Radiologic evaluations affecting surgical technique in ureteropelvic junction obstruction

Percutaneous retropelvic endopyelotomy for treatment of ureteropelvic junction obstruction

Purpose:

A new minimally invasive approach for endopyelotomy for the treatment of ureteropelvic junction obstruction (UPJO) is described. The results are compared with those of other lines of treatment.

Materials and Methods:

A total of 39 patients with UPJO underwent percutaneous retropelvic endopyelotomy. Retrograde percutaneous renal access, using the Lawson catheter and deflecting guidewire, was done for creation of the nephrostomy tract. Using holmium laser through a 28-Fr nephroscope, a small window was made in the posterolateral surface of the renal pelvis. The nephroscope was advanced from the renal pelvis to the retropelvic space through that window. Crossing vessels were easily detected and were either coagulated or avoided. The window incision was extended distally, and the narrow ureteropelvic junction (UPJ) was incised using holmium laser.

Results:

The entire procedure was done in the supine position within 1 h. The presence of secondary stones, hugely dilated renal pelvis, high insertion of the UPJ, and whether UPJO was primary or secondary, did not alter the results. The only factor that affected the results was split function of the obstructed renal unit. The success rate was 100% when the split function exceeded 35%. When the split function was <35%, the success rate dropped to 56%.

Conclusion:

Percutaneous retropelvic endopyelotomy is a promising approach for the treatment of UPJO that gave favorable results. The use of the nephroscope provided a wide visual field. The wide-field facilitated detection of crossing blood vessels with no incident of vascular injury. It also facilitated endopyelotomy with high precision. Ureteral injury was not a risk factor.

Ureteroscopic management of upper tract transitional cell carcinoma and ureteropelvic obstruction

Introduction:

Technological advances have increased the application of the endoscopic management of upper tract transitional cell carcinoma (TCC) and ureteropelvic junction obstruction (UPJO).

Materials and Methods:

Published, peer-reviewed articles on endoscopic treatment of upper tract TCC and UPJO were identified using the MEDLINE database.

Results:

Although nephroureterectomy remains the gold standard for upper tract TCC treatment, low-grade, low-stage and small tumors, especially in patients with solitary kidneys or poor renal function can be managed with encouraging success rates, despite the considerable recurrence rate. Endoscopic alternatives to pyeloplasty for UPJO can be used especially in cases with absence of crossing vessels, stricture length less than 1.5 cm, severe hydronephrosis and renal function less than 30%.

Conclusion:

Proper patient selection is critical for the successful endoscopic management of treatment of upper tract TCC and UPJO.

Magnetic resonance imaging in the evaluation of pelvi-ureteric junction obstruction: an all-in-one approach

OBJECTIVE

To study the ability of comprehensive magnetic resonance imaging (MRI) to replace multiple imaging methods in the evaluation of patients with pelvi-ureteric junction obstruction (PUJO).

PATIENTS AND METHODS

Between May 2003 and November 2005, 46 consecutive patients (22 male and 24 females; mean age 31.6 years) with symptomatic primary PUJO were included. All had comprehensive MRI, including MR urography (MRU), dynamic MRI and MR angiography (MRA). Morphological results of MRU were compared with that of renal ultrasonography or intravenous urography, while the anatomical results of MRA were compared with the operative findings. A correlation between MR clearance and radioisotope clearance was done using linear regression analysis.

RESULTS

MRU showed the morphology of the collecting system in all patients, and the ureter below the PUJ in 31 of 46 (67%), but renal stones were missed in three of 10 patients. MRA showed crossing vessels in 22 patients (48%). There was a strong correlation between MR clearance and radioisotope clearance (r = 0.823, P < 0.001). From the MRI results, 35 patients (19 with crossing vessels and 16 with marked hydronephrosis) had pyeloplasty and 11 had an endopyelotomy. Findings during pyeloplasty showed one false-negative and one false-positive result of the preoperative MRI. Therefore, the sensitivity, specificity and accuracy of MRA were 95%, 94% and 94%, respectively. The outcome was successful in 44 (96%) patients. One failure after pyeloplasty was managed with endopyelotomy and the other was treated with pyeloplasty after endopyelotomy.

CONCLUSION

Comprehensive MRI is a valuable and accurate single-imaging method for evaluating patients with PUJO.

Maximizing clinical information obtained by CT

CT scanning is an integral part of the urologist's practice today. It is the most commonly used imaging modality and the one with which urologists are most familiar. CT urography, CT angiography, and 3D reconstruction enable the urologist to perform comprehensive evaluations of patients who have different urologic diseases, using a single imaging modality. It is thus prudent that urologists become familiar with CT applications, to maximize the clinical information available from them.

Adult Ureteropelvic Junction Obstruction: Insights with Three-dimensional Multi–Detector Row CT

Ureteropelvic junction obstruction (UPJO) is a benign, congenital condition that remains an enigma in terms of both diagnosis and therapy. On the basis of a series of cases that were referred to the authors in their clinical practice, they found that the unprecedented quality and novel perspectives of multi-detector row computed tomography (CT) with two- and three-dimensional postprocessing allow a comprehensive, single-study assessment of the ureterovascular relationships in UPJO. This topic is important because the causative role of crossing vessels may be questioned on the basis of such studies, and the therapeutic approach may be altered by using precise anatomic images customized to the pathologic features of the individual patient. Although CT images can provide only circumstantial or supportive evidence of the pathophysiology of UPJO, they greatly facilitate therapeutic intervention when it is clinically indicated and may eliminate the need for it in select cases. Careful attention to the postprocessing of CT images may show that the crossing vasculature has no direct relationship to the transition point of the UPJO in many cases.

Endoluminal ultrasonography before retrograde endopyelotomy: can the results match laparoscopic pyeloplasty?

OBJECTIVE

To present the results of endopyelotomy using endoluminal ultrasonography (EUS) to identify crossing vessels, as the success rates of endopyelotomy are generally lower than pyeloplasty, especially in patients with crossing vessels.

PATIENTS AND METHODS

Forty-one consecutive patients who underwent EUS before a planned retrograde endopyelotomy were analysed retrospectively. EUS was used to direct the endopyelotomy incision for patients with crossing vessels. Treatment was considered successful if the patient was asymptomatic and unobstructed or improved on renography. The results were compared to those from 18 patients treated by laparoscopic pyeloplasty, some of whom had undergone EUS.

RESULTS

Crossing vessels were identified in 27 of the 41 patients (66%). Primary treatment consisted of endopyelotomy for 26 patients and laparoscopic pyeloplasty for 15. The overall success rate for 24 endopyelotomy patients with an adequate follow-up (mean 19 months) was 71%, with more success in patients with no crossing vessels (11 of 13 (85%) vs six of 11 (55%)). Of the 18 patients treated by laparoscopic pyeloplasty (mean follow-up 15.1 months) 17 were successful.

CONCLUSION

The results for endopyelotomy were disappointing in patients with crossing vessels, despite using EUS. The results suggest that patients with crossing vessels should be treated by laparoscopic pyeloplasty. More data are needed to compare endopyelotomy with laparoscopic pyeloplasty in patients with no crossing vessels.