Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction

Efficacy of Endopyelotomy for Secondary Pelvi-Ureteric Junction (PUJ) Obstruction in Terms of Improvement in Renal Function

Objective The objective of this study is to measure renal function improvement after endopyelotomy for secondary pelvi-ureteric junction (PUJ) obstruction using technetium-99m diethylene-triamine-pentaacetate (DTPA) renal scintigraphy. Material and methods This descriptive study was carried out at the Department of Urology, Institute of Kidney Diseases, Peshawar, Pakistan from June 1, 2021, to May 31, 2023. The study included 118 secondary PUJ blockage patients who underwent endopyelotomy. Patient demographics, clinical history, and preoperative imaging findings were obtained. DTPA renal scintigraphy assessed renal function improvement postoperatively at intervals to determine the efficacy of endopyelotomy. Results The majority of the patients included in the study were male (n=65, 55.1%). The average age of the patients was 45.2 years, with the majority falling within the age range of 46-60 years (n=42, 35.6%). All patients had ultrasonography and computed tomography imaging done, and preoperative renal functions were obtained. Comorbidities included hypertension in 32 (27.12%) and diabetes in 18 (15.25%). DTPA renal scintigraphy showed improved renal function in 81.35% of patients at three months, 88.13% at six months, and 83.05% at 12 months; 15.3% of patients needed further treatments, and 5.1% had PUJ blockage recurrence. Conclusion This study offers significant insights into the results and complexities of endopyelotomy in patients suffering from PUJ blockage. The findings indicate that the technique efficiently enhances kidney function and alleviates symptoms in most patients. However, the study also emphasizes the need to monitor patients undergoing this procedure.

Balloon dilation for failed pyeloplasty in children?

Objective:

Pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). However, the failure rate of pyeloplasty is as high as 10% and repeat pyeloplasty is more difficult. This study aimed to evaluate the efficacy of balloon dilatation for failed pyeloplasty in children.

Materials and Methods:

Between 2011 and 2017, 15 patients, aged 6 months to 14 years, were treated with balloon dilation for restenosis of UPJO after a failed pyeloplasty. Ultrasound and intravenous urography were used to evaluate the primary outcome. Success was defined as the relief of symptoms and improvement of hydronephrosis, which was identified by ultrasound at the last follow-up.

Results:

All patients successfully completed the operation, 13 patients by retrograde approach and 2 patients by antegrade approach. Thirteen patients were followed for a median of 15 (4 to 57) months and 2 patients were lost to follow-up. Resolution of the hydronephrosis was observed in 5 cases. The anteroposterior diameter (APD) of the pelvis decreased by an average of 12.4 ± 14.4mm. Eight patients needed another surgery. The average postoperative hospital stay was 1.78 ± 1.4 days. Two patients experienced fever after balloon dilation. No other complications were found.

Conclusions:

Balloon dilatation surgery is safe for children, but it is not recommended for failed pyeloplasty in that group of patients, owing to the low success rate.

Laparoscopic single-incision triangulated umbilical surgery (SITUS) pyeloplasty: a description of the first 32 cases

INTRODUCTION AND OBJECTIVES

Transumbilical laparoendoscopic (LESS) procedures reduce access trauma. Laparoendocopic single-incision triangulated umbilical surgery (SITUS) utilizes straight instruments in a triangulated fashion, via three trocars placed through a single umbilical incision.

METHODS

Thirty-two consecutive patients underwent an SITUS pyeloplasty. Access is performed by incision of the umbilical fold by 3/4 of its circumference, a 5-mm camera port, and consequently, cranial and caudal 3 or 5 mm working trocars are placed at a distance of 3-6 cm, thus allowing triangulation. SITUS laparoscopy utilizes the standard straight instruments with a length of 43 cm.

RESULTS

All procedures were successfully performed and no conversion to open, or conventional laparoscopic approach was deemed necessary. Thirty patients underwent a dismembered and two a Fenger pyeloplasty. A crossing vessel was identified in 68.75% of the cases. The median laparoscopic and suturing times were 130 and 30 min, respectively; median blood loss was 50 ml. The median duration of hospitalization was 4 days. The visual analogue scores (VAS) reported were 1 on the first and 0 on the third postoperative day. The indwelling double-J or mono-J stents were removed after a median time of 5 weeks and 4 days, respectively. The overall success rate was 96.8%.

CONCLUSIONS

The SITUS technique for pyeloplasty is an attractive alternative to conventional laparoscopy and a viable competitor to LESS surgery. It combines the common principles of traditional laparoscopy, such as conventional instrumentation and triangulation, with the benefits of single-port surgery.

Functional Results of Laparoscopic Pyeloplasty in Children: Single Institute Experience in Long Term

OBJECTIVE

The aim of this study was to evaluate the long-term functional outcomes of laparoscopic pyeloplasty (LP) in children for consecutive cases of single institute.

MATERIALS AND METHODS

Our laparoscopy database was investigated for children in terms of LP between June 2008 and April 2015. All the patients had ureteropelvic junction obstruction (UPJO) and LP was performed. Demographic data including age, gender, side of UPJO, operation time, estimated blood loss (EBL), hospital stay and complications according to Clavien classifications were recorded. Renal ultrasonography and diethylenetriamine penta-acetate (DTPA) scintigraphies were respectively performed 3, 12 and 24 months after surgery. Statistical analyses were performed and p value was accepted as significant at <0.05.

RESULT

Mean follow-up was 34 ± 4.7 months. The mean age was 13 (6-72) months. A total of 153 (110 boys and 43 girls) LP patients enrolled. Of that, 93 (60.78%) LP were in left side and 60 (39.21%) were in right side. Three cases needed open conversation according to difficulties in anastomosis. Aberrant crossing vessel was observed in 12 (7.84%) patients. The mean operation time was 155 ± 21 min and the mean EBL was 22 ± 11.1 ml. The mean hospital stay was 3.4 days. Anastomotic leakage was the common complication (in 13 patients) that was successfully managed conservatively (Clavien 1). Eight patients experienced unsuccessful LP and underwent open pyeloplasty (Clavien 3b). The mean split renal function significantly increased in DTPA scintigraphy in follow-up. The overall success was 91%.

CONCLUSIONS

The LP procedure can be an effective and safe surgical method for childhood UPJO, specifically in the experienced hands of pioneer centers.

Long-term follow-up results of laparoscopic pyeloplasty

Purpose

To assess the long-term follow-up results of laparoscopic pyeloplasty for ureteropelvic junction obstruction.

Materials and Methods

Sixty-five patients (mean age, 43.8 years) who underwent standard laparoscopic pyeloplasty by transperitoneal approaches were enrolled in this study. The chief complaint was flank pain (n=57 patients); the remaining cases were detected incidentally. Twenty-three patients had undergone previous abdominal surgeries, including open pyeloplasty and endopyelotomy. Mean stricture length was 1.06 cm. Grade 3/4 and 4/4 hydronephrosis was detected in 36 and 14 patients, respectively. An obstructive pattern was present on the renal scan in 53 patients (81.5%).

Results

Fifty-seven patients were treated with dismembered Anderson-Hynes pyeloplasty and eight patients with Fenger pyeloplasty. During the operation, crossing vessels were found in 27 patients (41.5%). Mean operating time was 159.42 minutes. Although there were no cases of open conversion, two patients with colon and spleen injuries were detected postoperatively. The mean starting time of postoperative ambulation and diet was 1.54 days and 1.86 days, respectively. Mean hospital stay was 8.09 days. Mean follow-up period was 36.5 months. Follow-up intravenous pyelography and renal scan showed improvements in 59 patients, and the radiologic success rate was 90.8%. Eight patients showed failure on radiologic or symptomatic evaluation, and the overall success rate was 87.7%. In the comparative analysis between the success and failure groups, drained amount was the only risk factor related to failure (554.41 mL. vs. 947.70 mL, p=0.024).

Conclusions

Long-term follow-up results support laparoscopic pyeloplasty as the standard treatment for ureteropelvic junction obstruction. Drained amount is a risk factor for failure of the operation.

Ex vivo evaluation of femtosecond pulse laser incision of urinary tract tissue in a liquid environment: implications for endoscopic treatment of benign ureteral strictures

BACKGROUND

The femtosecond (FS) pulse laser incises soft tissues with minimal peripheral damage and is a promising cutting tool for ureteroscopic endoureterotomy of benign ureteral strictures.

OBJECTIVE

To evaluate the feasibility of applying the FS laser to ureteroscopic endoureterotomy.

MATERIALS AND METHODS

A commercial Ti:Sapphire regenerative amplifier system (Coherent, RegA 9050, USA) was used in this study. Normal saline, 5% glucose solution, 4% mannitol solution, distilled water, and a 1% (v/v) suspension of whole blood with each of these solutions were tested for their attenuation rate (AR) of the FS laser's power. Bladder specimens from Sprague-Dawley (SD) rats were used as a surrogate model. The laser incised slots of 2 mm in length at bladder samples using three power grades (5×, 10×, and 20× the threshold power) combined with five effective pulse rates (40, 20, 10, 5, and 2.5 kHz), both in air and in normal saline. After samples were processed with standard hematoxylin-eosin staining procedures, the incision depth and collateral damage range were determined microscopically.

RESULTS

The ARs of blood suspensions with each of the three isosmotic solutions were significantly higher than the other five solutions (P < 0.001). The FS laser's cutting depth and the collateral damage were increased with the laser power or power density but the collateral damages were less than 100 µm. Microbubble formation was detected in the liquid environments tested and influenced the effective laser power.

CONCLUSIONS

Endoscopic application of the FS laser is feasible. Microbubble formation with the laser incision, however, may influence cutting effects. Proposed methods to address these issues include increasing the irrigation rate, using distilled water as irrigation or using gas insufflation instead of irrigation. It is necessary to evaluate these methods, as well as the long-term biologic response to laser incision, on living animal models in endoscopic settings before use on humans.

Ureteroscopic holmium:YAG laser endopyelotomy is effective in distinctive ureteropelvic junction obstructions

AIM

To evaluate the effectiveness and safety of holmium:YAG (Ho:YAG) laser endopyelotomy in distinctive ureteropelvic junction obstructions (UPJO) with distinctive aetiologies.

MATERIAL AND METHODS

Thirty-one patients diagnosed with UPJO of distinctive causes were included. Aetiology consisted of 7 congenital UPJO, 10 post-pyeloplasty UPJO, 7 post-lithotomy obstructions, 4 ureteropelvic junction obstructions post-extracorporeal shockwave lithotripsy stenoses and 3 post-ureteroscopic lithotriptic UPJO. Retrograde ureteroscopic Ho:YAG laser endopyelotomy was performed in all patients. Operation related parameters were studied

RESULTS

Average procedure duration was 46 min. Mean discharge was 1.81 days. There was no notable complication such as perforation or haemorrhage. All patients were followed for at least 12 months. The single success rate was 80.6%, leaving 6 patients undergoing secondary endopyelotomy, among whom 4 were successful while 2 required an open approach. The overall success rate was 93.5%. Failed pyeloplasty UPJO is more disposed to restenosis (p = 0.0075). Inversely implanted ureteral stent yielded a higher success rate (p = 0.0158).

CONCLUSIONS

Ho:YAG laser endopyelotomy is a safe, minimally invasive approach effective in both primary and secondary UPJO treatments. Implantation of inversed ureteral stents can be more beneficial.

Retroperitoneal laparoscopic dismembered pyeloplasty with a novel technique of JJ stenting in children

OBJECTIVE

• To report our experience with retroperitoneal laparoscopic dismembered pyeloplasty for pelvi-ureteric junction (PUJ) obstruction in children.

PATIENTS AND METHODS

• Between March 2007 and December 2009, 38 children with PUJ obstruction (mean age 8.3 years, range 3-14) underwent retroperitoneal laparoscopic dismembered pyeloplasty. • A ureteric catheter was inserted into the mid-ureter cystoscopically. During pyeloplasty, the proximal end of the ureteric catheter was extracorporeally sutured to the distal end of the JJ stent with silk. • The ureteric catheter was then pulled down and the stent was pulled antegrade into the ureter and bladder.

RESULTS

• The approach was retroperitoneal in all patients except one who required open conversion. The overall mean operative time was 162 min (range 145-210 min) and this appeared to decrease with experience. Mean hospital stay was 4 days (range 3-7 days). • Mean follow-up was 20.2 months (range 6-32 months). Satisfactory drainage with decreased hydronephrosis was documented in all patients on ultrasonography and intravenous urography.

CONCLUSION

• Our study shows that retroperitoneal laparoscopic dismembered pyeloplasty is a feasible and effective alternative to open pyeloplasty with a relatively minimal complication rate in children 3 years of age and older, but it should be undertaken by experienced laparoscopic surgeons.

Ureteroscopic holmium laser endopyelotomy for ureteropelvic junction stenosis after pyeloplasty

INTRODUCTION

Pyeloplasty is a standard and highly successful treatment for ureteropelvic junction obstruction. However, stenosis is a late complication causing symptom recurrence. The purpose of this study was to evaluate the use of holmium laser stenosis incision-"laser endopyelotomy"-to manage this.

PATIENTS AND METHODS

Fifteen adult patients were referred for loin pain recurrence after pyeloplasty. Subsequent to ureteropelvic junction stenosis confirmation with intravenous urogram and dynamic isotope renogram investigations, the patients underwent ureteroscopic laser endopyelotomy. Eleven patients had stents in situ before endopyelotomy. Ureteric stents (7F) were placed for 6 weeks postprocedure when ureteroscopy was repeated and stents removed. All patients had repeat intravenous urogram and renograms at 3 months postprocedure.

RESULTS

Patients presented at a median of 3.2 years (range, 9 months to 8 years) after pyeloplasty (nine open dismembered, three Culp, and three laparoscopic). Three patients (all nonstented) required a second incision. All patients were discharged from hospital within 23 hours with no complications. Symptomatic improvement was documented in all of the patients, and improved drainage was recorded in the 3-month nuclear scans.

CONCLUSION

Laser endopyelotomy is an appropriate minimally invasive procedure for postpyeloplasty stenosis. Results are better in patients with ureteric stents in situ before the procedure.

Retrograde ureteroscopic holmium laser endopyelotomy in a selected population of patients with ureteropelvic junction obstruction

OBJECTIVE

Significant controversy remains concerning the best way to treat ureteropelvic junction obstruction (UPJO). This study evaluates subjective and objective outcomes of retrograde holmium laser endopyelotomy in a selected population with UPJO.

MATERIAL AND METHODS

Forty-seven patients with UPJO were referred to retrograde endopyelotomy between April 2004 and March 2007. Patients with a very large pelvis, a high insertion of the ureter, a renal split function below 20% or a long (>2 cm) stenosed ureteropelvic segment, and patients younger than 18 years were not selected for endopyelotomy, but subjected to laparoscopic pyeloplasty. Renal function was estimated on renal diuretic scan before and after surgery with a mean renographic follow-up of 35 weeks. Subjective results were based on questionnaires which were returned from 44 patients with primary (n=37) or secondary (n=7) obstruction (mean follow-up 110 weeks). Success criteria were defined as symptom relief and improved or preserved renal function.

RESULTS

Twenty-nine patients (66%) experienced complete symptom resolution and 10 patients (23%) had significant symptom improvement (i.e. no need for pain-killing medication). Five patients (11%) had unchanged symptoms. No difference in postoperative renal function was observed between these three groups of patients. The differences between preoperative and postoperative renal function were non-significant in each group. No major complications were observed. Five patients (11%) were referred to retreatment owing to unchanged symptoms.

CONCLUSION

Retrograde ureteroscopic endopyelotomy is a safe and effective treatment option in patients with primary and secondary UPJO when selected properly.

Retrograde blind endoureterotomy for subtotal ureteral strictures: a new technique

INTRODUCTION

Many causes lead to ureteral strictures. Open procedures require major surgery, for example using the "Boari"-technique. Technical developments in endoscopy provide less invasive treatment modalities for ureteral strictures. These procedures require good visualization and the ability to pass an instrument through the stricture zone. In some cases of subtotal stricture, this cannot be achieved. We introduce a new, minimally invasive surgical technique to overcome this problem.

PATIENTS AND METHODS

Eighteen patients with subtotal ureteral strictures included in the studied group were treated according to the technique described below. After radiographic visualization of the impassable area, a glide-wire was inserted through the stenotic portion. Alongside the wire, a 4 French ureteral catheter was advanced up to the renal pelvis and contrast medium was filled into the renal pelvis and ureter. Now a laser fiber was extended through the ureteral catheter. Under direct fluoroscopic control, the laser was slowly pulled through the stenotic zone, until the contrast medium flew freely all along the ureter. To confirm treatment success standard retrograde URS was carried out following blind incision.

RESULTS

Eighteen patients with subtotal ureteral strictures in different locations were treated using this technique. Mean operating time was 37 min. The procedure was performed successfully in all patients. Seven out of 18 patients developed re-stenosis (38,8%) and 5 of these 7 patients required open surgery in the following.

CONCLUSION

The described technique provides a minimally invasive treatment option for extreme cases of ureteral strictures. In a significant number of patients open surgery can thus be avoided.

Endoureterotomy for Treatment of Primary Obstructive Megaureter in Children

PURPOSE

To describe a new approach to the treatment of primary obstructive megaureter (POMU) using endoscopic endoureterotomy. The results obtained with this technique are reviewed with long-term follow-up.

PATIENTS AND METHODS

A total of 47 children (mean age 3.7 years) with 52 POMU units and a history of failed conservative management underwent endoureterotomy of obstructed juxtavesical and intramural ureter. A 3F Double-J ureteral stent was introduced up to the obstructed segment of ureter. Then a zebra catheter was inserted into the affected ureter beside the stent, followed by a neonatal-size ureteroscope. Following delineation of the length of the narrowed portion of the ureter, a guidewire with a plastic sheath replaced the zebra catheter. A longitudinal incision was made through the detrusor muscle at the 6 o'clock position, leaving the bladder adventitia untouched. The Double-J stent was left in place, while its distal tip was fixed by long nylon suture and single knot to the external genitalia to permit easy removal 1 week after the procedure.

RESULTS

With a mean follow-up of 39 months (range 14-62 months), no leakage, ureteral-orifice obstruction, or reflux was observed. The postoperative success rate was 90% (47 of 52 ureters), defined as resolution or decrease in hydroureteronephrosis and improvement or stability of renal function determined by renal scan. In 37 ureterorenal units (71%), there was complete resolution of hydroureteronephrosis.

CONCLUSIONS

On the basis of previous studies demonstrating the value of endoureterotomy with stenting for the treatment of benign ureteral strictures in adults, we developed a modified endoscopic approach for the treatment of POMU and applied this technique in meticulously selected cases. Our results showed that this approach is a valid option for the treatment of children with POMU.

Retroperitoneal dismembered pyeloplasty: Initial experiences

AIM

To review the results of our first 40 cases of retroperitoneal dismembered pyeloplasty and to compare them with series of open and other minimally invasive treatments of pelviureteric junction (PUJ) obstruction. Also to compare our first 20 cases with the second 20 cases to see if there was an improvement in results with experience.

METHODS

A retrospective review of the first 40 laparoscopic pyeloplasties performed by a single lead surgeon at two institutions was performed. The diagnosis of PUJ obstruction was confirmed with an intravenous urogram as well as a renogram prior to surgery. A retroperitoneal, dismembered pyeloplasty was routinely performed with three or four ports. All patients were followed up with an intravenous urogram, renogram and review of symptoms at 4 months and annual renogram after that.

RESULTS

Average operation time was 236 min and this appeared to decrease with experience. Two cases had to be converted to open operations. The mean hospital stay was 3.4 days. Out of the 40 patients, 34 have had successful laparoscopic operations with total symptomatic relief as well as radiologically proven deobstruction. There were four major complications with 3 patients going on to have redo open pyeloplasty operations. There were seven minor complications.

CONCLUSIONS

In our experience, retroperitoneal dismembered pyeloplasty is an effective and safe means of treating PUJ obstruction. Our results seem to be comparable with series of open pyeloplasty and other laparoscopic series and are better than some other minimally invasive techniques.

Ureteroscopic laser approach in recurrent ureteropelvic junction stenosis

OBJECTIVES

Endourological procedures are widely used for treating ureteropelvic junction (UPJ) obstruction. Our aim was to establish the value of using laser retrograde endopyelotomy (REP) in cases with recurrence.

MATERIALS AND METHODS

Between November 2000 and June 2005 we performed 30 REPs in recurrent UPJ obstruction with grades 3 and 4 hydronephrosis (failed pyeloplasty, 17 cases; failed endopyelotomy, 13 cases). Our series was characterized by absence of renal calculi, stenosis length<2 cm, and absence of massive hydronephrosis. We used semirigid and flexible endoscopic equipment (Wolf and Storz) and holmium:YAG laser. In 11 cases, an indwelling double J was placed for 2 wk. An indwelling pyelostent 8/12 F was postoperatively placed for 8 wk.

RESULTS

All cases were evaluated at 6, 12, and 18 mo. Ultrasonography and urography were the main follow-up investigations. At 6 mo, we found normal UPJ and pyelocaliceal system in 9 cases (30%); a reduction of the hydronephrosis degree with normal UPJ in 4 cases (13.3%); and no changes of the hydronephrosis degree in 17 cases (56.6%), but with large UPJ passage in 13 of the 17 cases (76.5%). REP success did not correlate with the degree of hydronephrosis. The success rate after 18 mo was 83.3%. Patients experienced minor complications. The mean follow-up period was 31 mo (range: 18-52 mo).

CONCLUSIONS

REP may represent an efficient minimally invasive technique in recurrent UPJ stenosis, with a reduced rate of complications, short period of hospitalization, and good anatomical and functional results.

Minimally Invasive Treatment of Ureteropelvic Junction Obstruction: Optimizing Outcomes with Concomitant Cost Reduction

With the seemingly exponential increase in the use of minimally invasive techniques in urology, cost-benefit comparisons will continue to play a major part in establishing services and in improving those that already exist. The management of ureteropelvic junction obstruction is a focus of significant attention. An effective way of optimizing the economy of management is to understand the implications in terms of the success of each mode of treatment. Subsequently, costing models should be developed and applied in large-scale multicenter studies with the aid of health economists. The long-term benefits can then be assessed by also including patient's perceived quality of life. Economic assessment will not be enough to promote cost-effective practices. The take-up of any techniques will always be influenced not only by patient preference and surgeon expertise but also, perhaps ironically, by the way hospitals and surgeons are remunerated. In addition, the impact of the time taken to train a surgeon to carry out laparoscopic dismembered pyeloplasty competently may play a significant role. Until these issues are resolved, definitive recommendation for the treatment of ureteropelvic junction obstruction will continue to be made on an individual basis.

Laparoscopy Versus Dorsal Lumbotomy for Ureteropelvic Junction Obstruction Repair

PURPOSE

Laparoscopic pyeloplasty offers similar success rates compared to open surgery. However, the advanced laparoscopic skills required may limit its widespread application. In select patients the dorsal lumbotomy approach can provide similar postoperative advantages to minimally invasive surgery. We analyze the perioperative management of laparoscopy vs dorsal lumbotomy for the repair of ureteropelvic junction obstruction.

MATERIALS AND METHODS

In a retrospective review 13 patients who underwent dorsal lumbotomy pyeloplasty were compared to 19 patients who underwent laparoscopic pyeloplasty between 1998 and 2003. Preoperative confirmation of obstruction was obtained through excretory urogram or renal Lasix scan. All 13 patients undergoing dorsal lumbotomy had a dismembered pyeloplasty. Of the 19 laparoscopic cases 16 had a dismembered pyeloplasty and 3 had a Fenger procedure. Average followup was 12 months for the open group and 13.3 months for the laparoscopic group. Postoperative results were evaluated with excretory urogram or renal Lasix scan as well as subjective outcomes by the patients.

RESULTS

Operative time was slightly longer for the laparoscopy group at 231 minutes vs 200 minutes. Estimated blood loss and postoperative morphine requirements were also similar. Hospital stay was 3.3 days for the dorsal lumbotomy group compared to 2.4 for the laparoscopy group. The overall success rate for the laparoscopic group was 94.7% compared to 100% for the dorsal lumbotomy group. Each group had 1 complication, paresthesia of anterior/medial thigh that resolved by 6 months.

CONCLUSIONS

Our preliminary results show that a dismembered dorsal lumbotomy pyeloplasty is comparable to laparoscopic dismembered pyeloplasty with regard to intraoperative and postoperative hospital course.

Antegrade versus Retrograde Endopyelotomy for Pelvi-Ureteric Junction (PUJ) Obstruction

OBJECTIVES

To compare complication and success rates of antegrade and retrograde endopyelotomy performed over 10 years and to define possible risk factors associated with treatment failure.

METHODS

From 1994 to 2004, 61 patients underwent a total of 68 endoscopic treatments: 19 antegrade and 49 retrograde endopyelotomy procedures. Antegrade endopyelotomy was always performed using diathermy. In the first 18 procedures retrograde endopyelotomy was performed using diathermy. In the most recent 30 procedures the incision was made using holmium laser. Endoluminal ultrasound was used in 78% of retrograde endopyelotomy and in 5% of antegrade endopyelotomy.

RESULTS

The retrograde endopyelotomy patients demonstrated significantly lower complication rates (12.5% vs. 42%) and shorter hospital stay (1.5 vs. 7 days) than the antegrade endopyelotomy patients. The mean follow up of the patients who remained free from disease recurrence during the study period was 46 and 24 months for the antegrade and retrograde endopyelotomy group, respectively. The overall success rate (mean time to failure) of antegrade and retrograde endopyelotomy was 56% (31 months) and 70% (17 months), respectively. There was no statistically significant increase in the overall success rate of retrograde endopyelotomy using endoluminal ultrasound per se. Stratifying retrograde endopyelotomy by the type of energy used for the incision, the overall success rate (mean time to failure) was 80% (10 months) and 53% (21 months) for Holmium laser and diathermy, respectively (p = 0.0626).

CONCLUSIONS

The overall success of antegrade and retrograde endopyelotomy in this series appears to be largely a factor of lead-time bias and is similar enough to recommend retrograde endopyelotomy with holmium laser on the basis of its relative safety and shorter hospital stay.

Ureteroscopic Laser Endopyelotomy in Secondary UPJ Obstruction after Pyeloplasty Failure

OBJECTIVES

Secondary ureteropelvic junction (UPJ) obstruction after failure of open and laparoscopic repair may be challenging to resolve due to possible extensive fibrosis and the increased invasiveness of this procedure. Alternatively, ureteroscopic laser endopyelotomy may be a more acceptable procedure for patients and surgeons. We report our preliminary experience with ureteroscopic holmium laser endopyelotomy after open pyeloplasty failure and define the complications that arose and the results.

MATERIALS AND METHODS

We performed 6 retrograde endopyelotomies with a holmium laser for failed UPJ repairs following the Anderson-Hynes procedures. Patient follow-up was carried out every 3 months using sonography and renal scan, and again after 1 year using renal scan and urography.

RESULTS

Mean hospitalization was 2.1 days. Ureteroscopic laser endopyelotomy was successful in 4 cases (66.6%). In 2 patients, failure occurred at the third month of follow-up. Complications included 1 case of slight bleeding, which was resolved conservatively without the need for blood transfusion, and 2 cases of guidewire rupture.

CONCLUSIONS

Secondary UPJ obstruction is more challenging to resolve by open or laparoscopic approach. Retrograde endopyelotomy gives a valid alternative thanks to its success rate and its better acceptance by patients. We consider retrograde laser endopyelotomy the approach to choose when faced with secondary UPJ obstruction after open or laparoscopic failures.

Laparoscopic pyeloplasty: current status

OBJECTIVE

To review current publications and report our results and long-term follow-up of laparoscopic transperitoneal pyeloplasty for pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

In all, 147 laparoscopic transperitoneal pyeloplasties were performed between August 1993 and November 2000 (mean patient age 35.7 years, range 10-85). All patients were diagnosed with PUJ obstruction by symptoms and intravenous urography, radionuclide diuretic renography or ultrasonography. An Anderson-Hynes dismembered pyeloplasty (106), Y-V plasty (28), Fenger plasty (11) and others (two) were used, according to the intraoperative findings. Twenty-five patients had secondary obstruction, having had previous surgery to the PUJ. The mean (range) follow-up was 24 (3-84) months; all patients were followed clinically and radiologically.

RESULTS

The mean operative duration time was 246 (100-480) min and estimated blood loss was 158 mL. Crossing vessels were identified in 80 cases. The success rate for all, primary and secondary patients was 95%, 98% and 84%, respectively. With one exception, all failures occurred within 6 months. Twenty-one patients (22 renal units) had simultaneous laparoscopic pyeloplasty and lithotomy; they were treated successfully and all have an intact PUJ, and 20 renal units (90%) were stone-free. The overall complication rate was 8.8%.

CONCLUSIONS

This series has comparable success rates to those of open pyeloplasty and the morbidity was minimal. Laparoscopic pyeloplasty may soon become the standard operation for PUJ obstruction, especially with crossing vessels.

Dismembered Percutaneous Endopyeloplasty: A New Procedure

PURPOSE

We recently described a novel technique of percutaneous non-dismembered endopyeloplasty (Fenger type). Herein, we extend this transrenal technique further and report percutaneous dismembered endopyeloplasty (Anderson-Hynes type).

MATERIALS AND METHODS

In five pigs with unilateral ureteropelvic junction (UPJ) obstruction created 3 to 6 weeks earlier, percutaneous dismembered endopyeloplasty was performed. Percutaneous transrenal access to the UPJ was obtained, and the UPJ was completely dismembered from within the renal pelvis through the solitary percutaneous tract. The dismembered proximal ureter was circumferentially mobilized, and in two animals, the UPJ segment was completely excised and removed. A spatulated end-to-end endopyeloplasty anastomosis (Anderson-Hynes) was created transrenally with 5 to 10 interrupted sutures using a novel nephroscopic suturing device (Sew-Right SR-5; LSI Solutions, Rochester, NY). In two animals, the entire percutaneous procedure was performed with CO2 insufflation instead of fluid irrigation.

RESULTS

The technique was developed in three pigs. Subsequently, two pigs were treated and sacrificed at 2 and 5 weeks. All UPJs were dismembered successfully, and a precisely sutured mucosa-to-mucosa anastomosis was created. Intraoperative bleeding was negligible, and the operative time ranged from 3 to 5 hours, with the majority of the time dedicated to transrenal retroperitoneal dissection of the scarred, fibrotic UPJ. Carbon dioxide insufflation was efficacious because it minimized fluid extravasation and tissue edema and additionally enhanced visibility. Postoperative pyelograms revealed an adequately funneled UPJ, with good flow into the distal ureter. The two survival animals had minimal apparent morbidity from the procedure, and retrograde pyelograms at euthanasia revealed a patent anastomosis without extravasation. A 6F catheter easily crossed the reconstructed UPJ at autopsy in all animals.

CONCLUSIONS

Dismembered percutaneous Anderson-Hynes endopyeloplasty is technically feasible and is promising. Further technical experience and additional functional outcome analysis in the survival model are necessary. With the technique described herein, we introduce the concept of percutaneous intrarenal reconstructive surgery (PIRS), wherein advanced intrarenal and retroperitoneal dissection with reconstruction can be performed endourologically, further broadening the horizons of conventional percutaneous techniques.

Long-term results of Anderson-Hynes pyeloplasty in 180 adults in the era of endourologic procedures

INTRODUCTION

The aim of the present study wasto evaluate the long-term results of adult open pyeloplasties performed by the Anderson-Hynes technique in the era of new endourologic procedures.

MATERIALS AND METHODS

The medical records of 180 adult patients who underwent Anderson-Hynes pyeloplasty with a diagnosis of ureteropelvic junction (UPJ) obstruction, were retrospectively reviewed. Pre- and postoperative results were compared with clinical, radiologic and radionuclide studies. The mean age of the patients was 33.2 (16-65) years. The minimum clinical follow-up time was 12 months and the mean time from the operation was 9.4 years (between 1 and 17 years).

RESULTS

Success was defined as resolution of symptoms and decrease in pyelocaliceal volume and calicectasis. The overall success rate was 91.1%. The success rate was between 93.1 and 100% in patients with grades I-III and 62.5% in patients with grade IV hydronephrosis and contribute to renal function less than 25%. The pyelocaliceal volume returned to normal in 39 (21.7%) patients, significantly decreased in 82 (45.5%), and the flow of contrast media from renal pelvis to ureter improved in 43 (23.9%) and did not change or increased in 16 (8.9%). The failure happened in the first 3 months in 57% of patients and in long-term follow-up in 43% of patients.

CONCLUSION

Despite newer endoscopic techniques, Anderson-Hynes pyeloplasty, with an over 90% success rate remains the gold standard in the treatment of primary UPJ obstruction.

Renal imaging: what the urologist wants to know

Preoperative imaging in renal surgery is of utmost importance in contemporary surgical practice. From a diagnostic standpoint, imaging discovers many renal tumors incidentally before they become symptomatic. These tumors often are amenable to partial renal resection or minimally invasive surgical approaches. In general, surgical interventions for renal abnormalities have evolved to a less invasive endourologic or laparoscopic approach. Selection of the appropriate surgical intervention for renal tumors, collecting system tumors, and hydronephrosis depends heavily on the anatomy of the renal pathology. Thus, renal imaging is crucial in clinical decision-making. This article reviews the contribution of imaging to the surgical management of renal tumors, upper tract urothelial tumors, and ureteropelvic junction obstruction.

Retrograde ureteroscopic endopyelotomy

Several different procedures can be used to treat UPJ obstruction. Retrograde ureteroscopic endopyelotomy provides a safe and adequate first line of treatment for this condition. With the advent of smaller ureteroscopes and ancillary devices, this technique has evolved to include children. Adherence to strict endourologic principles and direct visualization make retrograde ureteroscopic endopyelotomy a safe and effective treatment modality. This procedure represents an extension of the basic endoscopic skills of the urologist, creating a short learning curve and wide margin of safety.

Ureteroscopic laser endopyelotomy: a single-center experience

PURPOSE

We review our experience with ureteroscopic endopyelotomy using a holmium laser for correction of ureteropelvic junction (UPJ) obstruction in order to further define the immediate and long-term results and complications.

PATIENTS AND METHODS

From 1999 to 2002, 11 men and 34 women (mean age 42 years) underwent 46 ureteroscopic holmium laser endopyelotomy procedures for treatment of primary (N=40) or secondary (N=5) UPJ obstruction. The inclusion criteria were a short (<2-cm) obstruction and absence of ipsilateral renal calculi. Demographic, intraoperative, and postoperative measures were obtained from a prospectively designed and updated database. The endopyelotomy was performed under direct vision using a semirigid (N=40) or flexible (N=5) ureteroscope with a laser setting of 1 J at 10 Hz. Radiographic confirmation of obstruction and the results of intervention was obtained by combinations of intravenous and diuretic urography, diuretic renography, ultrasonography, and CT. The first postoperative and latest radiographic follow-up studies were compared with the preoperative studies to determine whether the obstruction was resolved, unchanged, or worsened. Success was defined as symptomatic relief and radiographic resolution.

RESULTS

The mean operative time was 65 minutes (range 10-153 minutes). There were no intraoperative complications, although 5 patients (11.1%) experienced postoperative complications consisting of subcapsular hematoma, pyelonephritis, sepsis, urinary retention, or dysrhythmia. Forty-two patients (93%) had a hospital stay of <23 hours. Stents were removed 3 to 8 weeks (mean 5 weeks) postoperatively. The mean length of follow-up was 23.2 months (range 5-43 months). Symptoms were resolved in 65.4% of patients, improved in 7.7%, unchanged in 11.5%, and worse in 15.4%. Radiographically, at latest follow-up, the obstruction was resolved in 73.1% of patients, unchanged in 23.1%, and worse in 3.8%. Primary UPJ obstruction was associated with a symptomatic success rate of 68% compared with only 50% for secondary UPJ obstruction.

CONCLUSIONS

Ureteroscopic laser endopyelotomy is a minimally invasive, short-stay outpatient procedure associated with a 65.4% symptomatic and 73.1% radiographic success rate. In contrast to the findings in previous reports of results of retrograde or antegrade endopyelotomy, patients treated for primary UPJ obstruction experienced higher rates of success than those with secondary obstruction.

Impact of hydronephrosis and renal function on treatment outcome: antegrade versus retrograde endopyelotomy

OBJECTIVES

To compare, in a single-surgeon, single-institution study, the efficacy of antegrade and retrograde endopyelotomy in terms of success rate and morbidity and to identify which risk factors affect treatment outcomes.

METHODS

The results were retrospectively reviewed for 88 patients with ureteropelvic junction obstruction treated with endopyelotomy. Antegrade endopyelotomy was performed with a hook knife, scissors, or cutting balloon device. Retrograde endopyelotomy was performed with a cutting balloon device. Objective results were based on intravenous urogram and/or diuretic nuclear renal scan findings, and subjective results were based on direct patient query and questionnaire.

RESULTS

Ninety-three endopyelotomy procedures, 64 antegrade and 29 retrograde, were performed. The mean follow-up was 37.0 months (range 5 to 76). The overall success rates between antegrade and retrograde endopyelotomy (81.3% versus 75.9%) were not statistically different (P = 0.553). Patients with massive hydronephrosis and poor initial renal function were less likely to have successful endopyelotomy. Antegrade endopyelotomy, however, was more successful than retrograde endopyelotomy in patients with massive hydronephrosis (66.7% versus 20.0%; P = 0.046). The average operative time for antegrade and retrograde endopyelotomy was 93.9 and 32.7 minutes (P <0.001), respectively. The average length of hospital stay after antegrade and retrograde endopyelotomy was 3.20 and 0.14 nights (P <0.001), respectively.

CONCLUSIONS

Both antegrade and retrograde endopyelotomy are effective treatments for ureteropelvic junction obstruction associated with minimal morbidity. Antegrade endopyelotomy appears to be more successful in patients with high-grade hydronephrosis. Retrograde endopyelotomy results in a shorter hospital stay, a shorter operative time, and less postoperative pain.

Robotic pyeloplasty

In addition to the classic open surgery, a variety of minimally invasive therapeutic options have been developed for the treatment of ureteropelvic junction obstruction, including an endoscopic antegrade or retrograde ureteropelvic junction obstruction visually controlled incision or radioscopically controlled Acucise (Applied Medical, Laguna Hills, CA), which does not share the high success rate that results from open-surgical dismembered pyeloplasty. Laparoscopic pyeloplasty, which duplicates the open technique and differs only by the mode of access, has proven to have positive results when performed by experts, but remains a demanding technique that requires a long learning curve. Providing a three-dimensional vision, an unprecedented control of the endocorporeal instruments, and an ergonomic surgeon's position, robots may allow urologists with limited laparoscopic experience to rapidly master the endocorporeal management of ureteropelvic junction obstruction. They likely will propel minimally invasive urology forward in the next several years.

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.

Cost-effective treatment for ureteropelvic junction obstruction: a decision tree analysis

PURPOSE

We determined the optimal treatment for primary ureteropelvic junction obstruction based on cost using a decision tree model.

MATERIALS AND METHODS

A comprehensive literature search for articles addressing surgical correction of ureteropelvic junction obstruction was performed and data were abstracted on operative time, hospital stay, complications and success rate. The overall cost and individual cost centers at our institution for antegrade endopyelotomy, retrograde ureteroscopic endopyelotomy, Acucise (Applied Medical Resources, Laguna Hills, California) endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were compared. A decision tree model estimated the cost of treatment and followup for each modality using commercially available software. Sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost.

RESULTS

Based on cost center review retrograde ureteroscopic endopyelotomy was the least costly procedure ($2,891). In the decision tree model the rank order of overall treatment costs was: retrograde ureteroscopic endopyelotomy ($3,842), Acucise endopyelotomy ($4,427), antegrade endopyelotomy ($5,297), laparoscopic pyeloplasty ($7,026) and open pyeloplasty ($7,119). Despite various hospital stay, operative time, equipment cost and success rate data 1-way sensitivity analysis revealed that antegrade endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were never cost effective compared with retrograde ureteroscopic endopyelotomy or Acucise endopyelotomy, while 2-way sensitivity analysis favored retrograde ureteroscopic endopyelotomy.

CONCLUSIONS

Primary cost variables for ureteropelvic junction obstruction treatments include operative time, hospital stay, equipment cost and success rate. Decision tree analysis showed that retrograde ureteroscopic or Acucise endopyelotomy is the most cost-effective treatment modality at our institution. However, cost is only 1 of a number of factors that are considered when deciding on an optimal course of treatment.

[Endoscopic surgery in urology]

At this moment in time, endourology is incorporating extraluminal endoscopic techniques (laparoscopy, lumboscopy, retziuscopy), which the urologist is expected to master. The current advanced stage of development of intraluminal endoscopic surgery is mainly due to the most recent technological achievements (miniaturization of the lens, the use of more versatile materials and new energy sources). In the current cystourethroscopic procedures, compact endoscopes and flexible cystoscopes play an important role. The most important of these new techniques include tissue vaporisation procedures, interstitial application of substances or energies, low-pressure transurethral resection and percutaneous vesical surgery. Upper endoluminal procedures have been the ones to most benefit from modern technological developments. The most important features of present day ureterorenoscopes and their clinical applications are studied and also those of percutaneous nephroscopy (lithiasis, neoformations and others). In a review on the current situation of extraluminal endoscopy, a wide range of laparoscopic techniques--applicable to adrenal regions, kidneys, ureters, retroperitoneal and lymphatic systems, testicles and sperm ducts, bladder and prostrate gland--are discussed as well as the indications, advantages and drawbacks involved and the preferential surgical approaches.

The role of endourology in ureteropelvic junction obstruction

Endopyelotomy has benefited from abundant confirmatory investigations, and significant progress in different technical modalities has occurred. Retrograde techniques, including the Acucise (Applied Medical, Laguna Hills, CA) cutting balloon and the ureteroscopic Holmium laser incision, are becoming preferred approaches while the other modalities retain their specific indications. Long-term results and potential complications have been carefully studied and reported. Better identification of risk factors has prompted precise preoperative investigations and allowed for careful patient selection, leading to improved results. These results approach those of open pyeloplasty, but with minimal morbidity.