Failure After Laparoscopic Pyeloplasty: Prevention and Management

Subadventitial resection of the ureter-new method for surgical corrections of the ureteropelvic junction and ureterovesical junction obstructions

Objective

The aim of our study was to examine results of pyeloplasty using the new method-subadventitial resection of the ureter with preservation of the ureteral artery proposed by us and the possibility of using this method in one-stage surgery with ureteropelvic junction (UPJ) and ureterovesical junction (UVJ) obstructions or vesicoureteral reflux.

Methods

A retrospective analysis of 108 patients with hydronephrosis (including two patients with hydroureteronephrosis) who received treatment from March 1998 to March 2020 was carried out, with an average follow-up period of 36 months. Dismembered pyeloplasty using a subadventitial technique with preservation of ureteral blood supply was performed in 108 patients (including bilateral in two cases). In one patient with UPJ and UVJ obstructions and in one patient with UPJ obstruction and vesicoureteral reflux subadventitial resection of the ureter were performed in both segments.

Results

All patients managed to preserve the integrity of the ureteral artery during dismembered pyeloplasty, and two patients simultaneously underwent ureterocystostomy by subadventitial resection of the ureter. The method of pyeloureteroplasty with subadventitial resection of the ureter makes it possible to improve long-term results in patients with hydronephrosis, including those with lesions of the UPJ and UVJ segments. In all cases, it was feasible to achieve a decrease in the degree of hydronephrosis. Postoperative complications were observed in five cases (4.6%), in none of which there were complications associated with the surgical technique, and were eliminated without loss of renal function.

Conclusion

Our 22 years of experience shows that the technique of subadventitial resection of the ureter allows us to preserve the ureteral blood circulation during dismembered pyeloplasty and thus creates conditions for prevention of restenosis of UPJ and for single-stage ureteroplasty on the upper and lower ureteral segments.

Analysis of the efficacy and risk factors of surgical treatment of recurrent UPJO in adults

BACKGROUND

To compare the efficacy of secondary pyeloplasty and balloon dilation and to analyze the risk factors for secondary surgical failure in patients with recurrent uretero-pelvic junction obstruction (UPJO).

METHODS

We retrospectively analyzed 65 patients with recurrent UPJO who underwent secondary surgery between September 2011 and March 2019, of whom 33 had complete baseline data and follow-up data. General clinical information, perioperative data, and follow-up results were collected from patients. Risk factors for surgical failure in patients with recurrent UPJO were analyzed using logistic regression.

RESULTS

The failure rates of secondary pyeloplasty and balloon dilation in secondary surgery were 16.7% and 33.3%, respectively. Univariate analysis showed that ureteral stenosis length and operative time were associated with secondary pyeloplasty and balloon dilatation failure (p < 0.05), and ureteral stenosis length was an independent risk factor for secondary pyeloplasty failure (OR = 0.074, 95% CI: 0.006-0.864, p = 0.038). In the balloon dilation group, treatment failure rates were significantly lower in patients with stenotic segment lengths less than 1 ± 0.32 cm than in patients with stenotic segment lengths greater than 1 ± 0.32 cm (p = 0.019).

CONCLUSIONS

The secondary pyeloplasty may provide better benefit. Ureteral stricture length is an independent risk factor for failure of secondary pyeloplasty and a potential risk factor for balloon dilatation. Operation time is a potential risk factor for pyeloplasty and balloon dilatation.

Febrile urinary tract infection after Double-J stent removal is associated with restenosis after laparoscopic pyeloplasty: A propensity score matched analysis of 503 children

OBJECTIVE

To analyze the association between the febrile urinary tract infection (fUTI) after Double-J (DJ) stents removal and restenosis after laparoscopic pyeloplasty (LP).

STUDY DESIGN

We retrospectively reviewed the clinical data of patients who were treated with transperitoneal LP for ureteropelvic junction obstruction from 2016 to 2020. Patients were divided into two groups according to whether they developed fUTI after DJ stent removal within 48 h. The 1:3 Propensity Score Matched (PSM) method was used to balance confounding variables.

RESULTS

503 patients were included in the study. 28 (5.57%) patients developed fUTI after DJ stent removal. Compared with the non-fUTI group, age was younger, and weight was lower (P < 0.05) in the fUTI group. Restenosis occurred in 11 (2.2%) patients, of which six patients developed fUTI after DJ stent removal. The revision surgery rate in the fUTI group was significantly higher than in the non-fUTI group (21.4% vs. 1.1%, P < 0.01). After PSM, the results remained consistent. For 492 patients without restenosis, 22 patients developed fUTI. Compared with the non-fUTI group, the larger anteroposterior diameter (APD) and higher APD/cortical thickness (P/C) ratio were observed in the fUTI group at three months and six months postoperatively (P < 0.05), but the difference vanished at 12 months and 24 months after surgery (Figure).

DISCUSSION

FUTI after DJ stent removal is not uncommon after LP, and surgeons are often concerned about the possibility of restenosis. In the present study, although our results demonstrated a significant association between them, restenosis patients comprise only about 20% of fUTI patients. Based on our clinical observations, fUTI is often developed in children from 1 to 6 years of age, and the younger patients may be afraid of voiding because of the postoperative pain after DJ stent removal. Besides, intraoperative manipulation of DJ stent removal may lead to transient edema in the anastomotic site, causing the fUTI. For patients who develop fUTI after DJ stent removal but without persistent symptoms, the transient worsening of hydronephrosis during the early postoperative period may not impact long-term outcomes (As shown in Figure). Additional follow-up is needed to prevent the deterioration of renal function.

CONCLUSIONS

Our result demonstrated that fUTI after DJ stent removal is associated with restenosis after LP. For fUTI patients without restenosis, APD and P/C ratio exhibited transient worsening at three months and six months postoperatively, decreasing gradually during follow-up. Patients who develop fUTI after DJ stent removal should be monitored.

Redo laparoscopic pyeloplasty for recurrent ureteropelvic junction obstruction: Propensity score matched analyses of a high-volume center

PURPOSE

Review the experience of redo laparoscopic pyeloplasty (RLP) in patients with recurrent ureteropelvic junction obstruction (UPJO) in comparison to primary laparoscopic pyeloplasty (PLP) and redo open pyeloplasty (ROP), and determine the feasibility and effectiveness of RLP for recurrent UPJO in children.

METHODS

We retrospectively reviewed the clinical data of patients treated with transperitoneal PLP, RLP, and ROP for UPJO from December 2015 to December 2022. The Propensity score matching (PSM) was used to balance confounding variables. RLP patients were 1:4 matched with PLP and 1:3 matched with ROP. The primary outcomes were failure and post-operative complications. Complications were classified according to the Clavien-Dindo grading system.

RESULTS

The study included ten patients who underwent RLP, 43 patients who underwent ROP, and 412 patients who underwent PLP. The follow-up time ranged from 6 to 36 months in the RLP group, 12 to 60 months in the PLP group, and 24 to 54 months in the ROP group. In the RLP group, no failure but three post-operative complications (Clavien grade II) were observed during the follow-up. Compared with the PLP group, the older age, higher weight, larger pre-operative anteroposterior diameter (APD) and APD/cortical thickness (P/C ratio), longer operation time, and post-operative length of stay (LOS) in the RLP group (P < 0.05). After PSM, longer operation time and post-operative LOS were observed in the RLP group (P < 0.05). Compared with the ROP group, the older age, higher weight, and longer post-operative LOS in the RLP group (P < 0.05). After PSM, longer post-operative LOS was observed in the ROP group (P < 0.05). The failure and complication rates were comparable between RLP and PLP or RLP and ROP (P > 0.05).

CONCLUSIONS

Our result demonstrated that RLP performed as well as PLP except for a longer operation time. Compared with ROP, RLP has the advantages of a clearer surgical view, sufficient exposure, clearer anatomical landmark position, and minor trauma with a comparable clinical outcome. On experienced hands, RLP for recurrent UPJO after is a safe and effective procedure and should be considered an excellent alternative to the more commonly recommended ROP in select patients.

Personalized application of machine learning algorithms to identify pediatric patients at risk for recurrent ureteropelvic junction obstruction after dismembered pyeloplasty

PURPOSE

To develop a model that predicts whether a child will develop a recurrent obstruction after pyeloplasty, determine their survival risk score, and expected time to re-intervention using machine learning (ML).

METHODS

We reviewed patients undergoing pyeloplasty from 2008 to 2020 at our institution, including all children and adolescents younger than 18 years. We developed a two-stage machine learning model from 34 clinical fields, which included patient characteristics, ultrasound findings, and anatomical variation. We fit and trained with a logistic lasso model for binary cure model and subsequent survival model. Feature importance on the model was determined with post-selection inference. Performance metrics included area under the receiver-operating-characteristic (AUROC), concordance, and leave-one-out cross validation.

RESULTS

A total of 543 patients were identified, with a median preoperative and postoperative anteroposterior diameter of 23 and 10 mm, respectively. 39 of 232 patients included in the survival model required re-intervention. The cure and survival models performed well with a leave-one-out cross validation AUROC and concordance of 0.86 and 0.78, respectively. Post-selective inference showed that larger anteroposterior diameter at the second post-op follow-up, and anatomical variation in the form of concurrent anomalies were significant model features predicting negative outcomes. The model can be used at https://sickkidsurology.shinyapps.io/PyeloplastyReOpRisk/ .

CONCLUSION

Our ML-based model performed well in predicting the risk of and time to re-intervention after pyeloplasty. The implementation of this ML-based approach is novel in pediatric urology and will likely help achieve personalized risk stratification for patients undergoing pyeloplasty. Further real-world validation is warranted.

Complex Re-do robotic pyeloplasty using cryopreserved placental tissue: an adjunct for success

Introduction and Objectives:

Management of recurrent ureteropelvic junction obstruction (UPJO) following pyeloplasty presents a challenging clinical problem. Failure of initial pyeloplasty is, in part, secondary to ureteral devascularization and subsequent fibrosis. In this video, we present a case of an anastomotic augmentation with cryopreserved placental tissue (CPT) to improve tissue healing and angiogenesis, and aid with the success of re-do robotic pyeloplasty.

Materials and Methods:

We present a 46-year-old female with history of recurrent left-sided UPJO treated by initial endopyelotomy and then open pyeloplasty. She underwent re-do robotic pyeloplasty (DaVinci Si™, Intuitive Surgical) with CPT. The patient was placed in the flank position; a 12mm camera port, three 8mm robotic ports, and a 12mm assistant port were used. The renal pelvis and upper ureter were mobilized to reveal a dense scar at the UPJ. A dismembered pyeloplasty was performed with barbed suture. After completion of the anastomosis, a section of CPT (Stravix™, Osiris Therapeutics) was wrapped around the anastomosis. CPT is composed of umbilical amnion and Wharton's jelly, which contains a mixture of extracellular matrix, and growth factors. The CPT is prepared and thawed on the bedside table, and placed into the peritoneum through the 12mm port in the correct orientation. The wrap is secured to the anastomosis with a fibrin sealant (EVICEL™, Johnson & Johnson).

Results:

The patient experienced resolution of flank pain. MAG3 renogram demonstrated resolution of obstruction at 6 months, with improvement of T½ time from 34 minutes to 7 minutes, with sustained improvement with repeat scan 18 months after surgery. Ureteroscopy demonstrated a patent UPJ. Strategies for successful robotic pyeloplasty after initial failed management include: (1) use of appropriate CPT agent to support the anastomosis - selection of thicker, more durable CPT to allow passage through laparoscopic port, (2) preparation on bedside table with enough time to allow thawing, (3) marking Wharton's jelly side of tissue for orientation, and (4) use of sealing agent to secure CPT to the anastomosis and prevent dislodgement.

Conclusions:

We demonstrate a novel approach to manage recurrent UPJ obstruction with robotic surgery using CPT. Placenta-derived products may have an increasing role in the performance of complex robotic urologic reconstructive surgery.

[Advance in re-do pyeloplasty for the management of recurrent ureteropelvic junction obstruction after surgery]

Ureteropelvic junction obstruction (UPJO) is characterized by decreased flow of urine down the ureter and increased fluid pressure inside the kidney. Open pyeloplasty had been regarded as the standard management of UPJO for a long time. Laparoscopic pyeloplasty reports high success rates, for both retroperitoneal and transperitoneal approaches, which are comparable to those of open pyeloplasty. However, open and laparoscopic pyeloplasty have yielded disappointing failure rates of 2.5%-10%. The main causes for recurrent UPJO are severe peripelvic and periureteric fibrosis due to urinary extravasation, ureteral ischemia, and inadequate hemostasis. In addition, failing to diagnose lower pole crossing vessels before or during the primary procedure is also responsible for recurrent UPJO. In addition, poor preoperative split renal function, hydronephrosis, presence of renal stones, patient age, diabetes, prior endopyelotomy history, and retrograde pyelography history were considered as predictors of pyeloplasty failure. The failure is usually defined by persistent pain, persistent radiographic obstruction (infection or stones), continued decline in split renal function, or a combination of the above. And the failure of pye-loplasty often occurs in the first 2 years after the surgery. The available options for managing recurrent UPJO with a salvageable renal unit include endopyelotomy, re-do pyeloplasty, stent implantation, percutaneous nephrostomy, ureterocalicostomy, and nephrectomy. Re-do pyeloplasty has such merits as high successful rates and rare complications, compared with endopyelotomy or ureterocalicostomy. And some investigators think that re-do pyeloplasty should be regarded as the gold standard for secondary therapy if feasible. Open pyeloplasty can enlarge the operating field, facilitate the exposure of the ureteropelvic junction, reduce the difficulty of operation, and thus reduce the occurrence of complications. There are no significant differences among the success rates of re-do pyeloplasty under open approach, traditional laparoscopy and robot-assisted laparoscopy, according to previous reports. However, traditional laparoscopic and robot-assisted pyeloplasty give advantages of cosmetology, small trauma, less postoperative pain, speedy recovery and shorter hospitalization, fewer complications and lower recurrent rates. If the primary pyeloplasty is an open operation in retroperitoneal approach, the traditional laparoscopic and robotic operation with retroperitoneal approach should be considered for secondary repair. The cause of recurrent UPJO should be evaluated before surgery and identified intraoperatively to minimize the possibility of recurrence.

The Comparative Effectiveness of Treatments for Ureteropelvic Junction Obstruction

OBJECTIVE

To examine the effectiveness of the 3 primary treatments for ureteropelvic junction obstruction (ie, open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy) as assessed by failure rates.

MATERIALS AND METHODS

Using MarketScan data, we identified adults (ages 18-64 years) who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was failure (ie, need for a secondary procedure). We fit a Cox proportional hazards model to examine the effects of different patient, regional, and provider characteristics on treatment failure. We then implemented a survival analysis framework to examine the failure-free probability for each treatment.

RESULTS

We identified 1125 minimally invasive pyeloplasties, 775 open pyeloplasties, and 1315 endopyelotomies with failure rates of 7%, 9%, and 15%, respectively. Compared with endopyelotomy, minimally invasive pyeloplasty was associated with a lower risk of treatment failure (adjusted hazards ratio [aHR] 0.52; 95% confidence interval [CI], 0.39-0.69). Minimally invasive and open pyeloplasties had similar failure rates. Compared with open pyeloplasty, endopyelotomy was associated with a higher risk of treatment failure (aHR 1.78; 95% CI, 1.33-2.37). The average length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P <.001).

CONCLUSION

Endopyelotomy has the highest failure rate, yet it remains a common treatment for ureteropelvic junction obstruction. Future research should examine to what extent patients and physicians are driving the use of endopyelotomy.

Matched comparison of primary versus salvage laparoscopic pyeloplasty

PURPOSE

To compare our experience with salvage laparoscopic pyeloplasty, using a matched control set of primary laparoscopic pyeloplasty patients.

METHODS

We retrospectively reviewed patients who underwent laparoscopic pyeloplasty from 1996 to 2014 by a single surgeon. At least 12 months of follow-up was required. Salvage patients were matched 1:3 with primary patients. Matching was based on age ±5 years, body mass index (BMI) ±5, and type of pyeloplasty (dismembered vs. non-dismembered). Primary outcome was failure as defined as re-intervention following laparoscopic pyeloplasty (does not include temporary stenting without definitive retreatment).

RESULTS

Of 128 laparoscopic pyeloplasty procedures, ten were salvage. These patients were matched to 26 patients who underwent a primary laparoscopic pyeloplasty in a 1:3 manner. One salvage pyeloplasty failed to match due to BMI, and the closest matches were made. Four salvage patients had one overlapping match, reducing the primary group to 26 patients. There were no differences in pre-, intra-, and postoperative variables between groups, except for operative time (salvage 247 min, primary 175 min, p = 0.03). With similar duration of radiologic and symptomatic follow-up, there was no significant difference in the rate of freedom from intervention.

CONCLUSION

When matching for factors that could affect success, salvage laparoscopic pyeloplasty performed as well as primary pyeloplasty except for a longer operative time. In experienced hands, salvage laparoscopic pyeloplasty for ureteropelvic junction obstruction recurrence after prior pyeloplasty is a safe and effective procedure, and should be considered an excellent alternative to the more commonly recommended endopyelotomy.

Definitive Management of Failure After Pyeloplasty

INTRODUCTION

Failure after pyeloplasty is difficult to manage. We report our experience managing pyeloplasty failures.

METHODS

We retrospectively reviewed the case log of a single surgeon, from August 1996 to August 2014, to identify all patients undergoing a surgical procedure after failed pyeloplasty. We excluded patients without follow-up exceeding 1 year from initial postpyeloplasty procedure. Failure was defined as a need for additional definitive intervention.

RESULTS

Of 247 laparoscopic pyeloplasties, 68 endopyelotomies and 305 simple laparoscopic nephrectomies reviewed, 41 were performed after previous pyeloplasty and had sufficient follow-up. Laparoscopic nephrectomy was performed in nine patients. All three secondary laparoscopic pyeloplasties were successful. Of 29 secondary endopyelotomies, 10 (34%) were successful. Of the 19 failures after secondary endopyelotomy, 12 patients had tertiary pyeloplasty (5 laparoscopic and 7 open surgical), 5 (26%) underwent tertiary endopyelotomy, and 2 (11%) required nephrectomy. Our overall endopyelotomy success rate was 38% (13/34) vs 100% (11/11) for secondary or tertiary pyeloplasty (4 patients lost to follow-up). Median time to failure was 5 months for endopyelotomy. Median follow-up for patients free from intervention was 40.2 months.

CONCLUSIONS

Secondary pyeloplasty (including both laparoscopic and open surgical approach) is more than twice as successful as endopyelotomy after failed pyeloplasty. Secondary pyeloplasty is an excellent alternative to endopyelotomy in select patients with failure after initial pyeloplasty.

Robotic-assisted Laparoscopic Pyeloplasty: Analysis of Symptomatic Patients With Equivocal Renal Scans

OBJECTIVES

To review the objective and subjective success rates of robotic-assisted laparoscopic pyeloplasty in symptomatic patients with radiographic findings suggestive of uretero-pelvic junction obstruction (UPJO), but equivocal renal scans (diuretic T1/2 <20 minutes).

METHODS

We reviewed 77 patients with symptomatic UPJO, who underwent robotic-assisted laparoscopic pyeloplasty between August 2006 and March 2013. We grouped patients by renal scan findings into 1 of 2 groups, obstructed (diuretic T1/2 ≥20 minutes) or equivocal (diuretic T1/2 <20 minutes). All patients were symptomatic and had radiographic findings suggestive of UPJO (eg hydronephrosis).

RESULTS

Mean age was 40.7 years (range 17-80) with 70% female. UPJO occurred 44% left and 56% right, with 92% presenting with flank pain. Of 77 patients, 45 had obstruction on renal scan, with 41 (91%) having resolution of obstruction postoperatively and 44 of 45 (98%) having complete resolution of their initial symptoms. Thirty-two patients had equivocal findings with mean diuretic T1/2 of 12.6 minutes (range: 5.5-19.26) on renal scan. In this latter group, patients had significantly less of a decrease in their diuretic T1/2 postoperatively (4 vs 64 minutes, P = .018) and reported less pain resolution (53% vs 98%, P ≤.001) than group 1.

CONCLUSION

Many studies have demonstrated excellent success of pyeloplasty, with most series including patients meeting strict diagnostic criteria for obstruction. Our study examines outcomes in patients with clinically symptomatic UPJO and equivocal diuretic renography. In our cohort, equivocal patients were significantly less likely to have subjective resolution of symptoms than patients in the obstructed group.

Functional Results of Laparoscopic Pyeloplasty in Children: Single Institute Experience in Long Term

OBJECTIVE

The aim of this study was to evaluate the long-term functional outcomes of laparoscopic pyeloplasty (LP) in children for consecutive cases of single institute.

MATERIALS AND METHODS

Our laparoscopy database was investigated for children in terms of LP between June 2008 and April 2015. All the patients had ureteropelvic junction obstruction (UPJO) and LP was performed. Demographic data including age, gender, side of UPJO, operation time, estimated blood loss (EBL), hospital stay and complications according to Clavien classifications were recorded. Renal ultrasonography and diethylenetriamine penta-acetate (DTPA) scintigraphies were respectively performed 3, 12 and 24 months after surgery. Statistical analyses were performed and p value was accepted as significant at <0.05.

RESULT

Mean follow-up was 34 ± 4.7 months. The mean age was 13 (6-72) months. A total of 153 (110 boys and 43 girls) LP patients enrolled. Of that, 93 (60.78%) LP were in left side and 60 (39.21%) were in right side. Three cases needed open conversation according to difficulties in anastomosis. Aberrant crossing vessel was observed in 12 (7.84%) patients. The mean operation time was 155 ± 21 min and the mean EBL was 22 ± 11.1 ml. The mean hospital stay was 3.4 days. Anastomotic leakage was the common complication (in 13 patients) that was successfully managed conservatively (Clavien 1). Eight patients experienced unsuccessful LP and underwent open pyeloplasty (Clavien 3b). The mean split renal function significantly increased in DTPA scintigraphy in follow-up. The overall success was 91%.

CONCLUSIONS

The LP procedure can be an effective and safe surgical method for childhood UPJO, specifically in the experienced hands of pioneer centers.

Long-term follow-up results of laparoscopic pyeloplasty

Purpose

To assess the long-term follow-up results of laparoscopic pyeloplasty for ureteropelvic junction obstruction.

Materials and Methods

Sixty-five patients (mean age, 43.8 years) who underwent standard laparoscopic pyeloplasty by transperitoneal approaches were enrolled in this study. The chief complaint was flank pain (n=57 patients); the remaining cases were detected incidentally. Twenty-three patients had undergone previous abdominal surgeries, including open pyeloplasty and endopyelotomy. Mean stricture length was 1.06 cm. Grade 3/4 and 4/4 hydronephrosis was detected in 36 and 14 patients, respectively. An obstructive pattern was present on the renal scan in 53 patients (81.5%).

Results

Fifty-seven patients were treated with dismembered Anderson-Hynes pyeloplasty and eight patients with Fenger pyeloplasty. During the operation, crossing vessels were found in 27 patients (41.5%). Mean operating time was 159.42 minutes. Although there were no cases of open conversion, two patients with colon and spleen injuries were detected postoperatively. The mean starting time of postoperative ambulation and diet was 1.54 days and 1.86 days, respectively. Mean hospital stay was 8.09 days. Mean follow-up period was 36.5 months. Follow-up intravenous pyelography and renal scan showed improvements in 59 patients, and the radiologic success rate was 90.8%. Eight patients showed failure on radiologic or symptomatic evaluation, and the overall success rate was 87.7%. In the comparative analysis between the success and failure groups, drained amount was the only risk factor related to failure (554.41 mL. vs. 947.70 mL, p=0.024).

Conclusions

Long-term follow-up results support laparoscopic pyeloplasty as the standard treatment for ureteropelvic junction obstruction. Drained amount is a risk factor for failure of the operation.

Recurrent symptoms following pyeloplasty with a normal endoscopic evaluation: assessment and outcomes of a challenging patient cohort

OBJECTIVE

To aid in counseling and managing a challenging patient cohort, we review our experience using a structured endoscopic approach to assess individuals with recurrent symptoms but a normal anatomic evaluation after pyeloplasty.

METHODS

From 2008 to 2012, all patients presenting with recurrent symptoms after pyeloplasty for ureteropelvic junction (UPJ) obstruction were retrospectively evaluated. After baseline renal scanning, all underwent retrograde ureteropyelography, flexible ureteroscopy, UPJ balloon calibration, and provocative ureteral stenting. Patients without clear anatomic obstruction were assessed 2 weeks postoperatively at the time of stent removal and reassessed serially as outpatients before considering further operative management.

RESULTS

Nineteen patients had undergone an average of 1.4 UPJ procedures: pyeloplasty in all 19, retrograde endopyelotomy in 6, and balloon dilation in 1. Mean age was 35.2 years, time from original management to symptom recurrence was 80 months, Lasix T1/2 was 16.6 min, and differential renal function of the affected kidney was 43%. Mean follow-up after endoscopic assessment was 16.2 months. Thirteen patients (68%) achieved long-term pain-free status after endoscopic evaluation alone, and 2 (11%) were rendered symptom free after repeat robotic pyeloplasty. Of the 4 remaining patients (21%) with persistent pain after a negative endoscopic assessment, all were referred to a pain specialist. Two patients (11%) ultimately required laparoscopic nephrectomy for definitive symptom control.

CONCLUSION

Our findings support evaluation with retrograde pyelography, ureteroscopy, and balloon calibration for patients with recurrent symptoms before embarking on revision pyeloplasty. Surprisingly, two-thirds of our patients achieved pain-free status with an endoscopic approach alone.

Management of secondary pelviureteric junction obstruction

Pelviureteric junction obstruction (PUJO) of the kidney can lead to a number of different clinical manifestations, which often require surgical intervention. Although the success of pyeloplasty and endopyelotomy are good, there are still a number of patients who fail primary treatment and develop secondary PUJO. These treatment failures can be a challenging cohort to manage. This article aims to provide a comprehensive overview on the surgical options available to the urologist for managing secondary PUJO as well as providing some guidance on assessing factors that will influence management decisions.

Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis

CONTEXT

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized.

OBJECTIVE

To critically analyze the current status of laparoscopic and robotic repair of UPJO.

EVIDENCE ACQUISITION

A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria.

EVIDENCE SYNTHESIS

Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population.

CONCLUSIONS

Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.

Trends in the treatment of adults with ureteropelvic junction obstruction

BACKGROUND AND PURPOSE

Minimally invasive pyeloplasty is an effective treatment for patients with ureteropelvic junction obstruction that offers quicker convalescence than open pyeloplasty. Technical challenges, however, may have limited its dissemination. We examined population trends and determinants of surgical options for ureteropelvic junction obstruction.

PATIENTS AND METHODS

Using the State Inpatient and Ambulatory Surgery Databases for Florida, we identified adults who underwent ureteropelvic junction obstruction repair between 2001 and 2009. After determining the surgical approach (minimally invasive pyeloplasty, open pyeloplasty, or endopyelotomy), we estimated annual utilization rates and the effects of patient, surgeon, and hospital predictors on surgery type, using multilevel multinomial logistic regression.

RESULTS

Rates of minimally invasive pyeloplasty increased 360% (P for monotonic trend < 0.01), while rates of open pyeloplasty decreased 56% (P<0.01). Rates of endopyelotomy were substantially higher and remained relatively stable (P=0.27). Compared with open pyeloplasty, minimally invasive pyeloplasty was used more commonly among patients with private insurance (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.2-2.3), those treated at teaching hospitals (OR 1.6; CI 1.0-2.6), and those treated by high-volume surgeons (OR 2.9; CI 2.0-4.2). Its use was less frequent among patients with multiple comorbidities (OR 0.53; CI 0.37-0.76). Similar associations were observed when comparing receipt of minimally invasive pyeloplasty with endopyelotomy; however, patients who underwent endopyelotomy were older.

CONCLUSIONS

The use of minimally invasive pyeloplasty has dramatically increased, largely replacing open pyeloplasty, while the use of endopyelotomy, albeit significantly more common than the other approaches, has remained stable. The surgical approach is influenced by several patient, surgeon, and hospital factors.