Techniques of endopyelotomy

Minimally-invasive correction of ureteropelvic junction obstruction: do retrograde endo-incision techniques still have a role in the era of laparoscopic pyeloplasty?

BACKGROUND

This study was designed to review the long-term results and complications of the two techniques of retrograde endopyelotomy; ureteroscopic holmium laser endopyelotomy versus Acucise endopyelotomy. The results were then compared with the laparoscopic pyeloplasty results from a recent publication.

PATIENTS AND METHODS

: The study was conducted retrospectively from January 2004 to July 2007. Seventy-two patients with ureteropelvic junction obstruction (UPJO) underwent retrograde endopyelotomy using either ureteroscopic laser endoincision (42 patients) or fluoroscopic guided hot-wire balloon (Acucise) endoincision (30 patients). Preoperative radiological assessment included intravenous pyelogram (IVP), helical computerized tomography and diuretic renography. The follow-up period ranged from 12 to 42 months. Subjective success was guided by the change in the preoperative flank pain while objective success on radiological evaluation was documented by either nonobstructed curve of diuretic renogram and/or T1/2 less than 10 min.

RESULTS

The mean patient age was 42.6 ± 7.5 years for the laser group and 39.2 ± 15.1 years for the Acucise group (p = 0.24). The operative time was 66.8 ± 22.2 min in the laser group and 59.8 ± 20.3 min in the Acucise group (p = 0.84). By objective standards (renal scan), a total of 56 (77.8%) cases were successful (nonobstructed curve). This number included 34 cases in the laser group (80.9%) and 22 cases in the Acucise group (73.3%) (p = 0.2). Overall 16 failure cases were evident clinically within 1 year of the procedure (eight cases in each group). Most of the failure cases (13/16) presented with clinical obstructive symptoms during the early follow-up period (within 3 months postoperatively) and were then confirmed radiologically (six cases in the laser group and seven cases in the Acucise group) while only three patients had failures at 6, 9 and 11 months postoperatively. There was no statistically significant difference as regards intra-operative complications between the two groups (p = 0.4). Intra-operative bleeding was seen in three cases in the Acucise group while postoperatively it was reported in one case.

CONCLUSION

The retrograde endopyelotomy approach is safe and effective for the treatment of patients with UPJO. Both ureteroscopic laser and the hot-wire balloon (Acucise) techniques have an important role in the management of UPJO, especially in secondary cases, and they provide comparable long-term objective and subjective outcomes. Laparoscopic pyeloplasty provides far better results but with higher costs, and requires well-equipped centers and involves a long learning curve.

Pad per day usage, urinary incontinence and urinary tract infections in nursing home residents

BACKGROUND

many elderly suffer from urinary incontinence and use absorbent pads. Pad use per day (PPD) is a frequently used measure of urinary incontinence. Nursing home residents are often dependent on help from nursing staff to change pads. This study was performed in order to determine whether PPD is a reliable method to quantify urinary incontinence in nursing home residents. Furthermore, the association between urinary tract infections (UTIs), PPD and fluid intake was studied.

METHODS

data were retrieved from a multicentre, prospective surveillance among nursing home residents. Data on the use of absorbent pads, fluid intake and incontinence volumes were collected during 48 h. During a 1-year follow-up period, data on UTIs were collected.

RESULTS

in this study, 153 residents were included, of whom 118 (77%) used absorbent pads. Residents who used absorbent pads were at increased risk of developing UTIs compared to residents who did not use pads (41 vs 11%; P = 0.001). Daily fluid intake was not associated with UTIs (P = 0.46). The number of pad changes showed no correlation with the risk of developing UTIs (P = 0.62). Patients with a given PPD presented a wide range of incontinence volumes.

CONCLUSION

the use of absorbent pads is associated with an increased risk of developing UTIs. PPD and daily fluid intake are not correlated with the risk of developing UTIs. PPD is an unreliable measure of urinary incontinence in nursing home residents.

Percutaneous endopyelotomy for secondary ureteropelvic junction obstruction: Prognostic factors affecting late recurrence

OBJECTIVE

To determine prognostic variables which influence late recurrence after initially successful percutaneous endopyelotomy for secondary ureteropelvic junction obstruction (UPJO).

MATERIAL AND METHODS

Between July 1987 and March 2002, 67 patients with secondary UPJO were treated with percutaneous endopyelotomy at our center. Long-term follow-up data were available for 50 patients with initially successful results (42 after a single treatment and eight after repeated endopyelotomy). Follow-up excretory urography and diuretic renal scans were performed for objective evaluation. Late recurrence was diagnosed if obstruction developed after > 1 year of follow-up. Univariate (Kaplan-Meier method) and multivariate (Cox regression model) analyses of pre-, peri- and postoperative factors were carried out for detection of significant variables affecting the late recurrence rate.

RESULTS

The follow-up period ranged from 1.27 to 13.85 years (mean 6 +/- 4.3 years). Late recurrence of UPJO was observed in seven cases (14%): 4/42 initially successful cases (9.5%) and 3/8 cases of repeated endopyelotomy (37.5%). In univariate analysis, the significant factors were severity of stenosis at the UPJ (p = 0.04), preoperative serum creatinine (p = 0.04), repetition of endopyelotomy (p = 0.03) and development of postoperative complications (p = 0.02). In multivariate analysis, all of the above factors, with the exception of severity of stenosis at the UPJ, were independent significant factors affecting late recurrence.

CONCLUSIONS

As late recurrence was observed in 14% of cases after percutaneous endopyelotomy, long-term follow-up is needed, especially in patients with elevated preoperative serum creatinine, those in whom postoperative complications developed and those in whom a first attempt at endopyelotomy failed.

A retrospective study of ureteroscopy performed at the sultan qaboos hospital, salalah from august 2001 -august 2006

In the modern era of management of disorders of the upper urinary tract, ureteroscopy forms an important part in the armamentarium for the diagnosis and treatment of a variety of disorders that occur in the upper urinary tracts. The modern ureteroscopes have better vision and are less traumatic, making ureteroscopy a relatively safe procedure. Major complications are rare. An audit of a total of 128 ureteroscopies done in the Department of Urology over a six year period from August 2001 till August 2006 at the Sultan Qaboos Hospital, Salalah, was undertaken. The results are discussed in detail and compared with results from other centers. The management of a rare but dreaded major complication is discussed in detail.

Use of Lower Pole Nephrostomy Drainage Following Endorenal Surgery Through an Upper Pole Access

PURPOSE

PNL via an UP puncture is efficient for treating complex stone disease. Access via the UP can provide better visualization, allowing greater stone clearance with a rigid instrument due to its more favorable alignment with the axis of the intrarenal collecting system. However, the presence of a NT through the upper pole tract, especially with a supracostal puncture, can generate significant patient discomfort. We reviewed our experience with a technique using tubeless UP access for PNL with concomitant placement of a NT via a LP calix.

MATERIALS AND METHODS

We performed a retrospective review of our experience using tubeless UP access for PNL with concomitant placement of an LP NT for postoperative drainage. Patient demographics, the number and location of accesses, stone size, stone-free rates, concurrent/additional procedures and complications were recorded.

RESULTS

A total of 63 tubeless UP accesses were performed in 62 patients undergoing PNL, including unilateral access in 61 and bilateral access in 1. Supracostal UP punctures were used in 58 patients, including 40 above the 12th, 17 above the 11th and 1 above the 10th rib. Each patient underwent at least 2 accesses and 3 had 3 or more accesses placed. LP access was nondilated in 37 patients and dilated in 26. Of the patients 56.6% were stone-free after a single procedure, increasing to 96.2% following secondary procedures. Three of the 62 patients (4.8%) required transfusion, 3 (4.8%) required intervention for pleural morbidity and 1 (1.6%) required a stent for a nonsealing upper pole access.

CONCLUSIONS

Tubeless UP access provides maximal efficiency for stone clearance during PNL, while minimizing the morbidity of an intercostal tube.

Percutaneous Lithotripsy: Indications

Although percutaneous nephrolithotomy (PCNL) is more invasive than extracorporeal lithotripsy (ESWL) it still plays an important role in the treatment of renal stones and indications to PCNL are mainly the cases where ESWL gives poor outcome results. When considering the indications to treat a patient affected by a renal stone, we have to evaluate factors related to: the stone, the kidney, the patient, the instruments and finally the urologist. We believe that elective indications to PCNL are: a stone burden >2cm; staghorn and complex stones; stones in hydronephrotic kidneys or associated to UPJ obstruction; lower calyceal stones when >10 mm or in a calyx with an unfavorable anatomy; ureteral stones impacted in the UPJ with severe hydronephrosys; stones in caliceal diverticula.

Ten years' experience of retrograde balloon dilatation of pelvi-ureteric junction obstruction

OBJECTIVE

To analyse the long-term success of retrograde balloon dilatation (RBD) of pelvi-ureteric junction obstruction (PUJO).

PATIENTS AND METHODS

The records of 58 adult patients (mean age 48 years, range 18-94) who had RBD between 1990 and 2001 were reviewed retrospectively. All symptomatic patients were included and assessed by dynamic renography. Success was judged as a symptomatic and/or functional improvement. Recurrence of symptoms was recorded and any evidence of deterioration of function despite improved symptoms. Complications were also recorded.

RESULTS

In all, 44 (76%) patients were asymptomatic after RBD. There was no relationship between symptomatic change and renographic improvement; some patients who were rendered pain-free had either no improvement or even deterioration in their split renal function. Conversely, some patients who had a demonstrable improvement in their renal function continued to be symptomatic. However, a long-term follow-up (mean 6.1 years) of nine patients who were symptomatically improved showed good maintenance of split renal function.

CONCLUSION

RBD is an effective treatment for PUJO and its success is maintained in the long term.

Ureteropelvic junction obstruction: an innovative approach combining metallic stenting and virtual endoscopy

PURPOSE

We report our experience with auto-expandable metallic stents for treating ureteropelvic junction obstruction.

MATERIALS AND METHODS

We treated 4 patients with a mean age of 45 years who had ureteropelvic junction obstruction with placement of a self-expandable intraureteral metallic stent (Wallstent, Schneider, Zurich, Switzerland). All patients presented with recurrent ureteropelvic junction obstruction after open pyeloplasty. Excretory urography and 3-dimensional reconstruction computerized tomography were performed 1 and 6 months after stent insertion. Virtual endoscopy images were obtained at followup due to the need to define ureteral patency.

RESULTS

Mean followup was 16 months (range 9 to 24). Wallstent placement was successful and immediate patency was achieved in all cases. During followup 3 patients required no further intervention and the stented ureteropelvic junction remained patent. In the remaining patient stricture recurred 2 months after initial stent insertion due to the ingrowth of scar tissue through the prosthesis. Additional intervention was deemed necessary after placing a longer 6 cm., completely coaxial overlapping metal stent. Virtual endoscopy and excretory urography findings concurred. Virtual endoscopy allows visualization of the stented ureteropelvic junction lumen cephalad and caudal to the prosthesis. It also enables easy navigation within the stent at different angles of view.

CONCLUSIONS

The concept of applying metallic stents for ureteropelvic junction obstruction and adjacent adynamic ureteral segments combined with virtual endoscopy is strengthened by the results of this study.

Percutaneous endopyelotomy

OBJECTIVES

During the past 10 years, numerous reports around the world have documented the safety and success rate of antegrade endopyelotomy. We describe the classic endopyelotomy in conjunction with some new alternatives for making the incision.

TECHNICAL CONSIDERATIONS

Antegrade endopyelotomy is performed through the 0.5-in. incision of the percutaneous nephrostomy created by way of an upper or middle calix. Using the hook-shaped cold knife, an endopyelotome is positioned, and the entire procedure can be performed under direct vision, which determines the exact position, depth, and extent of the incision. The ureteropelvic junction (UPJ) obstruction is incised in a posterolateral position, and the hook is withdrawn from the proximal ureter. Using nephroscopic scissors, a small full-thickness puncture is made into the renal pelvis and then the scissors is opened, under constant visual control, until it reaches the peripelvic space. The section of the pelvic wall is completed with the scissors running through the UPJ, without any interchange of the nephroscope. A holmium laser has been also used, with the 365-microm fiber introduced through a stent-pusher. Under direct vision, the UPJ is incised with fiber, permitting observation and coagulation of bleeding from small vessels. After the procedure, either a 14-8.2F endopyelotomy stent or a 14-7F tapered endoureterotomy stent is placed over the guidewire.

CONCLUSIONS

Percutaneous antegrade endopyelotomy is a safe and effective treatment of UPJ obstruction for most patients, regardless of the method used to perform the incision.

[Pyeloureteral junction stenosis: our experience and review of the literature]

OBJECTIVES

To study patients with ureteropelvic junction obstruction treated in our department and a retrospective study of this pathology, focus our attention in the diagnosis and treatment.

MATERIAL AND METHODS

62 patients from 7 weeks to 68 years old (mean 29 +/- 1.9). Half of the patients were men and the other half women. In 30 patients the UPJ obstruction was on the right side and 32 patients was on the left side.

RESULTS

The most frequent symptom was the flank pain (46.8%). To confirm the diagnosis, we had IVU in the 61.3% of the patients and ultrasound in the 38.7%. The treatment was the Anderson-Hynes pyeloplasty in the 96.8% of the patients. In 33 patients we used a ureteral catheter. The overall success rate was 90.3%. The 29% of the patients presented postoperative complications.

CONCLUSIONS

Open pyeloplasty is the gold standard treatment of the UPJ obstruction in selected cases, mainly in children.