Antegrade transpelvic endopyelotomy in primary obstruction of the ureteropelvic junction

Endourologic techniques for ureteropelvic junction obstruction therapy. Comparative animal study

PURPOSE

The aim of this work is to compare 3 endourologic techniques for treating a ureteropelvic junction (UPJ) obstruction. To accomplish this, we performed a study in a porcine animal specimen, in which we compared laparoscopic pyeloplasty that emerges as the future gold standard technique, with 2 endopyelotomy techniques.

MATERIAL AND METHODS

Twenty-four healthy large white female pigs were randomly divided in 3 groups-group I (laparoscopic pyeloplasty), group II (endopyelotomy-Acucise, Applied Medical, Rancho Margarita, CA), and group III (endoballoon rupture endopyelotomy). Percutaneous and endoluminal ultrasonographic and fluoroscopic studies were analyzed during the different phases of the study. The study was divided in 3 phases. First one included premodel documentation of normal urinary tract and laparoscopic UPJ obstruction induction. During second phase at 6 weeks later, diagnosis and endourologic treatment were carried out. Fifteen weeks after obstruction treatment, follow-up imaging studies and postmortem evaluation of all animals were performed.

RESULTS

After the sonographic and fluoroscopic assessment, we determined the percentage of success rate for each technique-with an 87.5% for groups I and II and 75% for group III. Significant statistical differences were found between the 2 pyelotomy groups and the pyeloplasty group regarding the duration of the intervention. Significant statistical differences are evident in the evolution of the UPJ's diameter between groups I and III.

CONCLUSIONS

Laparoscopic pyeloplasty is the technique that produces fewer side effects in the reconstructed area, as well as a wider dilation of the UPJ. Nevertheless, as we show in this study, we found similar results between endopyelotomy in selected patients than pyeloplasty, and it is simpler and less invasive than the latter.

Collagen Changes in the Ureteropelvic Junction after Failed Antegrade Endopyelotomy

PURPOSE

We evaluated the collagen content and differentiation of the ureteropelvic junction (UPJ) of patients who underwent Anderson-Hynes dismembered pyeloplasty after failure of antegrade endopyelotomy.

MATERIALS AND METHODS

A total of 12 UPJ obstructions were examined more than 12 months after endopyelotomy with both histochemical staining to analyze total collagen content and immunohistochemical staining to analyze collagen types I and III. The specimens were compared with 12 primary UPJ obstructions and 6 normal UPJs. Statistical analysis was performed using Fisher's test and Wilcoxon matched-pairs signed-rank test.

RESULTS

Immunohistochemical staining revealed that collagen type I was located in the interfascicular space and collagen type III in the intrafascicular space in all UPJs. We found more collagen in obstructed than in normal UPJs. Collagen type III was more abundant in secondary than in primary UPJ obstructions (P < 0.01). In obstruction after endopyelotomy, the staining intensity of collagen type III was greater than the intensity of collagen type I (P < 0.01).

CONCLUSION

Our results suggest that the success of antegrade endopyelotomy was impaired by an inflammatory process. This condition determined a shift of collagen differentiation toward type III, which is more fibrous than type I.

Antegrade endopyelotomy in pelvic kidney

Antegrade endopyelotomy was performed in a patient with pelvic kidney. Nephrostomy tube had been placed in the patient during a previous open pyelolithotomy. The nephrostomy tract was used for establishing percutaneous access. The ureteropelvic junction (UPJ) was balloon dilated and incised laterally under vision. At 3-month-follow-up renal dynamic scan showed no evidence of UPJ obstruction.

Endopyelotomy in Childhood: Our Experience with 37 Patients

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Cost-effective laparoscopic pyeloplasty: Single center experience

OBJECTIVE

Laparoscopic pyeloplasty (LPP) is a minimally invasive treatment option for ureteropelvic junction (UPJ) obstruction. We report here our experience of performing cost-effective LPP on 24 patients at a single center.

METHODS

Between October 1999 and March 2002, LPP was performed in 24 patients (17 male, seven female; age range 8-51 years) including two patients who had failed previous endourologic treatments. In two patients with concomitant renal stones, laparoscopic pyelolithotomy was also performed. LPP was conducted in a cost-reductive manner by both transperitoneal (n = 12) and retroperitoneal (n = 12) access. To reduce the cost, an indigenous balloon to create the retroperitoneal space, reusable ports, ordinary polyglactin suture and intracorporeal free-hand suturing were employed. To reduce operative time, antegrade stenting was also performed in some cases.

RESULTS

Laparoscopic Anderson-Hynes pyeloplasty was performed in 16, Foley Y-V pyeloplasty in five and Fenger pyeloplasty in three patients. One patient required conversion to open surgery due to tension at the anastomosis site during Anderson-Hynes pyeloplasty. The mean operating time, blood loss, analgesic (pethidine) requirement, duration of drain and hospital stay for the retroperitoneal and transperitoneal groups were 170.3 and 187.6 min, 102.2 and 145.9 mL, 125 and 136.4 mg, 2.1 and 2.5 days, and 3.4 and 4.3 days, respectively. No significant complications were encountered apart from prolonged ileus in three patients in the transperitoneal group. The mean follow-up period was 10.8 months with a range of 2-24 months. Postoperative renal scan was performed at 3 months in 21 patients, and 1 year in 11 patients. There was evidence of equivocal obstruction in one patient, but there were no obstructions in the remaining patients.

CONCLUSION

Although LPP is technically demanding, it is emerging as a viable, minimally invasive alternative to open pyeloplasty for UPJ obstruction with a success rate similar to that of open pyeloplasty. It allows the duplication of open surgery steps (unlike endoscopic procedures), thereby providing durable and sustained results. LPP can also be performed safely, effectively and efficiently in a cost-efficient manner.

[Endoscopic surgery in urology]

At this moment in time, endourology is incorporating extraluminal endoscopic techniques (laparoscopy, lumboscopy, retziuscopy), which the urologist is expected to master. The current advanced stage of development of intraluminal endoscopic surgery is mainly due to the most recent technological achievements (miniaturization of the lens, the use of more versatile materials and new energy sources). In the current cystourethroscopic procedures, compact endoscopes and flexible cystoscopes play an important role. The most important of these new techniques include tissue vaporisation procedures, interstitial application of substances or energies, low-pressure transurethral resection and percutaneous vesical surgery. Upper endoluminal procedures have been the ones to most benefit from modern technological developments. The most important features of present day ureterorenoscopes and their clinical applications are studied and also those of percutaneous nephroscopy (lithiasis, neoformations and others). In a review on the current situation of extraluminal endoscopy, a wide range of laparoscopic techniques--applicable to adrenal regions, kidneys, ureters, retroperitoneal and lymphatic systems, testicles and sperm ducts, bladder and prostrate gland--are discussed as well as the indications, advantages and drawbacks involved and the preferential surgical approaches.

Laparoscopic pyeloplasty: the first 100 cases

PURPOSE

Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction obstruction. Long-term followup has not yet been reported. We present experience with the first 100 consecutive cases of laparoscopic pyeloplasty performed at our institution.

MATERIALS AND METHODS

A retrospective review of 100 consecutive laparoscopic pyeloplasties in 99 patients (means age 37.3 years) between August 1993 and January 1999 was performed. All patients had radiographic evidence of obstruction with signs, symptoms or deterioration of renal function. Repair was for primary ureteropelvic junction obstruction in 83 patients and secondary obstruction in 17. The 4 types of repairs performed were Anderson-Hynes dismembered (71 cases), Y-V plasty (20), Heineke-Mirhulicz (8) and Davis intubated ureterotomy (1). Type of repair used was dictated by intraoperative findings. Twenty patients had nonobstructing renal stones and underwent concomitant pyelolithotomy. All patients were assessed for symptoms and radiographic evaluation for anatomical obstruction.

RESULTS

Average operating room time was 4.2 hours, which decreased with surgeon experience. Average blood loss was 181 cc and hospital stay was 3.3 days. Two patients required blood transfusion. A crossing vessel was found in 57 patients. With a mean clinical and radiographic followup of 2.7 and 2.2 years, respectively, 96% of the patients were free of obstruction on followup radiographic imaging. Of the patients who underwent concomitant pyelolithotomy, 18 (90%) were stone-free at last followup. All failures occurred within the first postoperative year. There were 12 complications in this series.

CONCLUSIONS

In experienced hands laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction. The results appear durable and comparable to open pyeloplasty with decreased postoperative morbidity.

Retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction

PURPOSE

We developed a new approach of retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction as an alternative to conventional antegrade or retrograde endopyelotomy.

MATERIALS AND METHODS

From February 1997 to August 1999 we treated 5 cases of ureteropelvic junction obstruction due to crossing vessels that were diagnosed by helical computerized tomography. Ureterovascular hydronephrosis characterized by a malrotated renal pelvis with anterior crossing vessels was observed in 4 cases and ureteropelvic junction obstruction with a posterior crossing artery was present in 1. After endoureterotomy stent insertion under cystoscopic guidance we performed retroperitoneoscopic endopyelotomy with the kidney in standard position. Crossing vessels were transposed to a higher position to remove obstruction and fixed with peripelvic tissue via retroperitoneoscopy. In all cases a longitudinal incision approximately 1.5 cm. long was made with a potassium titanyl phosphate laser.

RESULTS

Convalescence was uneventful in all patients and the endoureterotomy stent was removed 4 to 8 weeks after surgery. Postoperatively helical computerized tomography showed the successful transposition of crossing vessels and significant hydronephrosis resolution in all cases. All patients were asymptomatic during followup of 17 to 28 months.

CONCLUSIONS

Despite our small number of patients our results are sufficient to conclude that retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels is a simple and reliable method for treating ureterovascular hydronephrosis and associated conditions.

Laparoscopic surgery in urology

Not more than 10 years ago, laparoscopy was introduced to the armamentarium of urology. The start was slow, with pelvic lymphadenectomy, nephrectomy and varicocelectomy being about the only indications. However, very soon great enthusiasm developed, and almost every urological operation was performed by means of laparoscopy. For several reasons this exaggerated enthusiasm had to be followed by disappointment. First of all, laparoscopy turned out not to be as easy as many would have liked it to be. Due to a low frequency of operations, many surgeons were never able to overcome their learning curve, and the early literature reflects this problem. Unlike general surgery where cholecystectomy developed into a pacemaker operation, which forced everybody to go ahead with laparoscopy, urology was long searching for good and frequent indications for this new technique. Within the last few years, the pendulum has swung back to the other side. Adrenalectomy was one of the first indications where laparoscopy proved superior to open surgery in every aspect. Several other good indications have followed, some of which, namely cryptorchidism, nephrectomy and pyeloplasty, will be presented in detail to give an example. But the breakthrough that recently occurred is due to the success of laparoscopy in the field of oncologic surgery. Laparoscopic radical nephrectomy has shown its surgical efficiency as well as its oncologic efficacy. However, the main interest is now focused on radical prostatectomy, since this is the most frequently performed operation in urology by now. Recently this operation could be developed to a standardized technique, but only time will tell its true impact. Several indications will change in the future, but laparoscopy is here to stay.

Antegrade endopyelotomy

Antegrade endopyelotomy has become the procedure of choice for patients with UPJ obstruction. Overall success rates of 85% can be expected when the procedure is used in a broad spectrum of patients. Contraindications include an uncorrected bleeding diathesis, untreated infection, and any anatomic abnormality precluding safe percutaneous access.