Retrograde balloon cautery incision of ureteropelvic junction obstruction

Comparison of Retrograde Balloon Dilatation and Laparoscopic Pyeloplasty for Treatment of Ureteropelvic Junction Obstruction: Results of a 2-Year Follow-Up

Objective

To evaluate the efficacy of laparoscopic pyeloplasty relative to retrograde balloon dilatation for the treatment of ureteropelvic junction obstruction (UPJO).

Methods

This retrospective study enrolled UPJO patients with stricture length < 2 cm who had been treated with laparoscopic pyeloplasty (LP; 44 cases) or balloon dilatation (BD; 38 cases) from Jan 2010 to Jan 2012, according to patients’ preference after consultation. Demographics and clinical parameters were collected. Patients were followed-up at 3, 6, 12, and 24 months. Ultrasonography, intravenous urography, and diuretic renography were applied to evaluate the remission of hydronephrosis.

Results

Both groups were comparable with respect to age, UPJO location, gender, and other baseline parameters. Compared to the LP group, patients receiving BD experienced significantly shorter operative time, analgesia time, hospital stay, and urethral catheter indwelling time, and less cost (P<0.001). Three and 6 months after their respective procedures, the success rates of the LP (97.7%, both) and BD (94.7% and 86.8%) groups were similar, and at 12 and 24 months the long-term success rate of LP (95.5%, both) was better than that of BD (78.9% and 71.0%).

Conclusions

LP showed better long-term success rate than did BD in the management of UPJO with length of stricture < 2 cm. Considering that BD is more minimally invasive, simpler and easier to perform, and costs less, we recommend it for some selective UPJO patients as the first-line therapy.

Robot-assisted laparoscopic pyeloplasty: a review of minimally invasive treatment options for ureteropelvic junction obstruction

Our aim was to examine the current status of minimally invasive approaches to ureteropelvic junction (UPJ) obstruction and compare it to the gold standard of open pyeloplasty. A review of the literature was conducted using PubMed and Medline databases for UPJ obstruction. Open pyeloplasty achieves good results, in the range of 90-100%. Laparoscopic pyeloplasty results are as good as those of open surgery. However, the goal of laparoscopic pyeloplasty as a means of providing minimally invasive surgery to a larger number of patients has not been achieved. The reason for this is the difficulty faced by most urologists in acquiring the technical skills to perform a laparoscopic pyeloplasty. In reports of robot-assisted pyeloplasty, results in the range of 88-97% appear to be achieved. Robotic technology has the potential to make minimally invasive pyeloplasty an easier skill to acquire for a larger number of urologists. Long-term data are still required to determine its efficacy.

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.

Ureteral access sheath facilitates inspection of incision of ureteropelvic junction

PURPOSE

The Acucise (Applied Medical, Rancho Santa Margarita, California) electrocautery balloon is a highly successful device used in managing congenital and secondary ureteropelvic junction obstruction. Correct orientation of the cutting wire is essential during insertion of the Acucise catheter to avoid injury to crossing vessels. Moreover, confirmation of the lateral ureteropelvic junction incision is typically verified by fluoroscopic identification of extravasated contrast material. We describe a technique of facilitated passage of the Acucise balloon through a ureteral access sheath followed by ureteroscopic visualization of the incision, affording the opportunity to improve the incision with the holmium laser if necessary.

MATERIALS AND METHODS

After retrograde pyelography and guidewire placement, a 12/14Fr, 35 cm. ureteral access sheath is fluoroscopically introduced to the proximal ureter. The Acucise balloon is advanced across the ureteropelvic junction and the balloon is partially inflated to confirm proper placement. Following lateral Acucise incision, flexible ureteroscopy allows direct visualization of the ureteropelvic junction, confirming a through-and-through incision. Completion of a partial incision can be performed if needed with a 200 micro holmium laser fiber followed by routine stent placement.

RESULTS

During the last 8 months we have used the Acucise device through a ureteral access sheath to treat congenital or secondary ureteropelvic junction obstruction in 8 patients. All incisions demonstrated extravasation of contrast material on retrograde pyelography, and 6 incisions (75%) were noted to be transmural by flexible ureteroscopic inspection. Two patients (25%) with only a partial incision despite contrast extravasation underwent extended incision using the holmium laser. Short-term followup demonstrated patency of the ureteropelvic junction in 7 of the 8 patients (87.5%) with 1 eventually requiring a secondary open pyeloplasty.

CONCLUSIONS

The ureteral access sheath greatly facilitates placement of the Acucise device and allows rapid ureteroscopic confirmation of the incision. Insertion and removal of the ureteral access sheath and flexible ureteroscope do not compromise or significantly increase the duration of the procedure. Moreover, flexible ureteroscopic visualization allows confirmation of a complete transmural incision and potentially increases success rates of this minimally invasive approach to ureteropelvic junction obstruction. Continued followup is necessary to confirm the long-term benefits of this procedure.

Ureteral stents and their use in endourology

Ureteral stents have assisted urologists in the performance of surgery of the urinary tract for many years. They can have both diagnostic and therapeutic value, but are used most frequently as adjuncts to endoscopic or minimally invasive procedures. This review provides an update of the current uses for ureteral stents, technology of biomaterials, complications associated with indwelling ureteral stents and the future of stents in urology.

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.