ADULT ENDOPYELOTOMY: IMPACT OF ETIOLOGY AND ANTEGRADE VERSUS RETROGRADE APPROACH ON OUTCOME

Intraoperative and postoperative complications of laparoscopic pyeloplasty: a single surgical team experience with 236 cases

PURPOSE

To describe and analyze a single surgical team's experience with intraoperative and postoperative complications arising from the Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) procedure in the treatment of patients with ureteropelvic junction obstruction (UPJO).

PATIENTS AND METHODS

There were 236 consecutive patients who underwent transperitoneal LP over a period of 8 years (2004-2012). These patients' records were retrospectively analyzed for intraoperative and postoperative complications. Of the 236 patients, 111 (47.0%) were males and 125 (53%) were females. In 226 patients, surgical indication was primary UPJO, and in 10 patients, recurrent obstruction. Two hundred and eleven patients (89.4%) were symptomatic.

RESULTS

Mean operative time was 96.5 minutes (range 45-360 min). The mean blood loss was 20 mL (range 5-500 mL), and no blood transfusions were necessary. The overall success rate was 97% (229 patients) with a mean follow-up of 38 months (range 6-84 mos). In 86 of the 94 patients who presented with a crossing vessel (91.5%), the anomalous crossing vessel was transposed to the ureteropelvic junction (UPJ) dorsally because of evident obstruction. The mean postoperative hospital stay was 4.2 days (range 3-14 days). All 211 preoperative symptomatic patients reported a complete resolution of symptoms after the procedure. Intraoperative incidents occurred in nine (3.8%) patients, while postoperative complications occurred in 32 (13.5%) patients.

CONCLUSIONS

Our retrospective analysis confirms that LP is an efficacious and safe procedure resulting in a reported success rate of 97% and a concomitant low level of intraoperative (3.8%) and postoperative complications (13.6%). Major complications necessitating active management occur in a low percentage of cases (5.9% of patients). The most frequent and severe intraoperative complications are related to the Double-J stent insertion. The most common postoperative complication is urine leakage.

Ureteropelvic junction obstruction: which is the best treatment today?

The aim of this review is to critically compare the different procedures performed for the treatment of ureteropelvic junction obstruction (UPJO) in order to identify, currently, the best treatment that a urologist should propose to patients with this condition. Three different types of procedures were assessed: open pyeloplasty (OP), endopyelotomy, and laparoscopic pyeloplasty (LP). Regarding efficacy, success rates of 94.1, 62-83, and 95.9-97.2% were reported for OP, endopyelotomy, and LP, respectively. Concerning operative time and length of hospital stay, no extensive data are available in the literature, although endopyelotomy seems to provide shorter times with respect to those reported after OP and LP. Regarding the complication rate, it was very similar after the different techniques and due to the respective approaches. Overall, our data support the conclusion that LP provided a balance between the highly successful technique reported by OP and the quick postoperative recovery provided by the endoscopic approach. Anyway, in spite of these clear advantages, the reproducibility of LP is still strongly limited by the challenge of the learning curve. The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA), providing an extraordinary vision and precision of surgical movement, appears to be changing this scenario, allowing naïve surgeons to achieve very good results after few procedures. In this setting, robot-assisted pyeloplasty seems to be emerging as the new standard of care in the patients with UPJO, which will further take place over the other techniques once its costs decrease.

Treatment outcomes after endopyelotomy performed with or without simultaneous nephrolithotomy: 10-year experience

INTRODUCTION

The incidence of renal calculi associated with ureteropelvic junction obstruction (UPJO) has been reported to be as high as 20%. Although it has been suggested that simultaneous stone removal be performed with endopyelotomy (EP) for patients with UPJO, no crossing vessel, and renal calculi, there are no large series to date reporting in a rigorous fashion the success rate for resolution of the UPJO. This study intends to determine if stone extraction performed with EP increases failure rate.

MATERIALS AND METHODS

A retrospective review was performed for all patients who underwent EP by a single surgeon between August 1996 and November 2006. One hundred forty-six procedures for UPJO were done in 139 patients. Success rate was compared in 105 cases (72%) of isolated UPJO and 41 (28%) cases with UPJO and ipsilateral calculi. Determination of overall success required subjective improvement and objective data based on intravenous pyelogram, computed tomography, and/or nuclear scintigraphy.

RESULTS

Overall success rate was 71% in patients undergoing EP only and 90% in 41 patients who had simultaneous nephrolithotomy (p = 0.04). The odds ratio of failure after EP was 2.9 for severe/massive preoperative hydronephrosis. When considered alone and after adjusting for the severity of preoperative hydronephrosis and/or renal function, simultaneous nephrolithotomy did not increase the EP failure rate.

CONCLUSION

This study demonstrates that UPJO resolves at an equal rate after EP performed with or without ipsilateral renal calculi. Patients with UPJO and renal calculi should undergo stone extraction and EP in the same setting with the expectation of excellent results.

Antegrade endopyelotomy versus laparoscopic pyeloplasty for primary ureteropelvic junction obstruction

OBJECTIVES

A retrospective study was performed to compare the results of laparoscopic pyeloplasty and antegrade endopyelotomy and complications observed after the two procedures.

MATERIALS AND METHODS

Seventy-five endopyelotomies and 90 laparoscopic pyeloplasties in patients with primary ureteropelvic junction obstruction (UPJO) were performed. The diagnosis of UPJO was based on a complete medical history, ultrasonography, urography (IVU), and/or diuretic renography. In 52 cases, a Whitaker test was performed before endopyelotomy. The mean follow-up was 31 months in the endopyelotomy group and 28.5 months in the laparoscopy group. Complete success was defined as absence of any clinical symptoms combined with significant reduction of hydronephrosis on diuretic IVU and ultrasonography, and no sign of obstruction on diuretic IVU, diuretic renography, or Whitaker test.

RESULTS

Complete success was observed in 55.4% of patients after endopyelotomy and in 95.3% of patients after laparoscopic pyeloplasty. In patients with primary UPJO, laparoscopic procedures yield better therapeutic results than endopyelotomy, irrespective of the degree of hydronephrosis. The number of complications after the two procedures was comparable with the exception of intraoperative bleeding, which was more frequent in the case of endopyelotomy.

CONCLUSIONS

Laparoscopic pyeloplasty should be the procedure of choice in the treatment of primary UPJO.

Case report: laparoscopic pyeloplasty for ureteropelvic junction obstruction of lower moiety in duplex system

BACKGROUND AND PURPOSE

Ureteropelvic junction (UPJ) obstruction can be associated with renal anomalies. We report a case of laparoscopic dismembered pyeloplasty in a lower moiety of a complete duplex system.

CASE REPORT

A 40-year-old woman presented with right flank pain. Intravenous urography revealed a typical UPJ obstruction on the right side, and a diuretic renal scan showed 35% uptake of the tracer and a glomerular filtration rate of 57 mL/min with delayed excretion (T1/2 28 minutes). Transperitoneal laparoscopic dismembered pyeloplasty was performed. The operative time was 140 minutes with a blood loss of 30 mL. Diclofenac sodium (total requirement 150 mg) was used for analgesia. A diuretic renal scan at 3 months showed 41% uptake and a glomerular filtration rate of 66 mL/min, with prompt drainage without obstruction of the right kidney (T(1/2) 18 minutes). At 6 months' follow-up, the patient was symptom free.

CONCLUSION

To our knowledge, our report is the third where laparoscopic pyeloplasty for a duplex system was carried out. Prior placement of Double-J stent made identification of the ureter draining the lower moiety during laparoscopic surgery much easier. The principles of open surgery could be duplicated.

Long-Term Outcome of Endopyelotomy for The Treatment of Ureteropelvic Junction Obstruction: How Long Should Patients Be Followed Up?

PURPOSE

To evaluate the long-term success rate of endopyelotomy for the treatment of ureteropelvic junction (UPJ) obstruction.

PATIENTS AND METHODS

Between January 1995 and December 2003, 85 endopyelotomies (10 percutaneous, 75 retrograde) were performed in 77 patients with a mean age of 35.2 +/- 13.9 years. The mean number of procedures per patient was 1.14, with 69 patients undergoing a single procedure. Endopyelotomies were performed using either a cold knife (N = 26), Ho:YAG laser (N = 47), or hook electrode (N = 12). Treatment success was defined as symptomatic relief with radiographic resolution or stabilization of renal function, as judged by an excretory urogram or diuretic renogram. Kaplan-Meier analysis was used to determine the long-term probability of success.

RESULTS

With a median follow-up of 37.3 months (range 3-98 months), the overall success rate was 67.5%, and the median time to failure was 7.7 months (range 1-50 months). Kaplan-Meier estimates of success were 87.8% at 6 months, 76.9% at 12 months, 72.2% at 18 months, 68.7% at 24 months, 64.8% at 36 months, and 61.6% at 60 months. The success rate was not significantly affected by the etiology, surgical approach, or incisional method. Similarly, the degree of preoperative hydronephrosis or renal function did not affect the success rate.

CONCLUSIONS

The success rate of endopyelotomy decreases as the follow-up increases. Although most failures were detected within 1 year of the procedure, it appears that follow-up of at least 36 months is required for patients who have undergone endopyelotomy for UPJ obstruction.

Retrograde endopyelotomy: a comparative study of hot-wire balloon and ureteroscopic laser

PURPOSE

This study compared the immediate and long-term results and complications of hot-wire balloon endopyelotomy and ureteroscopic holmium laser endopyelotomy.

PATIENTS AND METHODS

Between March 1994 and January 2002, 64 patients with a primary (N = 52) or secondary (N = 12) ureteropelvic junction obstruction underwent retrograde endopyelotomy using either a fluoroscopically guided hot-wire balloon incision (N = 27) or a ureteroscopically guided, direct-vision holmium laser incision (N = 37). This study group included 46 women and 18 men aged 13 to 79 years (mean 38.9 years). The indications and contraindications to a retrograde approach were identical in each group and included documented functionally significant evidence of obstruction, no upper-tract stones, obstruction <2 cm, and no radiographic evidence of entanglement of crossing vessels at the ureteropelvic junction. Immediate and long-term outcomes were obtained from a prospective registry, with success defined as resolution of symptoms and radiographic relief of obstruction as determined by follow-up with intravenous urography, diuretic renography, or both. Follow-up ranged from 39 to 133 months (mean 75.6 months).

RESULTS

Length of hospital stay, indwelling stent duration, and long-term success rates (77.8% v 74.2% in the hot-wire balloon and holmium-laser group, respectively) were equivalent. However, two patients in the hot-wire balloon group developed bleeding necessitating transfusion and selective embolization of lower-pole vessels. No patient in the ureteroscopic group suffered a major complication.

CONCLUSIONS

These two alternatives for retrograde endopyelotomy provide comparable success rates for similarly selected patients. However, because significant hemorrhagic complications developed with greater frequency in those treated with the hot-wire balloon, our preference is for a ureteroscopic approach, as it allows direct visual control of the incision and thus, a lower risk of significant bleeding.

Salvage Laparoscopic Pyeloplasty in the Worst Case Scenario: After Both Failed Open Repair and Endoscopic Salvage

BACKGROUND AND PURPOSE

Historically, open pyeloplasty has been the gold-standard treatment for primary ureteropelvic junction (UPJ) obstruction, with success rates >90%. Over the past decade, laparoscopic pyeloplasty has emerged as a highly successful alternative for primary UPJ and secondary obstruction. For patients failing open pyeloplasty, endoscopic procedures such as antegrade and retrograde endopyelotomy have been used as salvage therapies with success rates as high as 87.5%. Persistent obstruction after an initial open pyeloplasty and a subsequent unsuccessful salvage endoscopic procedure presents a difficult scenario, often necessitating complex and challenging repairs. We reviewed our experience with salvage laparoscopic pyeloplasty as a reconstructive option for this difficult group of patients.

PATIENTS AND METHODS

Between January 2002 and April 2005, 66 laparoscopic pyeloplasties were performed. Four patients, who had persistent obstruction after both open pyeloplasty and subsequent salvage endoscopic procedures, were the subject of this analysis. Operative time, length of stay (LOS), pain score resolution, and physiologic success rates were evaluated. Success was defined as resolution of obstruction on physiologic testing (renal scan).

RESULTS

The mean operative time was 310 minutes and the mean LOS 1.2 days. Three patients experienced resolution of obstruction by nuclear scan. The remaining patient, who has persistent obstruction but stable function on nuclear scan and resolution of pain, has refused evaluation with Whitaker testing. All patients have experienced at least 50% reduction of pain. Utilizing our strict physiologic criteria for success, including a diuretic T(1/2) of <10 minutes, a success rate of 75% was obtained.

CONCLUSION

Our series of laparoscopic reconstructions of the UPJ in patients failing both an initial open pyeloplasty and subsequent salvage endoscopic procedures is the largest in the literature at present. As in open surgery, the ability to respond to intraoperative findings with techniques such as flap repair and renal mobilization are essential. Although time consuming, these repairs can be successful and maintain the advantages of laparoscopy.

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.

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.

Laparoscopic Ureterocalicostomy: Development of a Technique Simplified by Application of Nitinol Clips and a Wet Monopolar Electrosurgery Device

PURPOSE

We developed a technique for laparoscopic ureterocalicostomy with the use of intracorporeal suturing and subsequently simplified the technique by application of experimental Nitinol clips.

MATERIALS AND METHODS

We performed laparoscopic ureterocalicostomy on 16 domestic swine divided into four groups of four animals each. The kidney was exposed laparoscopically, and the renal artery was atraumatically clamped. The lower pole of the kidney was amputated to expose a lower-pole calix, and hemostasis of the cut renal surface was obtained with a wet monopolar electrosurgical device (Floating Ball device [FB]; TissueLink, Dover, NH). Anastomosis of the ureter to the lower-pole calix was performed over a guidewire using 3-0 Vicryl suture in group 1 and Nitinol clips in group 3. A double-J ureteral stent was then deployed retrograde under fluoroscopic guidance. In addition, we evaluated the use of fibrin glue as a sealant over the sutured or clipped anastomotic site (groups 2 and 4, respectively). Ureteral stents were removed after 3 weeks, and the animals were evaluated and sacrificed after an additional 3 weeks.

RESULTS

Laparoscopic ureterocalicostomy was completed in all 16 animals. In each case, excellent renal parenchymal hemostasis was obtained with the FB device, with a mean hemostasis time of 4.1 minutes. The mean anastomotic time with standard suture reconstruction was 37.1 +/- 5.4 minutes, while the anastomotic time with the Nitinol clips was 29.0 +/- 8.0 minutes (P = 0.0339). Retrograde pyelograms in groups 1 and 3 (no fibrin glue) showed a patent anastomosis with no hydronephrosis in three of the four animals in each group. One animal in group 1 and one animal in group 3 developed large urinomas secondary to anastomotic failure. The animals that received fibrin glue over the anastomotic site (groups 2 and 4) all showed narrowed anastomoses with severe hydronephrosis.

CONCLUSIONS

With available instrumentation, laparoscopic ureterocalicostomy is technically feasible. Nitinol clip technology significantly reduces collecting-system reconstruction time. Application of fibrin glue as a urinary tract sealant resulted in an unexpected adverse outcome.

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.

Retrograde Acucise endopyelotomy: long-term results

PURPOSE

We evaluated the long-term outcome of retrograde endopyelotomy with the Acucise cutting balloon as a first-line treatment of ureteropelvic junction obstruction (UPJO) in 36 patients (median age 44 years).

PATIENTS

Twenty-three patients had a primary UPJO. The median follow-up in the series was 24 (6-42) months.

RESULTS

Success, defined as a subjective and objective improvement, was obtained in 27 (75%). In multivariate analysis, only the presence of a crossing vessel (45% v. 81%) was a significant covariate for success. The success rates for primary and secondary UPJO were 74% and 77% respectively. The grade of obstruction had no impact on results. The median time to the nine failures was 3 months, and no failure occurred more than 6 months after the endopyelotomy. In 75% of the failures with no crossing vessel, redo retrograde Acucise endopyelotomy was successful.

CONCLUSION

Retrograde Acucise endopyelotomy is an efficient long-term treatment of UPJO with low morbidity. This technique is a reasonable choice for first-line treatment of UPJO.