessels as the cause of uretero-pelvic junction (UPJ) obstruction prior to planned endopyelotomy.

MATERIALS AND METHODS

A retrospective review of the medical records, surgical reports, and medical images was performed in 109 consecutive adult patients in our practice who underwent antegrade pyelography just prior to planned endopyelotomy for symptomatic UPJ obstruction between January 1996 and December 2002.

RESULTS

Fourteen patients were identified in whom a specific antegrade pyelographic appearance was detected in the diagnosis UPJ obstruction caused by crossing vessels. Surgical plans were changed in all 14 patients from antegrade endopyelotomy to open surgical pyeloplasty, during which the anterior (ventral) crossing vessels causing obstruction were confirmed. An additional three patients in the reviewed endopyelotomy group clinically failed their initial endopyelotomy procedure and were shown at the time of subsequent open or laparoscopic reconstructive surgery to have UPJ obstruction caused by anterior crossing vessels, but that diagnosis was missed at the time of the initial antegrade pyelogram.

CONCLUSION

A specific antegrade pyelographic appearance was identified to diagnose UPJ obstruction caused by anterior crossing vessels with a sensitivity of 82.4% and a specificity of 100%. The direct obstructing effect of the vessels on the ureter is defined with pyelography as an acute posteriorly angulated ureteral deformity just below a patent UPJ. Recognition of this specific antegrade pyelographic appearance permits use of an appropriate surgical technique for UPJ obstruction repair.

EXTRAPERITONEAL LAPAROSCOPIC PYELOPLASTY FOR PRIMARY AND SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION

PURPOSE

Greater experience with urological laparoscopy has lead to increasing interest in its use for reconstructive surgery, such as pyeloplasty.

MATERIALS AND METHODS

A total of 124 cases of laparoscopic pyeloplasty were performed, of which 11 followed failed primary treatment done elsewhere, namely balloon dilation (3), endopyelotomy (3); open pyeloplasty (3), endopyelotomy plus balloon dilation (1) and open pyeloplasty plus balloon dilation (1). Nine patients had renal calculi. A 4 port, balloon dissecting, extraperitoneal laparoscopic approach was used in all except 1 patient, who had a horseshoe kidney, necessitating a transperitoneal approach.

RESULTS

Operative time was 29 minutes longer in the secondary pyeloplasty group compared to primary cases (173.3 vs 144.0 minutes) but the conversion rate (0% vs 1.6%) and duration of postoperative hospitalization (2.8 nights each) were no greater. The complication rate was 3.6% and 9.1%, respectively. The success rate was 98.2% and 90.9% (p = 0.63) at a mean followup of 20.2 and 19.7 months, respectively. In the 9 patients with renal calculi a total of 18 calculi (94.7%) were successfully removed and the ureter was transposed medial to a crossing vessel in 50.0%. Trainee operating did not significantly prolong the procedure vs no training (162.0 vs 143.9 minutes, p = 0.06).

CONCLUSIONS

Extraperitoneal laparoscopic dismembered pyeloplasty is capable of addressing all causes of ureteropelvic junction obstruction with excellent functional results and low morbidity, and with an operative time similar to that of open pyeloplasty. Secondary laparoscopic pyeloplasty does not increase hospitalization, conversion or complication rates.

MANAGEMENT OF SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION AFTER FAILED PRIMARY LAPAROSCOPIC PYELOPLASTY

PURPOSE

Laparoscopic pyeloplasty has been established as a minimally invasive alternative to open pyeloplasty. However, little is known about the treatment of patients in whom this technique fails. We present our experience with treating ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty.

MATERIALS AND METHODS

From August 1993 to September of 2003, 227 patients underwent laparoscopic pyeloplasty for primary ureteropelvic junction obstruction. Of these patients 10 (4.4%), including 6 females and 4 males 24 to 62 years old (mean age 42.1), underwent secondary treatment after laparoscopic pyeloplasty failed. The type of secondary intervention varied by anatomical factors, and patient and surgeon preference. Success was defined as symptomatic relief and improved radiographic imaging at latest followup.

RESULTS

Secondary interventions were repeat laparoscopic pyeloplasty in 1 patient, retrograde endoscopic balloon dilation in 2 and endopyelotomy in 7 (laser, cold knife and cutting balloon endopyelotomy in 3, 2, and 2, respectively). No postoperative complications were seen. Patients were followed for a mean of 25.5 months (range 3 to 96) after the second procedure. Seven of 10 secondary interventions (70%) were successful with no obstruction on followup imaging. Three of 10 interventions (30%) failed, namely 1 laparoscopic pyeloplasty, 1 endoscopic balloon dilation and 1 laser endopyelotomy. Failure of the second procedure occurred at a mean of 9.3 months.

CONCLUSIONS

When given the choice, most patients select endoscopic management after failed primary laparoscopic pyeloplasty due to its minimally invasive nature and low complication rate. Success rates are 70% with repeat intervention. Some patients require a third intervention.

Percutaneous antegrade endopyelotomy: long-term results from one institution

OBJECTIVES

To assess the long-term efficacy of percutaneous antegrade endopyelotomy for the treatment of ureteropelvic junction (UPJ) obstruction performed at a single institution during a 10-year period. We provide alterations in investigation and management strategies on the basis of the results.

METHODS

From July 1990 to June 2001, 80 patients with clinical and radiographic evidence of UPJ obstruction underwent percutaneous endopyelotomy for the treatment of primary (n = 61) or secondary (n = 19) UPJ obstruction. The mean patient age was 35 years (range 4 to 76). Percutaneous endopyelotomy was performed in a standard fashion using either a hooked-knife (n = 77) or holmium laser (n = 3).

RESULTS

With a mean patient follow-up of 55 months (range 16 to 138), the overall success rate was 67% (53 of 79). The success rate for primary and secondary UPJ obstruction was 65% (39 of 60) and 74% (14 of 19), respectively. The mean time to failure was 15 months (range 1 to 79). Operative intervention for 24 of 26 patients with failure included open pyeloplasty (n = 18, 75%), indwelling ureteral stenting (n = 2, 8%), retrograde balloon dilation (n = 1, 4%), and nephrectomy (n = 3, 13%). Two asymptomatic patients with recurrent radiographic evidence of obstruction elected conservative follow-up. Significant crossing vessels were encountered at open pyeloplasty in 15 (83%) of 18 patients.

CONCLUSIONS

Our long-term results of percutaneous endopyelotomy demonstrated somewhat lower success rates than that reported in published studies. Long-term follow-up is critical in identifying late failures. The high prevalence of crossing vessels encountered at open pyeloplasty provided further evidence to support its role in endopyelotomy failure. Routine preoperative helical computed tomography to detect significant crossing vessels is recommended. Patients with crossing vessels are likely better served with operative techniques that specifically address this issue, namely open or laparoscopic pyeloplasty.

Ureteropelvic junction obstruction repair: when, how, what?

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Hellström technique revisited: laparoscopic management of ureteropelvic junction obstruction

OBJECTIVES

To present our experience with the treatment of adult ureteropelvic junction (UPJ) obstruction using a laparoscopic Hellström vascular relocation technique.

METHODS

Transperitoneal laparoscopy was performed in 35 patients for the management of UPJ obstruction. In 9 cases, we identified crossing lower pole vessels and performed the Hellström technique. We discuss our indications, intraoperative techniques, and outcomes when performing only vascular relocation in these patients.

RESULTS

All 9 patients presented with long-standing flank pain and were identified as having UPJ obstruction (7 primary, 2 secondary) on radiographic imaging. The intraoperative decision to perform the Hellström technique was based on the presence of the crossing vessels, a grossly normal appearance of the ureter and UPJ, and a small renal pelvis. The crossing vessels were completely mobilized, displaced cephalad, and fixed using intracorporeal sutures. The mean operative time and blood loss was 164 minutes and 15 mL, respectively. At a mean follow-up of 19 months (range 14 to 31), the patients were asymptomatic with no evidence of obstruction on Lasix nuclear renography.

CONCLUSIONS

Traditional treatment of UPJ obstruction, with or without crossing vessels, has been accomplished by pyeloplasty. Dismembered pyeloplasty is a standard method in cases of associated crossing vessels; however, we propose that the Hellström technique be considered in cases in which the ureter appears normal and the pelvic anatomy is unfavorable for transection and anterior reanastomosis of the ureter and pelvis. These considerations are particularly relevant during the laparoscopic approach in which intracorporeal suturing and knot tying are technically challenging.

Impact of hydronephrosis and renal function on treatment outcome: antegrade versus retrograde endopyelotomy

OBJECTIVES

To compare, in a single-surgeon, single-institution study, the efficacy of antegrade and retrograde endopyelotomy in terms of success rate and morbidity and to identify which risk factors affect treatment outcomes.

METHODS

The results were retrospectively reviewed for 88 patients with ureteropelvic junction obstruction treated with endopyelotomy. Antegrade endopyelotomy was performed with a hook knife, scissors, or cutting balloon device. Retrograde endopyelotomy was performed with a cutting balloon device. Objective results were based on intravenous urogram and/or diuretic nuclear renal scan findings, and subjective results were based on direct patient query and questionnaire.

RESULTS

Ninety-three endopyelotomy procedures, 64 antegrade and 29 retrograde, were performed. The mean follow-up was 37.0 months (range 5 to 76). The overall success rates between antegrade and retrograde endopyelotomy (81.3% versus 75.9%) were not statistically different (P = 0.553). Patients with massive hydronephrosis and poor initial renal function were less likely to have successful endopyelotomy. Antegrade endopyelotomy, however, was more successful than retrograde endopyelotomy in patients with massive hydronephrosis (66.7% versus 20.0%; P = 0.046). The average operative time for antegrade and retrograde endopyelotomy was 93.9 and 32.7 minutes (P <0.001), respectively. The average length of hospital stay after antegrade and retrograde endopyelotomy was 3.20 and 0.14 nights (P <0.001), respectively.

CONCLUSIONS

Both antegrade and retrograde endopyelotomy are effective treatments for ureteropelvic junction obstruction associated with minimal morbidity. Antegrade endopyelotomy appears to be more successful in patients with high-grade hydronephrosis. Retrograde endopyelotomy results in a shorter hospital stay, a shorter operative time, and less postoperative pain.

Ureteropelvic Junction Obstruction: Some new Acquisitions about Etiology, Pathophysiology and Diagnostics

The etiopathogenesis of uretero-pelvic junction obstruction (UPJO) has been the subject of many speculations and it remains, in some ways, a debatable matter. Some recently reported thorough research refer to neuro-mediated pathogenetic mechanisms rather than (or together with) myogenic ones.

Advances in US, radioisotopic functional imaging, CT and RM contribute to differentiate the obstructive conditions from the non-obstructive ones and to afford today a better assessment of renal functional damage. Particularly, diuretic renography is a non-invasive test for characterization of the renal functional abnormalities resulting from UPJO. Helical CT with angiography is a useful technique for identification of crossing vessels (pyelo-vascular tangle) which can be used for the pre-surgical planning of endopyelotomy. Endoluminal ultrasonography can be used to guide the position of the incision for endopyelotomy (US-guided endopyelotomy).

Laboratory examinations are important to determine the overall renal function (serum creatinine, acid-base balance, serum electrolytes, etc.), urinary MCP-1 and NAG (markers of tubular damage), and to rule out urinary tract infections.

The management of UPJO (watchful waiting; either open or laparoscopic dismembered pyeloplasty; endoluminal procedures) is greatly influenced by the diagnostic evaluation.

The paper aims to outline the advances in both physiopathology and diagnostics of UPJO on the basis of a review of the literature.

Laparoscopic treatment for ureteropelvic junction obstruction

OBJECTIVES

To assess retrospectively the subjective and objective outcomes achieved after laparoscopic treatment for ureteropelvic junction obstruction at our institutions.

METHODS

Between August 1999 and July 2001, 19 patients (11 women and 8 men), with a mean age of 31.2 years (range 17 to 67), underwent laparoscopic treatment for ureteropelvic junction obstruction. Of these, 17 patients were eligible for postoperative analysis. Nine of these patients had a history of prior surgical intervention on the affected side. The patients were subjectively assessed by an analog pain scale performed before and at least 6 months after surgery. Preoperatively, patients had a diuretic renal scan to confirm the presence of obstruction. Helical computed tomography was also performed preoperatively to assess for the presence of crossing vessels. The renal scan was repeated at least 12 weeks after surgery to document the relief of obstruction objectively.

RESULTS

Helical computed tomography correctly predicted the presence of crossing vessels in 12 patients (63%). The Anderson-Hynes and Fenger pyeloplasty techniques were performed in 16 and 2 patients, respectively. In 1 patient, a small crossing vein over the ureteropelvic junction was identified and divided without complications. The average operative time was 240 minutes (range 128 to 470). The blood loss was minimal, and no open conversions were required. The mean hospital stay was 2.9 days (range 2 to 7). Two postoperative complications occurred (11.7%). The average subjective follow-up was 14.4 months (range 6 to 27), and the average objective follow-up was 7.8 months (range 3 to 12). Of 17 assessable patients, 16 (94%) had subjective and objective success (postoperative improvement in analog pain score and half-life of radiotracer washout). The average split renal function improved from 34.1% to 38.5% (P <0.01).

CONCLUSIONS

On the basis of our data, laparoscopic pyeloplasty has a similar success rate compared with the traditional open approach and better results than other minimally invasive techniques. Longer follow-up and further experience are needed to validate these data.

Laparoscopic dismembered pyeloplasty: 50 consecutive cases

OBJECTIVE

To test the hypothesis that laparoscopic dismembered pyeloplasty offers the same good results as open pyeloplasty, but without the disadvantages of the loin incision (which is painful, prolongs hospitalization and prevents a return to normal activities for several weeks) in the treatment of pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

Fifty consecutive consenting patients presenting with PUJ obstruction underwent laparoscopic dismembered pyeloplasty carried out by one surgeon using an extraperitoneal approach.

RESULTS

Two (4%) procedures were converted to open surgery. The mean (range) operative duration was 164 (120-240) min. Fifteen (30%) of the patients had their ureter transposed anterior to a crossing lower-pole vessel; 22 (44%) patients had a separate renal pelvic suture line. The mean (range) postoperative parenteral analgesic requirement was 19.1 (0-111) mg of morphine sulphate. The mean (range) hospitalization was 2.6 (2-7) days. Two (4%) patients had complications. After a mean (range) follow-up of 18.8 (3-72) months all but one patient, who had failed endopyelotomy, had a normal renogram and were symptom-free.

CONCLUSION

These results suggest that a loin wound is not necessary for a successful outcome after dismembered pyeloplasty, and that in expert hands laparoscopic dismembered pyeloplasty should now be considered the standard of care.