Percutaneous retropelvic endopyelotomy for treatment of ureteropelvic junction obstruction

Percutaneous management of ureteropelvic junction obstruction

PURPOSE OF REVIEW

The development of endoscopic and minimally invasive techniques has revolutionized the treatment of ureteropelvic junction obstruction (UPJO). Patients can now undergo successful UPJO repair without the morbidity and complications associated with open surgery. Laparoscopic and robotic repair has supplanted open surgery as the gold standard, but percutaneous endoscopic treatment remains a relevant alternative to more invasive surgery. This review will focus on the percutaneous approach for the treatment of UPJO.

RECENT FINDINGS

Percutaneous endopyelotomy was popularized during the 1980 s due to advances in the field of endourology, allowing for well tolerated and reliable percutaneous access to the kidney. After percutaneous access to the kidney is achieved, the narrowed ureter at the UPJ is incised in a full thickness fashion in the posterolateral position from the ureteral lumen to the periureteral fat. Success rates for this procedure are nearly 90% at high-volume centres. The ideal patient who has success with percutaneous endopyelotomy has a short segment of narrowing less than 2 cm, no crossing vessel, good ipsilateral renal function and mild hydronephrosis.

SUMMARY

Although the development of laparoscopic and robotic approaches to pyeloplasty has produced outcomes that surpass those of percutaneous endopyelotomy, it remains a viable option in the appropriately selected patient, but success rates tend to decrease with longer follow up.

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.

Micropercutaneous endopyelotomy for the treatment of secondary ureteropelvic junction obstruction in children

INTRODUCTION

The management of recurrent pyeloureteral junction obstruction (PUJO) is controversial, as there is no suitable technique for its correction. Percutaneous endopyelotomy shows better results in recurrent PUJO compared to primary PUJO. Micro-percutaneous approaches reduce damage to renal parenchyma and facilitate access to renal pelvis.

OBJETIVE

To present our experience in the use of this minimally invasive technique for the treatment of recurrent PUJO.

STUDY DESIGN

A retrospective study was performed collecting data of patients with recurrent PUJO treated in our hospital using the percutaneous approach between July 2014 and January 2018. Micropercutaneous access was performed in all patients. In Valdivia position, a 5 or 6 mm high-pressure ballon is placed in the renal pelvis under cystoscopic and fluoroscopic guidance. The 4.8 or 8 Fr microperc puncture needle is placed into the pelvicalyceal system. Endopyelotomy is performed with a laser fiber or monopolar hook on a high-pressure balloon. To improve the exposure of the cutting area, the high-pressure balloon is placed at the pyeloureteral junction. Double J stent is left for weeks.

RESULTS

The ages of the patients were 4, 8 and 18 months, and 2 and 4 years. All patients had previously undergone pyeloplasty due to pyeloureteral junction obstruction. Operative time was 50 ± 21 min. Hospital stay after surgery was 24 h and hematuria disappeared within the 24 postoperative hours.

DISCUSSION

The number of patients with recurrent PUJO is small, making it difficult to establish a standard surgical approach for failed pyeloplasty. Redo pyeloplasty is considered the gold standard by some authors but alternative methods, such as endourological techniques, may also have a role in the treatment of failed pyeloplasty. The percutaneous approach has shown very good results in this treatment and the miniaturization of percutaneous surgery has improved with the micropercutaneus access. We consider micropercutaneous approach helped with a high pressure balloon in the pyeloureteral junction is an alternative and minimally invasive technique that has shown good results in our small cases series. However, we must take into account the limitation of the study considering the low number of patients. We need prospective studies to support our results.

CONCLUSION

Micropercutaneous endopyelotomy is a fairly effective technique to treat recurrent UPJO after failed pyeloplasty in children. In our experience, it reduces kidney damage without increasing complications.