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ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY IN CHILDREN

Ureteropelvic junction obstruction (UPJO) in duplex systems is rare, with laparoscopic pyeloplasty (LP) and laparoscopic pyelo-ureterostomy (LPU) being the main surgical options. However, guidelines for selecting the appropriate procedure based on anatomical variations are lacking. This study evaluates the outcomes of laparoscopic management of duplex UPJO in children, comparing LP and LPU. A retrospective review was conducted on children who underwent surgery for UPJO in duplex systems at two pediatric urology centers over 10years. Preoperative imaging included ultrasound, diuretic renogram, voiding cystourethrography, and magnetic resonance urography when needed. Retrograde pyelography confirmed anatomy. LP was preferred for lower moiety (LM) UPJO, while LPU was performed for short-segment or hypoplastic incomplete duplex. All children had double J stents for 4-6weeks. Statistical analysis used t tests and Chi-square tests. Among 25 children (complete: 11, incomplete: 14), LP was performed in 9/11 complete and 3/14 incomplete cases (p = 0.01). LPU was performed in 11 incomplete cases. The mean operative time was 113min for LP and 137min for LPU (p = 0.01). The median hospital stay was 2days. Two children had postoperative UTIs, and one had early stent expulsion. Outcomes were favorable in all cases. Duplex UPJO consisted of only 3.2% of a large cohort of UPJO from two busy pediatric urology centers. LP was possible in most UPJO in complete duplex, while most UPJO in incomplete duplex had to be managed with LPU. Although LPU was more challenging with longer operative time than LP, both LP and LPU had comparably good results. We strongly recommend intraoperative RGP in all cases of suspected duplex to decide the best surgical option in each case.

Laparoscopic Management of Ureteropelvic Junction Obstruction in Patients With Upper Urinary Tract Anomalies

Background: Historically open pyeloplasty has been regarded as the gold standard for the surgical management of ureteropelvic junction obstruction (UPJO). The treatment of this condition has evolved considerably over the past two decades resulting in new surgical approaches. One of these approaches is laparoscopic pyeloplasty,this technique aimed to achieve the same results as open surgery,with lower rates of morbidity and complications. Aim of the study: To compare the operative time,hospital stay,analgesic use,perioperative complications,and success rate between laparoscopic and open pyeloplasty in Al Diwaniya Teaching Hospital. Patients & Methods: From October 2014 to October 2016,40 patients (26 males and 14 females) with Ureteropelvic junction obstruction who had been admitted to the urology unit of Al Diwaniya Teaching Hospital were enrolled in this study. Their ages ranged from 10 to 44 years with a mean age of 24 years. The patients were selected on the basis of standard indications for PUJO repair. The patients were assigned into two groups. Twenty patients underwent transperitoneal laparoscopic pyeloplasty and 20 patients underwent open surgery. The choice between the two types of operation was selected according to surgeon's preference (only surgeon who has enough experience with laparoscopic surgeries perform laparoscopic pyeloplasty,while the other performed open surgery). Preoperative evaluations were done using abdominal ultrasound and IVP. Laboratory tests included urinalysis,urine culture,blood urea,and serum creatinine. Blood group was determined. We compared the operative time,complications rates,hospital stay and success rate of the two groups.Mean operative time was 2 hours and 3 hours in open and laparoscopic pyeloplasty groups,respectively. Mean hospital stay was shorter (24 hours) in the laparoscopic group and (48 hours) in open group. Mean follow-up period was 9 months. Postoperative complication rates were 20 % and 30 % in laparoscopic and open pyeloplasty groups,respectively. Success rates were 95% and 90 % for open and laparoscopic pyeloplasty groups,respectively. Repeated surgery was performed in 2 patients of laparoscopy and 1 of open pyeloplasty groups due to recurrence of stricture.The safety and efficacy of laparoscopic pyeloplasty is comparable to that of open pyeloplasty,with better cosmetic results and shorter hospital stay,therefore laparoscopic pyeloplasty can replace open surgery and may be considered the gold standard technique for the treatment of ureteropelvic junction obstruction in expert hands.

Endoscopic pyelotomy is a minimally invasive procedure that is increasingly used for the management of ureteropelvic junction (UPJ) obstruction. We report the results and advantages in the management of UPJ obstruction using a ureteroscopic retrograde laser-assisted approach (laser endopyelotomy; LEP). Thirty-four patients were treated between December 1994 and June 1997 by this new technique. Twenty-seven obstructions were primary. The mean time of follow-up is 18 months. An indwelling ureteral catheter was placed 3 weeks prior to treatment. Intraoperatively, after the removal of the stent, a guidewire was passed across the stenosis, and the ureter was entered with a semirigid ureteroscope. The LEP was then performed under visual control using a contact laser fiber until all obstructive fibers had been cut. Follow-up examinations included sonography, intravenous urography, and, in unclear cases, a radionuclide renal scan with furosemide application after 3 months. The success rate was 85%. The most important factor influencing the outcome was the grade of hydronephrosis. Postoperative side effects have been minimal, and minor complications occurred in only 5 patients (15%). Laser endopyelotomy is a minimally invasive procedure with less morbidity for the treatment of UPJ obstruction. Only patients with a severe extrinsic cause of obstruction should be excluded from this technique. These cases can be approached laparoscopically.

PurposeTo evaluate the impact of temporary internal ureteral stents on the surgical outcomes of dismembered pyeloplasty in children.Materials and MethodsThe medical records of 70 children (76 renal units) who underwent dismembered pyeloplasty for ureteropelvic junction (UPJ) obstruction at at Asan Medical Center between January 2005 and December 2010 were retrospectively reviewed. We classified the renal units into the stented group (22 renal units) and the nonstented group (54 renal units). Fifty-four of 70 patients were male and their mean age was 2.2±3.8 years old. The mean follow-up period was 29.6±16.8 months.ResultsSixty-four children had unilateral UPJ obstruction. The mean stent duration was 31.9 days. As shown by evaluation of radiologic images, there were no significant differences between the stented group and the nonstented group during the follow-up period (p>0.05). The mean preoperative and postoperative anteroposterior pelvic diameters (APPDs) of the nonstented group were 31.3 mm and 15.1 mm, respectively (p<0.001). The preoperative and postoperative grades of hydronephrosis were 3.9 and 2.9, respectively (p=0.037). The mean preoperative and postoperative APPDs of the stented group were 36.4 mm and 15.6 mm, respectively (p<0.001). The preoperative and postoperative grades of hydronephrosis were 4 and 3.1, respectively (p<0.001). Repeat obstruction was shown in 4 subjects as a postoperative complication (5.7%). Two children from each group had recurrent UPJ obstruction, with percentages of 3.7% and 9%, respectively (p=0.575).ConclusionsIn a comparison of nonstented and stented groups during pediatric dismembered pyeloplasty for UPJ obstruction, no significant differences were found in the resolution of hydronephrosis or overall postoperative complications.

The horseshoe kidney is the most common renal fusion anomaly which predisposes to hydronephrosis, infections, stones etc. and can be associated with a duplex system, vesicoureteral reflux and uretero-pelvic junction obstruction. Uretero-pelvic junction obstruction is the most frequent abnormality that requires surgical intervention. UPJO may be the result of high insertion of the ureter into the renal pelvis, abnormal ureteral course anterior to the isthmus and anomalous blood supply to the kidney. Management of UPJO with HSK can be challenging but despite the associated anatomical challenges, the principles of surgery remain the same regardless of the approach. Here we described our approach, findings and experience of two cases of UPJ obstruction with HSK managed with transperitoneal laparoscopic dismembered pyeloplasty.

ObjectiveTo evaluate the efficacy of laparoscopic pyeloplasty relative to retrograde balloon dilatation for the treatment of ureteropelvic junction obstruction (UPJO).MethodsThis retrospective study enrolled UPJO patients with stricture length < 2 cm who had been treated with laparoscopic pyeloplasty (LP; 44 cases) or balloon dilatation (BD; 38 cases) from Jan 2010 to Jan 2012, according to patients’ preference after consultation. Demographics and clinical parameters were collected. Patients were followed-up at 3, 6, 12, and 24 months. Ultrasonography, intravenous urography, and diuretic renography were applied to evaluate the remission of hydronephrosis.ResultsBoth groups were comparable with respect to age, UPJO location, gender, and other baseline parameters. Compared to the LP group, patients receiving BD experienced significantly shorter operative time, analgesia time, hospital stay, and urethral catheter indwelling time, and less cost (P<0.001). Three and 6 months after their respective procedures, the success rates of the LP (97.7%, both) and BD (94.7% and 86.8%) groups were similar, and at 12 and 24 months the long-term success rate of LP (95.5%, both) was better than that of BD (78.9% and 71.0%).ConclusionsLP showed better long-term success rate than did BD in the management of UPJO with length of stricture < 2 cm. Considering that BD is more minimally invasive, simpler and easier to perform, and costs less, we recommend it for some selective UPJO patients as the first-line therapy.

To present our initial experience with laparoscopic pyeloplasty and to evaluate the safety and short-term outcome of this technique in children. Thirteen kidney units in twelve children underwent laparoscopic dismembered pyeloplasty for the management of ureteropelvic junction obstruction (UPJO) at our institution between 2005 and 2008. Patient age at surgery was 18-177 months (mean 89.8 months). There were six boys and six girls. Ten had unilateral UPJO with a normal contralateral kidney, one had bilateral UPJO and one had UPJO of a solitary kidney. We used 3- and 5-mm instruments for grasping, blunt dissection, incising and suturing to facilitate safe and precise surgery. The outcome was measured by the operative time and resolution of obstruction and symptoms. Median operative time was 275 min (range 154-420). There was a slight relationship between age and operative time. No major perioperative complications occurred in any cases. Median renal pelvic anterior-posterior diameter at ultrasonography significantly decreased from 8.6 cm (range 3.8-22.0) preoperatively to 3.9 cm (1.0-8.9) postoperatively (P < 0.05). The median pre- and postoperative split renal function on diuretic renography in unilateral cases was 37.3% (range 29.7-46.4) and 39.5% (27.8-48.0), respectively. Overall, successful resolution of UPJO was observed in 12 of 13 kidneys (92.3%). Laparoscopic pyeloplasty represents a safe and effective option in the surgical treatment of children with UPJO.

Open pyeloplasty is the gold standard treatment for adult ureteropelvic junction obstruction (UPJO) with published success rates consistently over 90%. In recent years, the management of UPJO has been revolutionized by the introduction of endoscopic procedures and laparoscopic techniques. We analyzed the long-term results of endoscopic and other minimal access approaches for the treatment of UPJO.Early results for endopyelotomy were promising but long-term results were not encouraging. Laparoscopic pyeloplasty technique is well defined and duplicates the surgical principles of conventional open pyeloplasty. With such a large variety of minimally invasive procedures for the treatment of UPJO available, the treatment choice for UPJO must be based on the success and morbidity of the procedures, the surgeon’s experience, the cost of the treatment, and the patient’s choice. We feel that with the technological advances in instrumentation coupled with a decrease in cost and improved training of urological surgeons, laparoscopic pyeloplasty may evolve to be the new “gold” standard for the treatment of UPJO.

Over the last 20 years, the surgical management of ureteropelvic junction obstruction (UPJO) has been revolutionised by the development of endourological instrumentation and several minimally invasive procedures including: antegrade or retrograde endopyelotomy, retrograde balloon dilatation, and laparoscopic pyeloplasty. Currently, in our department, we offer percutaneous antegrade endopyelotomy (PAE) as primary treatment of UPJO in adults, believing it offers less morbidity, better cosmetic results, and quicker operating time compared with open pyeloplasty. We performed a retrospective audit of our results for the 14 patients who underwent percutaneous antegrade endopyelotomy between January 2000 and May 2004. Mean operative time was 53 min (range, 30-80 min), mean in-patient stay was 3.8 days (range, 2-7 days), and there were no major postoperative complications for this series with mean follow-up of 31.8 months (range, 12-52 months). Eleven out of the 14 patients (79%) showed radiological improvement on their 3-month MAG 3 (mercaptoacetyl-triglycyl) renogram, and 13 out of the 14 (93%) patients reported significant reduction or resolution of pain, compared with their preoperative state. The majority of urologists still offer open pyeloplasty as primary treatment for UPJO with laparoscopic pyeloplasty currently an evolving procedure in the UK. Our series reports comparable success rates for PAE compared to other series. Despite these results, we feel that the future role of percutaneous endopyelotomy will be as a salvage procedure following failed open or laparoscopic surgery. However, in patients with concurrent stone disease or requiring antegrade ureteric access, percutaneous endopyelotomy would be suitable as a primary treatment option.

Ureteropelvic junction obstruction causes histologic alterations in contralateral kidney

Aim: Our primary aim was to report the prevalence of recurrent stricture following primary pyeloplasty and the secondary treatment performed. The secondary aim was to identify the clinical or surgical factors related to recurrent ureteropelvic junction obstruction (UPJO). &#x0D; Materials and methods: A retrospective study was conducted on patients diagnosed with UPJO at the Hospital General de México “Dr. Eduardo Liceaga”, between 2011-2019. Patients that underwent primary pyeloplasty, and developed recurrent UPJO, underwent secondary treatment, and had follow-up ³6 months were included in the study. A descriptive analysis was carried out.&#x0D; Results: A total of 52 patients underwent open or laparoscopic pyeloplasty as primary treatment and 6 of them (11.5%) presented with recurrent UPJO at 44 months (median). Two of those patients presented with a non-functioning kidney and underwent simple laparoscopic nephrectomy and the remaining 4 patients underwent transperitoneal laparoscopic redo pyeloplasty as secondary treatment. The mean age of the patients with recurrence was 46 years, their mean BMI was 32.57±5 kg/m2, and two of them had urinary diversion prior to the primary pyeloplasty. Surgery duration was longer for laparoscopic redo pyeloplasty versus primary pyeloplasty (192 minutes versus 113 minutes) and intraoperative bleeding was similar (52cc versus 52.9cc). The surgical and histologic finding in laparoscopic redo pyeloplasty was peri-ureteral fibrosis. No aberrant vessels were found. Stricture was longer than 15 mm in the patients that underwent laparoscopic redo pyeloplasty (n=4). Obesity, lithiasis, and stricture length &gt;15mm were more frequent in the patients with recurrence. &#x0D; Conclusions: The prevalence of UPJO in our study population was 11.5%, which concurs with international parameters. Laparoscopic redo pyeloplasty is a useful tool in cases of UPJO.

MR Urography (MRU) is an increasingly used imaging modality for the evaluation of pediatric genitourinary obstruction. To determine whether pediatric MR urography (MRU) reliably detects crossing vessels in the setting of suspected ureteropelvic junction (UPJ) obstruction. The clinical significance of these vessels was also evaluated. We identified pediatric patients diagnosed with UPJ obstruction by MRU between May 2009 and June 2014. MRU studies were evaluated by two pediatric radiologists for the presence or absence of crossing vessels. Ancillary imaging findings such as laterality, parenchymal thinning/scarring, trapped fluid in the proximal ureter, and presence of renal parenchymal edema were also evaluated. Imaging findings were compared to surgical findings. We used the Mann-Whitney U test to compare continuous data and the Fisher exact test to compare proportions. Twenty-four of 25 (96%) UPJ obstructions identified by MRU were surgically confirmed. MRU identified crossing vessels in 10 of these cases, with 9 cases confirmed intraoperatively (κ = 0.92 [95% CI: 0.75, 1.0]). Crossing vessels were determined to be the primary cause of UPJ obstruction in 7/9 children intraoperatively, while in two children the vessels were deemed incidental and noncontributory to the urinary tract obstruction. There was no significant difference in age or the proportions of ancillary findings when comparing children without and with obstructing vessels. MRU allows detection of crossing vessels in pediatric UPJ obstruction. Although these vessels are the primary cause of obstruction in some children, they are incidental and non-contributory in others. Our study failed to convincingly identify any significant predictors (e.g., age or presence of renal parenchymal edema) that indicate when a crossing vessel is the primary cause of obstruction.

IntroductionIn an era of minimally invasive surgery, laparoscopic pyeloplasty has emerged as an alternative to conventional open pyeloplasty. Although the open method boasts a success rate of over 90%, laparoscopic pyeloplasty far exceeds patient satisfaction due to its low perioperative morbidity. The aim of this study was to evaluate the outcome of patients who underwent laparoscopic pyeloplasty due to congenital ureteropelvic junction obstruction (UPJO). Material and Methods A retrospective observational study was conducted at Sri Jayawardenapura general hospital from March 2014 to December 2020. All patients were subjected to CT urogram and diuretic renogram (DTPA) scan. Clinical, imaging and biochemical findings were recorded. Patients included were those who underwent laparoscopic pyeloplasty based solely on the clinical severity of the disease, those who underwent lap-nephrectomy or open surgery was excluded. Follow up was based on clinical and DTPA scan findings. Improvement in symptomatology, split renal function(SRF) by 5% and/or diuretic curve pattern were considered successful outcomes. Results A total of 40 patients who underwent LP were evaluated with a mean age of 32 years and slight male preponderance. The majority (82.5%) were symptomatic with pain and/or infection. All were diagnosed with hydronephrosis with impaired DTPA. An SRF &lt; 40% in the affected kidney was observed in 22(55%) of patients. Concomitant pyelolithotomy was performed in 7(17.5%) patients. Mean hospital stay was 3.5 days. At mean follow up of 22-months, improvement in symptoms were noted in 35(87.5%) patients and SRF improvement (&gt;5%) were noted in 11(27.5%); the function remained stable in 27(67.5%) and deteriorated in 2(5%) of patients. Discussion Although LP is technically demanding, it offers excellent symptomatic relief and renal preservation. It offers less morbidity, better aesthetic and post-operative convalescence: a promising viable option replacing open surgery.