Optimum duration of splinting after endopyelotomy

The role of percutaneous endopyelotomy for ureteropelvic junction obstruction

INTRODUCTION

Over the last 20 years, the surgical management of ureteropelvic junction obstruction (UPJO) has been revolutionised by the development of endourological instrumentation and several minimally invasive procedures including: antegrade or retrograde endopyelotomy, retrograde balloon dilatation, and laparoscopic pyeloplasty. Currently, in our department, we offer percutaneous antegrade endopyelotomy (PAE) as primary treatment of UPJO in adults, believing it offers less morbidity, better cosmetic results, and quicker operating time compared with open pyeloplasty.

PATIENTS AND METHODS

We performed a retrospective audit of our results for the 14 patients who underwent percutaneous antegrade endopyelotomy between January 2000 and May 2004.

RESULTS

Mean operative time was 53 min (range, 30-80 min), mean in-patient stay was 3.8 days (range, 2-7 days), and there were no major postoperative complications for this series with mean follow-up of 31.8 months (range, 12-52 months). Eleven out of the 14 patients (79%) showed radiological improvement on their 3-month MAG 3 (mercaptoacetyl-triglycyl) renogram, and 13 out of the 14 (93%) patients reported significant reduction or resolution of pain, compared with their preoperative state.

CONCLUSIONS

The majority of urologists still offer open pyeloplasty as primary treatment for UPJO with laparoscopic pyeloplasty currently an evolving procedure in the UK. Our series reports comparable success rates for PAE compared to other series. Despite these results, we feel that the future role of percutaneous endopyelotomy will be as a salvage procedure following failed open or laparoscopic surgery. However, in patients with concurrent stone disease or requiring antegrade ureteric access, percutaneous endopyelotomy would be suitable as a primary treatment option.

Comparative study of ureteral stents following endoureterotomy in the porcine model: 3 vs 6 weeks and 7F vs 14F

The aim of the study was to determine the optimal stent size and stenting duration following retrograde endoureterotomy of experimental ureteral strictures. Twenty healthy Large White female pigs were randomly divided into four groups, depending on stent size (7F vs 14F) and stenting duration (3 weeks vs 6 weeks). Three additional pigs were used as the control group. The internal ureteral diameter was measured 2 cm below the lower pole of the right kidney. Histopathological changes of the urinary tract, ultrasonographic and fluoroscopic studies, urine culture, and serum urea and creatine levels were analyzed during the different phases of the study. The study was divided into three phases. Phase I included premodel documentation of the normal urinary tract and laparoscopic ureteral stricture creation. During the second phase 1 month later, the diagnosis and endourologic treatment of strictures were performed. Phase III began 4 weeks after stent removal; follow-up imaging studies and postmortem evaluation of all animals were performed. Ureteral strictures developed in all animals 4 weeks after model creation. Results from ureteral diameter measurements and pathological studies revealed no statistically significant intergroup differences. However, prevalence of urinary infection proved to be directly related to stent size (14F) and permanence (6 weeks). The chi square results suggest a statistically significant relationship between the urinary tract infection and recurrent strictures (alpha = 0.046). We recommend the use of 7F stents for a period of 3 weeks or less, as these are more easily positioned and result in the reduction of secondary side effects (lower infection rate, less intramural ureteral lesions). A significant relationship between urinary tract infection and stricture recurrence was found in this experimental study.

Ureteric stenting 25 years on: routine or risky?

BACKGROUND

Ureteric stents have been used in urological practice for over 25 years and in many cases have become almost routine. The purpose of the present review is to highlight the uses, complications and risk management issues associated with their use.

METHODS

An extensive literature review was conducted and knowledge from past experience was accessed to give a summary of past and current ureteric stent use in urology.

RESULTS

Broadly, there are stone and non-stone indications for stenting. Complications may range from the commonly experienced 'stent syndrome' to the medico-legal dilemma of the forgotten stent. Risk management must be applied to all uses of stenting to minimize complications and achieve best practice.

CONCLUSION

Although almost routine in many areas of urological practice, the complications and implications for risk management of ureteric stenting cannot be ignored.

Endopyelotomy - a Minimally Invasive Surgical Option for Pelvi-ureteric Junction Obstruction: a Study Of 34 Cases

We performed antegrade endopyelotomy in 34 cases in the last 2½ years. In all cases standardized antegrade percutaneous method was used. A single guide wire and a cold knife were used to perform the endopyelotomy. Nephrostomy tube was retained for 48 hours and the repair stented for 6 weeks. Patients were followed up at 3 months, 6 months and 1 year post-operatively for subjective improvement and objectively by DTPA scans/IVU and ultrasound. The population included 2 bilateral cases, one horseshoe kidney and 3 children. The patient's age ranged from 9-59 years, average 32 years. There were 21 males and 13 females. 28 renal units were primary and 8 were secondary pelviureteric junction (PUJ) obstruction. Follow up period was 3-28 months. Most cases had significant symptomatic and functional recovery postoperatively. Five cases presented with urinary tract infection, which regressed after treatment. At 3(rd) month postoperatively the DTPA/IVU scan was equivocal in 7 cases. In these, a RGP was done which in every case showed a patent PUJ. In 5 cases that were still symptomatic, 6-8 weeks of further stenting produced symptom regression. Two cases failed and needed revision, one by open pyeloplasty and the other by endopyelotomy. Our success rate overall in these cases followed upto 1 year post operatively is 91.6%. We conclude that endopyelotomy is successful across a wide spectrum of cases.

Is a 2-week duration sufficient for stenting in endopyelotomy?

PURPOSE

Internal stenting is an integral part of endopyelotomy. Studies in animals show good healing after 1 to 2 weeks of ureterotomy. Inherent stent related problems warrant a minimum possible duration of stenting without compromising the results of endopyelotomy. We performed a prospective randomized trial to evaluate the optimum duration of stenting after endopyelotomy.

MATERIALS AND METHODS

A total of 57 consecutive patients with primary ureteropelvic junction obstruction were randomized to undergo 7/14Fr internal endopyelotomy stent placement for 2 (group 1) and 4 (group 2) weeks. A symptom based questionnaire was administered to all patients at stent removal. Followup was done with diuretic scanning at 3, 6, 9 and 12 months and then yearly, and thereafter with diuretic renography.

RESULTS

In each group 26 patients were available for evaluation. The 2 groups were comparable in terms of age, sex, symptoms and ipsilateral glomerular filtration rate. Mean followup was 22.3 (range 12 to 36) and 21.3 months (range 12 to 35) in groups 1 and 2, respectively. At the end of 1 year 24 group 1 (92.3%) and 23 group 2 (90.3%) patients had an improved drainage pattern. This difference was not significant. Stent related symptoms were present in a good proportion of patients in groups 1 and 2 but there was a significant difference in the incidence of urinary tract infections (11.5% versus 38.1%, p = 0.04). Of the group 2 patients 64% preferred 2 weeks of stenting.

CONCLUSIONS

Two weeks seems to be a sufficient duration to allow functional restoration across the ureteropelvic junction after endopyelotomy and decrease stent related complications.

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.