Surgical management of ureteropelvic junction obstruction in adults

Robot-assisted laparoscopic Anderson-Hynes pyeloplasty for ureteropelvic junction obstruction

OBJECTIVES

To explore surgical, functional, and symptomatic outcomes in a series of patients who underwent robot-assisted laparoscopic Anderson-Hynes pyeloplasty (RALP) for ureteropelvic junction obstruction using the DaVinci Si surgical robotic system.

METHODS

Retrospective study including patients aged 16 years or older who underwent RALP from June 2016 to December2021. The following outcomes were recorded: operative outcome and complications [classified according to the Clavien-Dindo Classification (CD)] within 30 days of the procedure as well as 1 year success rate and restenosis during follow-up.

RESULTS

In total, 194 patients were available for analyses with a median follow-up of 4.5 (IQR 3.0-6.0) years. The primary indications were loss of kidney function (45%), pain (36%), infection (11%), kidney stone (6%), and others (2%). The median operation time was 134 min (IQR 112-159), the median length of stay was 2 days (IQR 2-2), and the median time with double-j stent postoperatively was 24 days (IQR 22-27). Overall, 65 out of 194 patients (33%) experienced a postoperative complication (12% CD I, 13% CD II, 8% CD IIIa or IIIb). The 1 year success rate was 92% for patients treated because of deteriorating renal function, 78% for patients treated because of symptoms, 82% for patients treated because of infections, and 78% for patients treated because of kidney stones. Seven percent of the patients presented a recurrent ureteropelvic junction stricture during follow-up.

CONCLUSIONS

In our experience, robot-assisted laparoscopic Anderson-Hynes pyeloplasty performed with the DaVinci Si system is a safe with a few major complications and acceptable success rate.

Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume

PURPOSE

To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic.

MATERIAL AND METHODS

A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty.

RESULTS

There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume.

CONCLUSION

A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Anterograde Mini-Percutaneous Retropelvic Extra-Luminal Endopyelotomy: A Novel Approach to Uretero-Pelvic Junction Obstruction

Background Uretero-pelvic junction obstruction (UPJO) is a common cause of upper tract urinary obstruction. This condition is generally treated with various surgical options which include endoscopic (retrograde or anterograde), laparoscopic, open or robotic-assisted approaches. Herein, we describe a novel endoscopic retropelvic extra-luminal approach using a mini (14 Fr) nephroscope. Methods A 30-year-old male presented with symptomatic left UPJO and inferior pole renal stones, which were identified on computed tomography (CT) imaging. Mercaptuacetyltriglycine (MAG3) renogram demonstrated a functioning left kidney. With the patient positioned supine, a mini-perc (Karl-Storz) nephroscope was used to access the renal pelvis via the percutaneous route. The retropelvic space was thereafter accessed. Using a Holmium-YAG laser, the UPJO was splayed using an extra-luminal approach. Results Clear endoscopic vision, minimal bleeding, and overall satisfactory identification of the UPJO were achieved. At the 12-month follow-up, the patient remained stent and symptom-free. On follow-up CT imaging and MAG3 renogram, the system remained dilated with no obstruction noted. Conclusion Percutaneous anterograde retropelvic extra-luminal endopyelotomy is a novel approach that should be considered in patients with secondary renal calculi. This is the first report of the procedure being successfully performed utilizing the mini-perc access route.

Minimal Invasive Treatment in Pelvic-Ureteric Junction Obstruction: A Comprehensive Review

Pelvic-ureteric junction obstruction (PUJO) is a common condition, and one of the lead causes of hydronephrosis in children. Currently, the gold standard treatment of PUJO is open surgery using the Anderson–Hynes-modified dismembered pyeloplasty technique. However, with the advancement of medical technology, several minimal invasive approaches were developed, including endoscopic, laparoscopic, and robotic approach, from which the best choice of surgical technique was yet to be determined. Considering the advantages and disadvantages of these methods, the recommended option is to tailor the best surgical approach to each individual patient, and to the surgeons’ preference and experience. Considering these recent advances, a new algorithm is proposed to choose the best minimal invasive modalities invasive treatment to treat PUJO.

Multimodality imaging spectrum of complications of horseshoe kidney

Horseshoe kidney is the most common congenital renal fusion anomaly with an incidence of 1 in 400–600 individuals. The most common type is fusion at the lower poles seen in greater than 90% of the cases, with the rest depicting fusion at the upper poles, resulting in an inverted horseshoe kidney. Embryologically, there are two theories hypothesizing the genesis of horseshoe kidney – mechanical fusion theory and teratogenic event theory. As an entity, horseshoe kidney is an association of two anatomic anomalies, namely, ectopia and malrotation. It is also associated with other anomalies including vascular, calyceal, and ureteral anomalies. Horseshoe kidney is prone to a number of complications due to its abnormal position as well as due to associated vascular and ureteral anomalies. Complications associated with horseshoe kidney include pelviureteric junction obstruction, renal stones, infection, tumors, and trauma. It can also be associated with abnormalities of cardiovascular, central nervous, musculoskeletal and genitourinary systems, as well as chromosomal abnormalities. Conventional imaging modalities (plain films, intravenous urogram) as well as advanced cross-sectional imaging modalities (ultrasound, computed tomography, and magnetic resonance imaging) play an important role in the evaluation of horseshoe kidney. This article briefly describes the embryology and anatomy of the horseshoe kidney, enumerates appropriate imaging modalities used for its evaluation, and reviews cross-sectional imaging features of associated complications.

Evaluation of transverse dorsal lumbotomy in management of PUJ obstruction in patients younger than 6 months

OBJECTIVE

The transverse dorsal lumbotomy approach provides excellent exposure to the PUJ and causes minimal tissue damage. In this study, we assess the efficacy of dorsal lumbotomy in PUJ obstruction in children younger than 6 months.

METHODS

All children less than 6 months who were managed with the dorsal lumbotomy approach between 2009 and 2017 were reviewed prospectively. Data included: demographic data, pre/post-operative renal ultrasound scan with SFU grading and RDS, operative time, post-operative complications, and follow up results.

RESULTS

A total of 42 children with a mean age of 4.4 ± 1 months were included. On pre-operative RDS, all patients had an obstructive pattern and a SRF of 30.3 ± 9.3. The mean operative duration was 49 min and analgesia was minimal. Post-operative ultrasound at 6 months showed an improvement in hydronephrosis (p < 0.05) and a mean SRF of 39.3 ± 6.1 (p < 0.001).

CONCLUSION

Transverse dorsal lumbotomy approach is a safe and efficient alternative in patients less than 6 month.

Changing the Status Quo: The 100 Most-Disruptive Papers in Urology?

OBJECTIVE

To identify key papers in urology using a novel bibliometric index called the disruption score.

METHODS

A PubMed search was conducted to identify papers published in Journal of Urology, European Urology, Urology, Urologic Oncology, Journal of Endourology, and BJU International, Nature Reviews Urology. Selected urology papers published in other medical journals were also included. Using a validated dataset of disruption scores for all papers published in 1954-2014, the top 100 most-disruptive urology papers, as well as the top 100 most-cited papers, were identified. Comparisons between both lists and across journals were investigated.

RESULTS

A total of 72,623 published articles were included. Journal of Urology had the most articles in the most-disruptive papers list (n = 69) followed by BJU International (n = 16). New England Journal of Medicine had the most papers in the most-cited papers list (n = 26) followed by Journal of Urology (n = 23). Only 7 papers were common to both the most-disruptive papers and most-cited papers lists. Oncology was highly represented among the most-cited papers (n = 60), whereas the most-disruptive papers included a broader representation of urology. The most common study design among the most disruptive papers was small case-series/case reports, whereas the most common study design among the most-cited papers was randomized controlled trials.

CONCLUSION

The disruption score identified landmark papers in urology that have introduced innovative ideas. Disruption score captures a unique profile of scientific impact that may be used in combination with other bibliometric indices to identify scholarly achievements in urology.

Adult giant hydronephrosis diagnosed in the second trimester of pregnancy: A case report and literature review

Adult giant hydronephrosis in a normally sited kidney is unusual during pregnancy. The most frequent cause is congenital obstruction at the ureteropelvic junction. Ultrasound accompanied by magnetic resonance imaging (MRI) are valuable in reaching the diagnosis, especially when clinical assessment of an abdominal mass is inconclusive regarding aetiology. We report a case of giant hydronephrosis in a woman who presented at 23 weeks of gestation with abdominal distension. She was managed conservatively. Unfortunately, the pregnancy was complicated by severe pre-eclampsia at 32 weeks of gestation, necessitating delivery via emergency caesarean section. She had a smooth postpartum recovery, and subsequently standard imaging was performed before nephrectomy. The literature and previously reported cases of giant hydronephrosis in pregnancy are reviewed.

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Adult giant hydronephrosis is a rare differential diagnosis for abdominal mass in pregnancy.

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Management in pregnancy that had been attempted includes conservative, decompression procedure, stenting and nephrectomy.

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Timing and mode of delivery in pregnancy complicated by giant hydronephrosis is dictated by obstetrics indication.

Comparison of Safety, Efficacy and Outcomes of Robot Assisted Laparoscopic Pyeloplasty vs Conventional Laparoscopy

Pyeloplasty is considered the gold standard for the management of ureteropelvic junction obstruction in cases of flank pain, recurrent stone formation or infection, and deteriorating renal function. Over the last two decades, minimally invasive techniques such as robotic (RALP) and laparoscopic pyeloplasty (LP) have become increasingly popular and have been moderately replacing the open approach. This paper aims to provide a comprehensive up-to-date review on safety, efficacy and outcomes regarding robotic repair of UPJO compared to the conventional laparoscopic procedure. RALP represents a viable and innovative alternative to conventional LP with a comparable success and complication rate both in adult and in paediatric fields. The robotic approach seems to add further technical advantages when compared to conventional LP but sustains a higher costs. Currently, the choice to adopt one of the different minimally invasive approaches depends on the surgeon's preference or experience, and on institutional availability.

Laparoscopic transmesenteric pyeloplasty and isthmusectomy for adult horseshoe kidney with recurrent symptomatic hydronephrosis

INTRODUCTION

There is no consensus for the horseshoe kidneys with recurrent symptomatic hydronephrosis, so we presented our initial experience with a laparoscopic transmesenteric approach.

CASE PRESENTATION

Five patients with symptomatic ureteropelvic junction obstruction were identified by computed tomography urography. The laparoscopic transmesenteric approach was performed in such a way that the mesentery of the small intestine was incised along with the blood vessels longitudinally, and the isthmus was isolated to avoid injury to the mesenteric blood supply; then we cut the isthmus using an endostapler. The ureteropelvic junction obstruction was removed via the Anderson-Hynes technique. The operation time was 135-204 min, and the estimated blood loss was 50-120 mL. Patients had a 5.7-day stay postoperatively, there were no other injuries or complications, and ultrasound scans or computed tomography urography showed good postoperative effects.

CONCLUSION

Laparoscopic transmesenteric surgery is a feasible and safe procedure for selected cases with horseshoe kidney with recurrent symptomatic hydronephrosis.

Acute Presentation of Giant Hydronephrosis in an Adult

Giant hydronephrosis is defined as a dilated collecting system containing more than one liter of fluid. The diagnosis of giant hydronephrosis is rare due to improved diagnostics and the liberal use of abdominal imaging. Herein we report a 40-year-old woman who presented with acute onset abdominal pain and was diagnosed with giant hydronephrosis. She underwent a simple open nephrectomy and made an unremarkable recovery. Although giant hydronephrosis due to ureteropelvic junction obstruction is common in the pediatric and adolescent age group, it rarely presents in adults. Acute presentations, like abdominal pain, are exceedingly rare. Judicial use of cross-sectional imaging, as in our patient, can confirm the diagnosis and help in successful management.

Proximal ureteral reconstruction using renal capsule flap: a canine experimental model

Introduction

The aim of this article was to evaluate the effectiveness of using the renal capsule in ureteral reconstruction in a canine model.

Material and methods

Ten clinically healthy male adult dogs were used in this study. Dogs underwent ureteral reconstruction using a tube-shaped flap of the renal capsule.

Results

All but one animal (90%) survived till nephrectomy and thereafter. At 30 days after operation, the double-J stent was removed from the ureter, and at the 60^th day, intravenous pyelography confirmed openness of the duct. The internal surface of the tunneled flap was coated with thick, folded urothelium. Maturing granulation tissue and angiogenesis as well as fiber producing fibroblasts were observed in the lamina propria. The presence of smooth muscle cells beneath the lamina propria indicated complete reconstitution of the damaged ureter.

Conclusions

The results showed that the autologous renal capsular flap provided a practical option for treating ureteral defects in dogs with an acceptable outcome. So, using the selfsame renal capsular tissue is a feasible method for restoration of the injured proximal ureter.

Comparison of open, laparoscopic and robot-assisted pyeloplasty for pelviureteric junction obstruction in adult patients

Ureteropelvic junction obstruction (UPJO) is a frequently found congenital abnormality of the upper urinary tract treated with pyeloplasty. We hereby report a study to compare open pyeloplasty (OP), laparoscopic pyeloplasty (LP) and robotic assisted pyeloplasty (RAP) for UPJO in terms of functional and perioperative outcomes. 102 patients who underwent Anderson-Hynes dismembered pyeloplasty for UPJO were divided into three groups based on type of surgical techniques utilized as follows: OP (Group A; n = 34), LP (Group B; n = 34), and RAP (Group C; n = 34). Preoperative, intraoperative and postoperative data were recorded. The mean operative time was significantly more in the Group B (187.76 min) than the Group A (132.06 ± 30.1 min) and Group C (136.76 ± 25.1 min) (p < .001). Mean blood loss was more in OP group 86.47 ± 29. 35 ml versus 42.94 ± 20. 77 ml in RAP and 45.59 ± 20. 3 ml in the LP group (p < .001). The LP was found to be much tiring. Mean surgeon fatigue index (SFI) calculated was 7 ± 1.1 in the LP group compared to 4.12 ± 1.1 in RAP group and the difference was statistically significant (p< .001). Average VAS score in the first 2 days postoperatively was 6.66±1.58 in the OP group compared to 4.29 ± 1.16 in RAP group and 4.29 ± 1.31 in the LP group (p < 0.001). Pyeloplasty has a similar success rate and efficacy irrespective of the technique utilized. RAP improves the surgeons QOL (quality of life) and the fatigue scores, which is useful for surgeon longevity. RAP has become widely favorite and can be considered the approach of choice in the management of UPJO wherever infrastructure and finances allow.

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era

OBJECTIVE

To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure.

METHODS

Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve.

RESULTS

The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction.

CONCLUSIONS

Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

The role of urinary KIM-1, NGAL, CA19-9 and β2-microglobulin in the assessment of ureteropelvic junction obstruction in adults

PURPOSE

The objective of this study is to evaluate the diagnostic properties of urinary biomarkers in adults with ureteropelvic junction obstruction: KIM-1, NGAL, CA19-9, and β2-microglobulin. We also assessed urinary biomarker concentrations following pyeloplasty.

MATERIAL AND METHODS

We prospectively studied adults from December 2013 to February 2015. We included 47 patients with a mean age of 38.6 ± 12.7 years. Each patient provided four samples of voided urine for biomarker measurement, one at pre-operative consultation and the others at 1, 3, and 6 months of post-operative follow-up. The control group consisted of 40 healthy individuals with no hydronephrosis on ultrasound evaluation.

RESULTS

KIM-1 had an area under the curve of 0.79 (95% CI 0.70-0.89), NGAL 0.71 (95% CI 0.61-0.83), CA19-9 0.70 (95% CI 0.60-0.81), and β2-microgloblin 0.61 (95% CI 0.50-0.73). KIM-1 was the most sensitive marker with a cut-off of 170.4 pg/mg creatinine (sensitivity 91.4%, specificity 59.1%), whereas CA19-9 was the most specific with a cut-off of 51.3 U/mg creatinine (sensitivity 48.9%, specificity 88.0%). Urinary concentrations of biomarkers decreased after pyeloplasty.

CONCLUSIONS

The evaluation of urinary biomarkers is useful in adults undergoing pyeloplasty. KIM-1, NGAL, and CA19-9 were elevated and significantly decreased after surgery.

Agreement between static magnetic resonance urography and diuretic renal scintigraphy in patients with ureteropelvic junction obstruction after pyeloplasty

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is the most common cause of hydronephrosis within childhood that usually treat by surgery. According to anatomical variations in different individuals, scheduling similar procedures for all patients is not suitable, and thus the best decision for an appropriate surgical technique should be considered separately for each patient. Regardless of the type of applied technique, creating a funnel-shape UPJ with a suitable size is a successful treatment. In this context, the assessment of a successful surgical treatment in a short-term follow-up means repairing revealed anatomical defects. The present study aimed to compare the diagnostic value of static magnetic resonance urography (MRU) and diuretic-based renalscintigraphy (DRS) in patients with UPJO after pyeloplasty.

MATERIALS AND METHODS

A total of 30 consecutive patients with UPJO, who underwent unilateral pyeloplasty between 2012 and 2013 were assessed. All subjects underwent DRS and also MRU about 1-month after the former procedure.

RESULTS

The Kendall's tau correlation showed a very strong correlation between results of MRU and diuretic renal scintigraphy (r = 0.932, P < 0.001). This strong correlation was also shown by Somers'd test (r = 0.932, P < 0.001) similarly.

CONCLUSIONS

Our study shows a strong agreement between DRS and MRU to assess UPJO. MRU static fluid has a high accuracy for assessment of renal system anatomy. Due to the lack of dangerous consequences of contrast materials, MRU can be the best option instead of DRS.

Ureteropelvic Junction Obstruction by a Long Intraluminal Polyp and a Concurrent Crossing Vein in a Symptomatic 8-Year-old Child

Ureteropelvic junction obstruction due to intrinsic causes is often diagnosed antenatally during routine ultrasonography. Cases of extrinsic obstruction often present later and symptomatically, during childhood. We describe the rare case of an 8-year-old boy with a 2-day history of severe left flank pain, no fevers, and Society of Fetal Urology grade 3 hydronephrosis on ultrasonography. Laparoscopic dismembered pyeloplasty revealed a left ureteropelvic junction obstruction secondary to a large fibroepithelial polyp in the proximal ureter with a concomitant anterior crossing vein. We also provide a focused review of the pertinent published literature.

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.

Imaging of horseshoe kidneys and their complications

Horseshoe kidney is the most common renal fusion anomaly and the patients are prone to a variety of complications, such as stone disease, pelviureteric junction (PUJ) obstruction, trauma, infections and tumours. As result of the abnormal anatomy of a horseshoe kidney, imaging and treatment pathways vary substantially from the normal kidney. In this review, we describe the role of modern imaging in depicting horseshoe kidneys and their complications, in tandem with the role the interventional radiologist plays in treating these patients.