Minimally Invasive Techniques for the Management of Adult UPJ Obstruction

Early post-operative outcomes of robot-assisted pyeloplasty in patients with unilateral ureteropelvic junction obstruction

INTRODUCTION

Ureteropelvic junction obstruction (UPJO) is a commonly encountered abnormality and it can lead to serious consequences such as renal dysplasia eventually resulting in loss of kidney. Hence, early diagnosis and timely management remains the cornerstone of the treatment. The most anticipated technique amongst modern day urologist is the robot-assisted laparoscopic pyeloplasty (RALP). The study aims to determine early post-operative outcomes of robot-assisted laparoscopic transperitoneal pyeloplasty procedure in patients presenting with unilateral ureteropelvic junction obstruction to establish the local perspective.

METHODOLOGY

This is a descriptive study involving patients with ureteropelvic junction obstruction in a tertiary care facility in Karachi; Sindh Institute of Urology and Transplant (SIUT). A total of 46 participants were recruited. Robot-assisted laparoscopic transperitoneal dismembered Hynes-Anderson pyeloplasty was performed by a single surgeon with over 3 years of experience in the presence of the researcher. Early postoperative outcome total operative time, length of hospital stay, console time and blood loss were noted by the researcher as per operational definition. Data were analyzed on SPSS Version 22.

RESULTS

Mean age in our study was 46.51 years with the standard deviation of ± 10.87. Whereas, mean length of hospital stay, total operative time, total blood loss, console time, pre-hemoglobin, posthemoglobin, height, weight and BMI in our study was 1.19 ± 0.40 days, 64.58 ± 17.59 min, 9.56 ± 6.13 ml, 30.17 ± 4.99 min, 12.66 ± 1.47 ml, 11.79 ± 1.93 ml, 165.62 ± 8.23 cm, 68.34 ± 8.23 kg and 24.85 ± 3.34 kg/m2, respectively.

CONCLUSION

Recent advancements in technology have yielded the latest RALP technique which has been proven significantly better than existing approaches and similar results are reported by this study demonstrating improvement in peri-operative and post-operative outcomes ultimately ameliorating the quality of life of patients with UPJO.

Analysis of the Efficacy and Risk Factors for Failure of Balloon Dilation for Benign Ureteral Stricture

This study aimed to investigate the efficacy of balloon dilation in ureteral stricture and to analyze the risk factors for the failure of balloon dilation, which will hopefully provide some reference for clinicians to develop treatment plans. We retrospectively analyzed 196 patients who underwent balloon dilation between January 2012 and August 2022, 127 of whom had complete baseline and follow-up data. General clinical data, perioperative data, balloon parameters at the time of surgery, and follow-up results were collected from the patients. Univariate and multivariate logistic regression analyses were performed for the risk factors for surgical failure in patients undergoing balloon dilatation. The success rates of balloon dilatation (n = 30) and balloon dilatation combined with endoureterotomy (n = 37) for lower ureteral stricture at 3 months, 6 months, and 1 year were 81.08%, 78.38%, and 78.38% and 90%, 90%, and 86.67%, respectively. The success rates of balloon dilation at 3 months, 6 months, and 1 year in patients with recurrent upper ureteral stricture after pyeloplasty (n = 15) and primary treatment (n = 30) were 73.33%, 60%, and 53.33% and 80%, 80%, and 73.33%, respectively. The success rates of surgery at 3 months, 6 months, and 1 year for patients with recurrence of lower ureteral stricture after ureteral reimplantation or endoureterotomy (n = 4) and primary treatment with balloon dilatation (n = 34) were 75%, 75%, and 75% and 85.29%, 79.41%, and 79.41%, respectively. Multivariate analysis of the failure of balloon dilation showed that balloon circumference and multiple ureteral strictures were risk factors for balloon dilation failure (OR = 0.143, 95% CI: 0.023-0.895, p = 0.038; OR = 1.221, 95% CI: 1.002-1.491, p = 0.05). Balloon dilation combined with endoureterotomy in lower ureteral stricture had a higher success rate than balloon dilation alone. The success rate of balloon dilation in the primary treatment of the upper and lower ureter was higher than that of balloon dilation in the secondary treatment after failed repair surgery. Balloon circumference and multiple ureteral strictures are risk factors for balloon dilation failure.

Comparing the Effects of 2D and 3D Imaging Systems on Laparoscopic Pyeloplasty Outcomes in the Treatment of Adult Ureteropelvic Junction Obstruction

Background: The aim of this study was to compare the efficacy, safety, and the clinical and perioperative outcomes of two-dimensional (2D) and three-dimensional (3D) laparoscopic imaging systems in adult patients undergoing laparoscopic pyeloplasty in our clinics due to ureteropelvic junction (UPJ) obstruction. Methods: A total of 46 adult patients who had undergone laparoscopic pyeloplasty due to UPJ obstruction were included in the study. Cases that had undergone the operation before January 2019 were retrospectively evaluated with the 2D imaging systems. Cases after that date were evaluated by using the 3D imaging systems, and the operative, perioperative, and postoperative findings of these patients were recorded prospectively. Patients who had undergone laparoscopic pyeloplasty were classified into two groups as the "2D group" and the "3D group." To standardize the preoperative findings, the cases that were operated by a single surgeon experienced in both 2D and 3D imaging systems were included in the study. The demographic characteristics and the clinical findings of the patients were compared between the groups. Results: A total of 41 patients were included in the study. The mean age was 27.7 ± 9.17 years. Among the patients, 23 (56.1%) were in the 2D group and 18 (43.9%) were in the 3D group. No statistically significant difference was observed between groups with regard to the demographic characteristics of the patients. According to the perioperative and postoperative findings of the patients, the duration of the operation was significantly shorter in the 3D group. Conclusion: The duration of the operation was significantly reduced in the 3D image-guided laparoscopic pyeloplasty in the treatment of UPJ obstruction of the adult, compared with 2D image-guided operations. The 3D imaging systems provide a better image quality, an important convenience in intraoperative saturation, and low rates of complication in laparoscopic pyeloplasty, and they may be used safely and effectively.

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.

Robot-assisted laparoscopic pyeloplasty: A retrospective case series review

Introduction

Anderson-Hynes pyeloplasty has been gold standard in the management of pelviureteric junction obstruction (PUJO). It has evolved from open to laparoscopic and now robotic surgery. Open surgery has its drawback of long incision and scar mark, significant post-operative pain and long hospital stay. The main limitation of laparoscopic surgery had been the difficulty in endosuturing. Robotic surgery has incorporated the minimal access method of laparoscopy and endowrist movement of open surgery to overcome the challenge of intracorporeal suturing. Here, we present our initial experience of robotic pyeloplasty.

Patients and Methods

A total of 30 patients underwent robot-assisted laparoscopic pyeloplasty (RALP) over 19 months. Diagnosis of PUJO was made by computed tomography urography, diuretic renogram and retrograde pyelogram in selected patients. All patients underwent RALP by colon reflecting approach. Post-operative evaluation was done by DTPA scan at 3- and 6-month follow-up. Data were analysed after a mean follow-up of 11 months.

Results

The mean operative time was 148 min and the mean hospital stay was 3.5 days. While 93% of the patients showed objective improvement in their drainage pattern on DTPA renogram, 90% of the patients were symptom-free at the end of 6 months.

Conclusions

Robotic pyeloplasty is a safe and easily conquerable technique with comparable outcomes in the hands of surgeons who are beginners in this technique.

Quality of Life of Patients After Laparoscopic Pyeloplasty Due to Ureteropelvic Junction Obstruction: A Long-Term Observation

This study aims to define the quality of life (QoL) of patients who had undergone laparoscopic pyeloplasty due to ureteropelvic junction obstruction. The QoL was investigated in 26 patients after pyeloplasty, on average, at a 7.5-year follow-up. The operation was performed in a single center between 2002 and 2009 and its effectiveness was confirmed by diuretic renography. The QoL was assessed using the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. Additionally, we used an own questionnaire, created for this study, specifically assessing the health-related quality of life after pyeloplasty. Overall, 96% of patients were satisfied with the surgical procedure and all would agree to have another pyeloplasty procedure if needed. In one case, dissatisfaction was caused by persisting postoperative pain. All patients but one, dissatisfied due to persisting pain, reported that the postoperative pain intensity was not a problem that would impact the QoL or professional activity. We conclude that laparoscopic pyeloplasty did not adversely affect the patients' QoL, which might stem from beneficial functional outcomes making the patients satisfied with treatment results.

Factors affecting the effectiveness and success of retrograde holmium laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults

PURPOSE

To evaluate the factors affecting the effectiveness, safety, and success of retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults.

METHODS

Adult patients who underwent retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction between January 2012 and June 2016 at our clinic were retrospectively analyzed. Success was defined as the relief of symptoms and the resolution of obstruction, as assessed via radiography. Factors affecting success were analyzed, such as the clinical characteristics, procedural outcomes, complications, and the type of ureteroscopy used in the procedure.

RESULTS

Procedural success was achieved in 29 (74.4%) out of 39 patients, with a mean age of 38.3 ± 12.3 years during a median follow-up duration of 44 (33-65) months. Failure occurred at a median of 4.5 (3-22) months. It was detected that the presence of primary obstruction, ipsilateral kidney function being >30% of normal, and the length of obstruction being <1 cm positively affected procedural success (p = 0.009, p = 0.011, and p = 0.019, respectively). In the postoperative period, two Grade I and four Grade II complications were observed according to the Clavien-Dindo classification. There was a difference only in the operation time between semirigid (24) and flexible ureteroscopes (15), with the operation time being shorter with the use of a semirigid ureteroscope than with the use of a flexible uteroscope (p < 0.001).

CONCLUSION

Retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy is a minimally invasive method that can be used effectively and safely as the primary treatment of patients with ureteropelvic obstruction, when long-term results are also taken into consideration. The decision of performing laser endopyelotomy should be made after a detailed evaluation of the characteristics of the patient as well as of the obstruction.

Light-guided renal cyst fenestration during laparoscopic ureterocalicostomy in a patient with left ureteropelvic junction obstruction

INTRODUCTION

Laparoscopic ureterocalicostomy is a useful alternative to laparoscopic pyeloplasty for treating ureteropelvic junction obstruction under certain conditions. One concern regarding this technique is the inevitability of amputation of the renal lower pole to expose the lower renal calyx.

CASE PRESENTATION

A 43-year-old man who presented ureteropelvic junction obstruction and multiple renal cysts underwent laparoscopic pyeloplasty, which could not be performed because of the intrarenal ureteropelvic junction. We switched the surgical technique to modified laparoscopic ureterocalicostomy, wherein amputation of the lower renal pole was substituted with fenestration of a renal cyst under the guidance of ureteroscopic light. Computed tomography performed 2 months postoperatively showed good patency of the anastomosis.

CONCLUSION

Light-guided laparoscopic renal cyst fenestration followed by ureterocalicostomy is feasible in patients with ureteropelvic junction obstruction and lower pole renal cysts adjacent to the lower renal calyx.

Surgical management of pyelo-ureteral junction syndrome in a resource-limited setting: case of Zinder National Hospital, Niger

Background

Pyelo-ureteral junction syndrome (PUJS) is a frequent congenital malformation. We report the surgical management of PUJS by pyeloplasty according to Anderson-Hyne-Kuss’s procedure at the Zinder National Hospital..

Methods

This was a retrospective study from January 2013 to December 2016 (4 years), including patients who have undergone surgery for PUJS.

Results

Twelve (12) cases of PUJS had a surgery among which 66.7% were men with an average age of 32.5 ± 7.6 years. The clinical symptomatology was lumbar pain or renal colic in 92.3% of cases. This pain had evolved for more than 2 years for 58.3% of the cases. Ultrasound coupled with intravenous urography or CT-scan was performed to confirm the diagnosis of PUJS in 58.3 and 41.7% of cases. The average serum creatinine level at admission was 181.25 ± 67.3 μmol/L [Lab reference range: 53–97 μmol/L]. The Anderson-Hynes non dismembered pyeloplasty is used for all the patients. The release of a crossing lower pole vessel was performed in 25%, pyelolithotomy in 16.7%. The average surgery time was 118.3 ± 20.7 min. The average hospital length of stay was 10.8 ± 3 days. Immediate postoperative complications were recorded in 33.3% (n = 4). Postoperative outcomes were considered good by disappearance of clinical, biological and radiological signs.

Conclusion

The Anderson-Hynes non dismembered pyeloplasty gives good results and provides a successful alternative in an environment where laparoscopy and robotic surgery are not developed.

W-type suture in Anderson-Hynes laparoscopic pyeloplasty: a novel approach to an old technique

Introduction

Anderson-Hynes (A-H) dismembered pyeloplasty has remained nearly unchanged since its introduction in 1949. The authors present a modification of the uretero-pelvic anastomosis as described by Anderson and Hynes. The new approach, called the W-type suture, is thought to be more watertight and associated with fewer complications than the original.

Aim

To assess the effectiveness of the modification of Anderson-Hynes dismembered pyeloplasty named the W-type suture.

Material and methods

The research is a retrospective study of 99 patients who underwent laparoscopic A-H pyeloplasty. In 49 patients unmodified laparoscopic A-H pyeloplasty was carried out. Fifty patients underwent laparoscopic A-H pyeloplasty with the anastomosis made using the aforementioned W-type suture. To assess the effectiveness of the W-type suture, we compared urine leakage duration – a direct indicator of anastomosis tightness – and frequency of postoperative complications.

Results

The mean duration of urinary leakage was 3 ±1.16 days for the W-type suture anastomosis group and 3.57 ±1.14 days for the unmodified A-H pyeloplasty group (p < 0.05). The frequency of post-operative complications did not statistically significantly differ between the groups except for fever (18.4% vs. 4%; p < 0.05).

Conclusions

The analysis of the collected data showed that the W-type suture might be a promising alternative to a traditional approach of performing the ureteropelvic anastomosis. Further research should be done to minimize biases present in this study, which might have influenced our results.

Robot-assisted boari flap calycovesicostomy for failed uretero-pelvic junction obstruction: a novel approach to a complex problem

Uretero-pelvic junction obstruction (UPJO) is a common condition, often presenting in adulthood in developing countries. These cases can pose significant problems owing to late presentation and complications such as infection, stones, and impaired renal function. We present the case of a 28-year-old female who presented to us with recurrent symptoms and impaired drainage following a failed open pyeloplasty and robot-assisted ureterocalycostomy for right UPJO. She was managed by robot-assisted boari flap calycovesicostomy, an innovation which helped in salvaging her kidney; ensuring good drainage in the involved kidney. To our knowledge, this is the first such case in the literature in the management of complex UPJO.