Retrograde Acucise endopyelotomy: long-term results

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.

Minimally invasive surgical options for ureteropelvic junction obstruction: A significant step in the right direction

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.

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.

[Retrograde endopyelotomy using Holmium-Yag laser for uretero-pelvic junction obstruction]

OBJECTIVE

To evaluate our results of retrograde laser endopyelotomy for uretero-pelvic junction obstruction.

MATERIAL AND METHODS

Retrospective study of 27 consecutive retrograde laser endopyelotomies performed on 24 patients over a six years period (June 1999 to July 2005). Sixteen stenoses were primary. The level of obstruction was severe in 13 patients and moderate in 14 patients. A polar pedicle was diagnosed by pre-operative CT-angiography in seven cases. Balloon dilatation was performed in 17 procedures. A double J ureteral stent remained in place for six weeks mean. We evaluated results by a clinical examination and an excretory urography (at 1 and 6 months then annually). Mean follow-up was 35+/-22.7 months.

RESULTS

Mean operating time and mean length of hospital stay were 49.8+/-17.9min and four days (range: 2-10 days). Two cases of pyelonephritis were observed. The overall success was 70%. In the eight unresolved cases, the failure appeared at 2.7+/-1 month mean. Success criteria were moderate level of obstruction and primary junction. Here, patients so selected have 100% of success.

CONCLUSION

Study confirmed retrograde laser endopyelotomy was safety with a short length of hospital stay. This minimally invasive procedure should be reserved to primary moderate stenoses without polar pedicle.

Is Antegrade Endopyelotomy Really Less Invasive than Open Pyeloplasty?

OBJECTIVE

We investigated the invasiveness of antegrade endopyelotomy and open pyeloplasty in two consecutive series of patients with ureteropelvic junction obstruction.

PATIENTS AND METHODS

98 patients were treated by open pyeloplasty from 1980 to 1991, and 137 patients by antegrade endopyelotomy from 1991 to 1999. Diagnosis of ureteropelvic junction obstruction was made by excretory urogram and/or antegrade pyelography, diuretic renography and retrograde pyelography. Invasiveness was evaluated by the postoperative need for analgesics, the complication rate and the residual long-term symptoms after surgery.

RESULTS

The postoperative need for opiate analgesics was significantly higher in patients after open pyeloplasty than after antegrade endopyelotomy. Ten percent of the patients complained of problems with the lumbotomy scar after open pyeloplasty, which was not encountered after endopyelotomy. Complications after open pyeloplasty occurred in 24% and were more severe than the 11% seen after endopyelotomy. The primary success rate after open pyeloplasty was 98 and 89% after antegrade endopyelotomy. The long-term success rate, > or = 24 month postoperatively, was 96% (median follow-up 37 (24-196) months) and 76% (median follow-up 32 (24-73) months), respectively.

CONCLUSION

Open pyeloplasty and endopyelotomy both have a high success rate with better patency results after open pyeloplasty. Open pyeloplasty is more invasive and has a higher morbidity. Endopyelotomy is a minimally invasive procedure with faster recovery, fewer and minor complications, significantly less need for peri- and postoperative analgesics, less residual pain due to the access, and no functional and esthetic sequelae of lumbotomy.

Retrograde endopyelotomy: a comparison between laser and Acucise balloon cutting catheter

Endopyelotomy and laparoscopic pyeloplasty are the preferred modalities for treatment of ureteropelvic junction obstruction because of their minimally invasive nature. There are continuous efforts for improving endopyelotomy techniques and outcome. Retrograde access represents the natural evolution of endopyelotomy. The Acucise cutting balloon catheter (Applied Medical Resources Corp., Laguna Hills, CA) and ureteroscopic endopyelotomy using holmium laser are the most widely accepted techniques. The Acucise catheter was developed to simplify retrograde endopyelotomy and made it possible for all urologists, regardless of their endourologic skills. The Acucise catheter depends on incision and dilatation of the ureteropelvic junction under fluoroscopic guidance, whereas ureteroscopy allows visual control of the site, depth, and extent of the incision; the holmium laser is a perfect method for a clean precise incision. Review of the English literature showed that the Acucise technique was more widely performed, though laser had better (but not statistically significant) safety and efficacy profiles.

[Laparoscopic pyeloplasty]

Ureteropelvic junction (UPJ) obstruction in adults is usually symptomatic, secondary, and it tends to progress. Surgical correction of obstructed UPJ is necessary to preserve the renal function of the affected kidney. Pyeloplasty as a surgical management for UPJ obstruction in adults has proven its efficacy with high success rates on long-term results. Laparoscopic pyeloplasty in the management of primary or secondary UPJ obstruction in adults technically duplicate the open surgical technique. Laparoscopic pyeloplasty has developed to match success, morbidity and complication rates of open surgical pyeloplasty. However it was shown that laparoscopy had consistently a shorter convalescence than open surgery. Endopyelotomy is utilized to manage UPJ obstruction. Early results for endopyelotomy were promising but long-term results were not encouraging. In the management of UPJ obstruction in adults, long-term success rates for laparoscopic pyeloplasty were found to be superior to those of endopyelotomy. Therefore we believe that laparoscopic pyeloplasty will become as a standard management for UPJ obstruction in adults.

Evaluation of the duration of ureteral stenting following endopyelotomy: Animal study

BACKGROUND

The purpose of the present paper was to evaluate whether it is possible to reduce the duration of ureteral stenting following endopyelotomy, and thus reduce side-effects.

METHODS

Seventeen pigs were used. They were distributed at random into three groups. The study was divided as follows: phase I included baseline study of the urinary system and the creation of a ureteropelvic junction obstruction (UPJO) model. Phase II, 1 month later, consisted of diagnosing UPJO, Acucise endopyelotomy of the same, and the placement of a ureteral stent. Ureteral stents were left in situ for 1 week in group I, for 3 weeks in group II and 6 weeks in group III. Phase III, 3 months after treatment, consisted of follow up and post-mortem studies of the animals. The following procedures were carried out during each phase: ureteropelvic junction (UPJ) diameter measurement, ultrasound percutaneous and endoluminal studies, urine culture and determination of blood urea and creatinine levels.

RESULTS

On removal of the stent, the presence of urinoma was observed in two animals in group I. There were statistically significant differences between group I and III with regard to evolution of the internal diameter of the UPJ. However, the least severe histological lesion at the UPJ level was found in group II.

CONCLUSIONS

Ureteral stent placement for 1 week is insufficient in order to assure correct healing and evolution of the UPJ following endopyelotomy. Stenting for 3 weeks is effective, and it is not necessary to extend stenting time to 6 weeks. Endoluminal ultrasound is of great use in determining the effects of endourological techniques in the ureter and the retroperitoneal space. It is also useful for deciding which therapeutic technique to use, and for inserting the Acucise in order to prevent iatrogenic problems.

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.

The use of endoluminal ultrasonography for preventing significant bleeding during endopyelotomy: evaluation of helical computed tomography vs endoluminal ultrasonography for detecting crossing vessels

OBJECTIVE

To evaluate, in a prospective study, the efficiency of helical computed tomography (CT) and endoluminal ultrasonography (ELUS) for detecting significant crossing vessels, a major cause of bleeding complications when treating patients with pelvi-ureteric junction (PUJ) obstruction, and to compare our results using ELUS with those of an earlier multicentre study (not using ELUS), to see whether the complication rate decreased.

PATIENTS AND METHODS

The study included 27 patients with a PUJ who had isotope renography, intravenous urography, helical CT and ELUS before surgery. Depending on the findings of ELUS, patients were treated with a pure lateral Acucise incision (Applied Medical, Irvine, CA, USA) an Acucise with changed cutting direction, or (later) a laparoscopic pyeloplasty.

RESULTS

ELUS detected 15% more crossing vessels than helical CT; 16 patients had Acucise (seven lateral, nine other cutting direction), eight were treated with a laparoscopic pyeloplasty and three with other procedures. By contrast with earlier reports and as a consequence of using ELUS, there was no bleeding, vs 16% in the study not using ELUS. The success rate of 73% of the endourological approach is comparable with previous reports.

CONCLUSION

ELUS is more sensitive in detecting relevant crossing vessels than helical CT and therefore the use of ELUS can better prevent bleeding complications. ELUS can also improve the success rate by helping in selecting the correct treatment. Because it is minimally invasive and safe, ELUS combined with Acucise (or other possible endourological techniques, like holmium laser incision) should be the first choice of treatment for PUJ stenosis.

Prospective, Randomized Comparison of Ureteroscopic Endopyelotomy Using Holmium:YAG Laser and Balloon Catheter

PURPOSE

We compared the safety and efficacy of the 2 retrograde endopyelotomy techniques.

MATERIALS AND METHODS

A prospective study was done from January 2001 to October 2003. Preoperative radiological evaluation included excretory urography, multiphasic helical computerized tomography and diuretic renography. Exclusion criteria were marked hydronephrosis, ipsilateral renal function less than 25% and renal stones or a significant crossing vessel at the ureteropelvic junction. Eligible patients were randomized to ureteroscopic laser endopyelotomy and retrograde Acucise endopyelotomy (20 per group). UPJ obstruction was primary in 14 patients and secondary in 26. The ureteropelvic junction was incised in the lateral direction and an endopyelotomy Double-J stent (Medical Engineering Corp., New York, New York) was left for 6 weeks. Subjective and objective outcomes were evaluated 3 and 6 months after stent removal, and every 6 months thereafter.

RESULTS

Mean operative time +/- SD was comparable in the laser and Acucise groups (64.7 +/- 22.4 and 58.7 +/- 20.2, respectively). The overall complication rate in the Acucise group was more than in the laser group (25% vs 10%). At a mean followup of 29.9 +/- 10.8 months (range 6 to 48) the laser group showed a higher success rate than the Acucise group (85% vs 65%) but the difference in the complication and success rates was not statistically significant.

CONCLUSIONS

Despite the advanced endourological skills required for ureteroscopic laser endopyelotomy its safety and efficacy seem to be better than those of Acucise endopyelotomy. However, a larger number of patients is needed to confirm these findings.

Acucise endopyelotomy: A technique with limited efficacy for primary ureteropelvic junction obstruction in adults

AIM

To retrospectively evaluate the ef fi cacy of Acucise endopyelotomy in a series of patients with primary ureteropelvic junction obstruction (UPJO).

METHODS

Twenty-four patients with a symptomatic primary UPJO underwent Acucise endopyelotomy. Patients with high-grade hydronephrosis and/or poor renal function were excluded. Patients were followed by ultrasound imaging, intravenous urography, diuretic renography, and clinical review.

RESULTS

The overall success rate was 58% (14/24 patients), with a median follow up of 32 months. Of the ten patients in whom Acucise endopyelotomy failed, seven underwent open pyeloplasty, one required nephrectomy, and two received a permanent ureteral stent. A poor outcome was noted in patients without perioperative extravasation.

CONCLUSIONS

Our experience with Acucise endopyelotomy indicates that the success rate is lower than initially reported. Larger studies are needed to clarify the role of Acucise endopyelotomy in comparison with other techniques.

Ureteropelvic junction obstruction repair: when, how, what?

PURPOSE OF REVIEW

To review factors that affect the success of ureteropelvic junction obstruction repair and recent developments in minimally invasive procedures for the repair of ureteropelvic junction obstruction.

RECENT FINDINGS

Recent reports and studies further confirm earlier findings that the success rate of endopyelotomy is decreased when a crossing vessel is the primary cause of ureteropelvic junction obstruction, poor renal function and significant hydronephrosis. Various minimally invasive procedures have emerged recently for the treatment of ureteropelvic junction obstruction. These include laparoscopic pyeloplasty, robotically assisted laparoscopic procedures, and percutaneous endopyeloplasty. These procedures offer potential advantages over conventional endopyelotomy, including better success rates in the presence of crossing vessels, wider caliber reconstruction of the ureteropelvic junction, and full-thickness healing with primary intent.

SUMMARY

With such a large variety of minimally invasive procedures for the treatment of ureteropelvic junction obstruction available, the treatment choice for ureteropelvic junction obstruction must be based on several factors, including the success and morbidity of the procedures, the surgeon's experience, the cost of the procedure, and the patient's choice.

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.

Single-center comparison of laparoscopic pyeloplasty, Acucise endopyelotomy, and open pyeloplasty

PURPOSE

To compare Acucise endopyelotomy (Applied Medical, Irvine, California), laparoscopic pyeloplasty, and open pyeloplasty in the treatment of ureteropelvic junction (UPJ) obstruction.

PATIENTS AND METHODS

A retrospective review of all adult patients undergoing surgical correction of UPJ obstruction between December 1999 and August 2001 at Vanderbilt University Medical Center was performed. Patients undergoing UPJ correction with Acucise endopyelotomy (N = 9), laparoscopic pyeloplasty (N = 16), and open pyeloplasty (N = 7) were compared in regard to demographic information, operative data, recovery parameters, cost data, and outcome (as determined by diuretic renography, the Whitaker test, or both).

RESULTS

Success rates of 56%, 94%, and 86% were obtained for Acucise endopyelotomy, laparoscopic pyeloplasty, and open pyeloplasty, respectively. There were no differences between the Acucise endopyelotomy and laparoscopic pyeloplasty groups in age, American Society of Anesthesiology (ASA) score, length of follow-up, estimated blood loss (EBL), hospital stay, total hospital cost, or analgesic requirement. The Acucise patients demonstrated shorter operating times (1.7 v 3.3 hours; P < 0.001) and time to oral intake (7.9 v 16 hours; P = 0.008) than the laparoscopic pyeloplasty group. When the laparoscopic pyeloplasty patients were compared with the open pyeloplasty patients, there was no difference in operative time, EBL, time to oral intake, or total hospital costs. The laparoscopically treated patients demonstrated significantly lower analgesic requirements (27.2 v 124.2 mg of morphine sulfate equivalent; P = 0.02) and shorter hospital stays (1.4 v 3.0 days; P = 0.03) than the open surgery patients. The Acucise patients demonstrated shorter operative time (1.7 v 3.4 hours; P < 0.001), shorter hospital stay (1.3 v 3.0 days; P = 0.02), and lower analgesic requirement (22.4 v 124.2 mg of morphine sulfate equivalent; P = 0.02) than the open surgery patients.

CONCLUSIONS

Laparoscopic pyeloplasty achieves a success rate equal to that of open pyeloplasty while providing a recovery similar to that obtained with Acucise endopyelotomy and is gaining popularity as the treatment of choice for UPJ obstruction.

Ureteral access sheath facilitates inspection of incision of ureteropelvic junction

PURPOSE

The Acucise (Applied Medical, Rancho Santa Margarita, California) electrocautery balloon is a highly successful device used in managing congenital and secondary ureteropelvic junction obstruction. Correct orientation of the cutting wire is essential during insertion of the Acucise catheter to avoid injury to crossing vessels. Moreover, confirmation of the lateral ureteropelvic junction incision is typically verified by fluoroscopic identification of extravasated contrast material. We describe a technique of facilitated passage of the Acucise balloon through a ureteral access sheath followed by ureteroscopic visualization of the incision, affording the opportunity to improve the incision with the holmium laser if necessary.

MATERIALS AND METHODS

After retrograde pyelography and guidewire placement, a 12/14Fr, 35 cm. ureteral access sheath is fluoroscopically introduced to the proximal ureter. The Acucise balloon is advanced across the ureteropelvic junction and the balloon is partially inflated to confirm proper placement. Following lateral Acucise incision, flexible ureteroscopy allows direct visualization of the ureteropelvic junction, confirming a through-and-through incision. Completion of a partial incision can be performed if needed with a 200 micro holmium laser fiber followed by routine stent placement.

RESULTS

During the last 8 months we have used the Acucise device through a ureteral access sheath to treat congenital or secondary ureteropelvic junction obstruction in 8 patients. All incisions demonstrated extravasation of contrast material on retrograde pyelography, and 6 incisions (75%) were noted to be transmural by flexible ureteroscopic inspection. Two patients (25%) with only a partial incision despite contrast extravasation underwent extended incision using the holmium laser. Short-term followup demonstrated patency of the ureteropelvic junction in 7 of the 8 patients (87.5%) with 1 eventually requiring a secondary open pyeloplasty.

CONCLUSIONS

The ureteral access sheath greatly facilitates placement of the Acucise device and allows rapid ureteroscopic confirmation of the incision. Insertion and removal of the ureteral access sheath and flexible ureteroscope do not compromise or significantly increase the duration of the procedure. Moreover, flexible ureteroscopic visualization allows confirmation of a complete transmural incision and potentially increases success rates of this minimally invasive approach to ureteropelvic junction obstruction. Continued followup is necessary to confirm the long-term benefits of this procedure.

Treatment of iatrogenic postoperative ureteral strictures with Acucise endoureterotomy

OBJECTIVES

To determine factors influencing the outcome of Acucise endoureterotomy in patients with iatrogenic postoperative ureteral strictures after different open surgical procedures.

MATERIAL AND METHODS

Acucise endoureterotomy was performed in 18 patients with ureteral strictures after pyeloplasty (n = 5), renal transplantation (n = 5), ureteroenteric anastomosis (n = 3), calicoureterostomy (n = 1), ureterocystoneostomy (n = 1), hysterectomy (n = 1), ureterorenoscopy (n = 1) and transurethral resection of the ureteral orifice (n = 1). Success was determined as relief of clinical symptoms, improvement of renal function or improvement of radiographic findings.

RESULTS

The overall success rate was 61% (mean follow-up: 21.5 months). Six out of 18 patients showed relevant side effects. Neither the localization of the stricture nor the duration of postoperative ureteral stenting but the length of the stricture had influence on the postoperative outcome. Decreased renal function to less than 25% of the total function was always associated with failure of the treatment. The time period between the ureteral injury and the appearance of the ureteral stricture had influence on the outcome of the treatment.

CONCLUSIONS

Acucise endoureterotomy is effective in the treatment of postoperative ureteral strictures, but only in selected cases. The selection criteria are the time period from the primary operation to the appearance of the stricture (>6 months), the length of the stricture (<1.5 cm) and the renal function (>25% of the total function). In other cases, open surgical treatment of the ureteral stricture may provide better results.

Bioabsorbable SR-PLGA horn stent after antegrade endopyelotomy: a case report

PURPOSE

To evaluate the suitability of a bioabsorbable stent as a partial internal catheter after percutaneous endopyelotomy in ureteropelvic junction (UPJ) obstruction therapy.

PATIENT AND METHODS

The material for the helical spiral stents was a copolymer of polylactide and glycolide (PLGA; L:G ratio 80/20). The self-reinforcement (SR) was accomplished by heating and drawing by Bionx Implants Ltd, Tampere, Finland. The stents were horn shaped, with an initial outside diameter 6 to 3.0 mm +/- 0.2 mm and a length of 90 mm. The stent was partially degraded before insertion so it would degrade faster from the distal end, proceeding gradually to the proximal end. According to in vitro estimation, the degradation time of the material was 2 to 2.5 months. The railroaded cold-knife technique was used for antegrade endopyelotomy. After relief of the UPJ obstruction, the stent was pushed to the upper ureter.

RESULTS

The 37-year-old male patient had under open pyeloplasty 5 years previously. He had a pelvic stone 32 mm in diameter and tight restenosis of the UPJ. Percutaneous lithotripsy, incision of the stenosis, and application of the SR-PLGA helical horn-shaped spiral stent was without early or late complications. Eighteen months after the operation, retrograde pyelography showed the UPJ to be totally unobstructed.

CONCLUSIONS

The bioabsorbable horn-shaped SR-PLGA helical spiral stent proved a suitable alternative for stenting of the UPJ after antegrade endopyelotomy, bringing a reduced need for postoperative percutaneous kidney drainage and no need for subsequent stent removal. The bioabsorbable helical stent works as a partial catheter, which prevents vesicoureteral reflux and reduces the risk of postoperative renal infection.

The role of Acucise endopyelotomy in the treatment of ureteropelvic junction obstruction

OBJECTIVE

Open surgical pyeloplasty has been the gold standard for the correction of ureteropelvic junction obstruction (UPJO). Endourological management of UPJO has gained increased acceptance, with reported success rates of 57-87%. It has been suggested that Acucise endopyelotomy (AE) should be the procedure of choice for patients with UPJO. The aim of this study was to assess the effectiveness of AE in the treatment of UPJO and the factors contributing to surgical outcome.

MATERIALS AND METHODS

Forty-two patients (34 primary, 8 secondary UPJO) underwent AE between June 1995 and December 1999. Presenting symptoms were; pain 34 (80.9%), UTI 10 (23.8%) and haematuria 5 (11.9%). Preoperative evaluation included ultrasound and/or intravenous urogram with diuretic renography. Hydronephrosis was graded in 36 patients. Of these 4, 14, 9 and 9 had grade I, II, III and IV hydronephrosis, respectively. Twenty-four patients were stented prior to endopyelotomy and one required nephrostomy. Overall (true) success was defined as clinically pain free and radiologically no evidence of obstruction on diuretic scan.

RESULTS

The average operating time was 45 min and mean hospital stay was 2.7 days. Mean follow-up was 27 months (range 6-55). The objective success rate was 52% and the subjective success rate was 64%. A total of 19 patients (45.2%) had long lasting clinical and radiographic treatment success. Three (7%) patients required nephrectomy and five (12%) underwent open pyeloplasty. Success rate for grade I/II hydronephrosis was 55.5% and only 27.7% with grade III/IV hydronephrosis. Normal renograms were found in 12 (48%) of those with perioperative extravasation compared to three (25%) without. Only one of the eight patients with secondary UPJO had a normal post-operative renogram. Size or type of stent used had no effect on surgical outcome. The substandard results were noted in patients with grade III/IV hydronephrosis, poor pre-operative renal function, secondary UPJO and without perioperative extravasation.

CONCLUSIONS

Acucise endopyelotomy is a safe and minimally invasive procedure for the management of UPJO. Although the results of AE are suboptimal, its lower degree of invasiveness makes it reasonable choice for first-line treatment. Careful selection of patients will improve the results of AE, although multicentre randomized trials are needed to make a valued comparison with other techniques.

Laparoscopic dismembered pyeloplasty: 50 consecutive cases

OBJECTIVE

To test the hypothesis that laparoscopic dismembered pyeloplasty offers the same good results as open pyeloplasty, but without the disadvantages of the loin incision (which is painful, prolongs hospitalization and prevents a return to normal activities for several weeks) in the treatment of pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

Fifty consecutive consenting patients presenting with PUJ obstruction underwent laparoscopic dismembered pyeloplasty carried out by one surgeon using an extraperitoneal approach.

RESULTS

Two (4%) procedures were converted to open surgery. The mean (range) operative duration was 164 (120-240) min. Fifteen (30%) of the patients had their ureter transposed anterior to a crossing lower-pole vessel; 22 (44%) patients had a separate renal pelvic suture line. The mean (range) postoperative parenteral analgesic requirement was 19.1 (0-111) mg of morphine sulphate. The mean (range) hospitalization was 2.6 (2-7) days. Two (4%) patients had complications. After a mean (range) follow-up of 18.8 (3-72) months all but one patient, who had failed endopyelotomy, had a normal renogram and were symptom-free.

CONCLUSION

These results suggest that a loin wound is not necessary for a successful outcome after dismembered pyeloplasty, and that in expert hands laparoscopic dismembered pyeloplasty should now be considered the standard of care.

Endopyelotomy in the symptomatic older child

OBJECTIVE

To evaluate the results of endopyelotomy in children, an established method in adult practice as a treatment for pelvi-ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

Endopyelotomies undertaken between 1992 and 1999 by one surgeon in an established endourology unit were reviewed retrospectively. Children aged > 5 years presenting with pain and obstruction on isotope renography were selected for endopyelotomy. Patients with crossing vessels detectable on spiral computed tomography were treated by open pyeloplasty. Access to the renal pelvis was provided by a uroradiologist. Endopyelotomy was carried out through an Amplatz sheath of (median) 26 F. After applying traction to invaginate the PUJ an incision was made postero-laterally using electrocautery via an 11 F paediatric resectoscope. Stenting was maintained for 6 weeks. In all, 13 patients (median age 10 years, range 5-14) were treated; two had associated calculi.

RESULTS

The symptoms resolved and the obstruction was relieved in only six patients, with a median (range) follow-up of 50 (26-68) months. The seven patients in whom endopyelotomy failed, as indicated by persistent pain, proceeded to open pyeloplasty at a median (range) of 4 (1.3-79) months. Of these, two had presented with associated multiple calculi and significant hydronephrosis (one with an associated duplex system) and three had crossing lower pole vessels at open operation. One developed a urinoma after the original endopyelotomy and one had a retained stent fragment removed at the time of pyeloplasty.

CONCLUSIONS

Endopyelotomy in the symptomatic child requires a careful preoperative evaluation. Crossing lower pole vessels warrant an open pyeloplasty.

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.