Laparoscopic management of ureteropelvic junction obstruction in patients with upper urinary tract anomalies

PURPOSE: We report our experience with the laparoscopic management of ureteropelvic junction obstruction in patients with upper urinary tract abnormalities. MATERIALS AND METHODS: Between July 1994 and May 2002, 7 men and 4 women with upper urinary tract anatomical abnormalities were referred to our institution for management of symptomatic ureteropelvic junction obstruction. Anomalies included horseshoe kidneys in 5 cases, pelvic kidneys in 3, a pancake kidney in 1, a malrotated kidney in 1 and a duplicated collecting system in 1. Three patients had associated renal stones that were extracted during reconstruction. Mean patient age was 37.4 years (range 25 to 60). One patient had undergone a previously unsuccessful endopyelotomy and 2 had a history of abdominal surgery. RESULTS: Mean operative time was 195 minutes (range 85 to 403) and mean estimated blood loss was 122 cc (range 20 to 300). No patient in this series required transfusion. Average length of hospital stay was 3.2 days (range 2 to 5). Renal function failed to improve after surgery in 1 patient with poor renal function and severe hydronephrosis. The remaining 10 patients (91%) had durable clinical and/or radiographic success during a followup of 32.6 and 21.3 months, respectively. There were no major complications. CONCLUSIONS: Laparoscopic pyeloplasty is an effective treatment alternative for ureteropelvic junction obstruction associated with renal or urinary tract anomalies.     

Salmonella urinary tract infection associated with ureteropelvic junction obstruction

Although rare, urinary tract infections in children by salmonella species have been associated with a high incidence of structural anomalies. We report on a 5-year-old patient with Salmonella enteritidis urinary tract infection associated with ureteropelvic junction obstruction.     

Bilateral ureteropelvic junction obstructions in newborn identical twins

Identical twin black females were born with bilateral ureteropelvic junction obstructions. Dismembered pyeloplasties performed in the neonatal period have apparently been successful. Although a tendency for bilaterality is more frequently reported in early infancy, the authors are unaware of a similar occurrence reported in identical twins.     

Endoscopic management of ureteropelvic junction obstruction in children

A variety of endoscopic methods are available for managing ureteropelvic junction obstruction in children, and these methods can be considered for use in selected circumstances.     

Horseshoe kidney in an infant associated with ureteropelvic junction and ureterovesical junction obstructions

A 4-month old baby was seen in August, 1982 because of abdominal distension. The findings of the physical examination were normal except for a man's fist sized mass in the left upper abdomen. IVP revealed left nonvisualizing kidney. CT scans revealed a large mass in the left abdomen with low density contents and renal scintigraphy revealed a horseshoe kidney. The tentative diagnosis was horseshoe kidney associated with hydronephrosis due to ureteropelvic junction obstruction. Left pyeloplasty was performed in September 1982 and postoperative X-ray examinations revealed left ureterovesical junction obstruction. Left ureteroneocystostomy was performed in October, 1982 and postoperative course was uneventful. Horseshoe kidney in infants is rare in the Japanese literature and our case is quite unique in that horseshoe kidney is associated with ureteropelvic junction and ureterovesical junction obstruction.     

Surgical tactics in multiple obstructions of the urinary tract in children

One the basis of the results of surgical treatment of 84 children the authors identified 5 main groups of multiple obstructions: 1) obstruction of the vesicourethral segment in combination with obstructions of segments located above--37 (44.1%) patients; 2) unilateral obstruction of the ureterovesical and ureteropelvic segments--11 (13.1%) patients; 3) bilateral obstruction of the ureterovesical segments--19 (22.6%) patients; 4) bilateral obstruction of the ureteropelvic segments--11 (13.1%) patients; 5) other variants of obstructions of the ureterovesical and ureteropelvic segments--6 (7.1%) patients. It was established that urodynamic disorders conducive to the occurrence and progress of chronic pyelonephritis in multiple obstructions of the urinary tract in children are determined not only by the nature of congenital morphologic changes in the urodynamic segments, but by the features of their functions, interaction, and mutual influence, which should be taken into account in choosing the tactics of surgical intervention. In combination of obstruction in the vesicourethral segment, as well as in the ureterovesical segments, operative treatment should be started on the vesicourethral segment because urodynamics in the ureterovesical segments in children under 3 years of age may become normal without a surgical intervention on them. Correction of obstruction in the ureterovesical segment facilitates restoration of urodynamics in the ureteropelvic segment in unilateral obstructions, which determines the sequence of the operative intervention.     

Endopyeloureterotomy using the holmium:YAG laser for the management of adult ureteral and ureteropelvic junction obstructions

AIM: To determine the efficacy of endopyeloureterotomy using a holmium:YAG laser for the management of adult benign ureteral and ureteropelvic junction obstructions. PATIENTS AND METHODS: We reviewed the clinical outcomes of eight primary procedures performed in 5 patients. The causes of the strictures were idiopathic in five and stone impaction in three procedures. All strictures except one were approached in a retrograde fashion with either a rigid (8.0 Fr) or flexible (9.3 Fr) ureteroscope. The only energy source employed was the laser, and no balloon dilation was performed. In all cases, a 4.8-Fr ureteral stent was left indwelling, and retrograde ureteropyelography was performed within 6-8 weeks to remove the catheter. RESULTS: Follow-up was performed in all patients for a mean period of 14.9 (minimum 10) months. Two strictures in 1 patient failed to be stent free, while six strictures were patent on postoperative radiographic imaging. There were no perioperative complications. CONCLUSIONS: Endopyeloureterotomy using a holmium:YAG laser is safe and effective. Its relative noninvasiveness and its retrograde approach make it a first-line alternative for the management of benign upper urinary tract strictures in adults.     

The management of children with vesicoureteral reflux and ureteropelvic junction obstruction

We reviewed our management of children with vesicoureteral reflux and ureteropelvic junction obstruction in the same renal unit. Of the children who underwent pyeloplasty for ureteropelvic junction obstruction 9 per cent also had vesicoureteral reflux. These children were almost exclusively boys. Ureteropelvic junction obstruction was caused mostly by a stricture or fixed kinks of the upper ureter. Vesicoureteral reflux was primarily grade IV and was associated with abnormal morphology of the ureteral orifice. Pyeloplasty was the initial surgical correction and ureteral reimplantation was performed expectantly.     

A retrospective analysis of ureteropelvic junction obstructions in patients with horseshoe kidney

BackgroundUreteropelvic junction obstruction (UPJO) is often encountered in patients with a horseshoe kidney (HSK) and may require surgical intervention. This study retrospectively investigated obstruction causes in HSK patients with UPJOs to determine the most suitable surgical method.MethodsTwenty HSK patients with UPJO who underwent pyeloplasty between July 2000 and June 2020 and were followed-up for more than six months in our institution were included in the study. The clinical characteristics, obstruction causes, and surgical outcomes were analyzed.ResultsThe median age at the time of the operation was 4.1 years [interquartile range (IQR): 1.8–10.6]. Hydronephrosis (HN) was found prenatally in 5 patients (25.0%). Pyeloplasty was performed by open, laparoscopic, and robotic techniques in 6, 10, and 4 patients, respectively. Sixteen patients (80.0%) had high ureteral insertion. Twelve patients (60.0%) had crossing vessels, and eight had a high ureteral insertion and crossing vessels. The median follow-up duration was 4.0 years (IQR: 1.8–8.9); no patient required additional surgery. The median differential renal function was 38.0% (IQR: 16.9–43.0%) preoperatively and 38.0% (IQR: 13.3–48.2%) postoperatively.ConclusionsUPJOs in HSKs were primarily caused by a high ureteral insertion and crossing vessels. Dismembered pyeloplasty was successfully performed in all surgical modalities such as the open, laparoscopic, and robotic approaches. Attention must be given to patients with HSKs, even in those without HN, to avoid UPJO development.     

经皮顺行腔内切开术治疗肾盂输尿管连接部梗阻

目的:探讨应用经皮顺行腔内切开术(PAE)治疗肾盂输尿管连接部梗阻(UPJO)的适应症、疗效及技巧。方法:UPJO患者75例,其中肾盂输尿管连接部(UPJ)闭锁26例(34.7%)。男38例,女37例,平均年龄35(21～68)岁。左侧31例,右侧44例。原发性UPJO 39例(合并结石37例),开放UPJO成形术后8例,腹腔镜UPJO成形术后4例,开放手术取石术后14例,PCNL术后10例。均经B超、KUB、IVU、CT、逆行肾盂造影检查确诊。结果:Ⅰ期成功内切开69例(92.0%),4例(5.3%)间隔1周后Ⅱ期手术成功,2例放弃Ⅱ期治疗。单一应用PAE 59例(80.8%),PAE联合输尿管镜逆行内切开14例(19.2%)。术后3～6个月拔除输尿管支架管,随访6个月时,62例(84.9%)无复发,复发患者11例(15.1%)中包括UPJ闭锁患者10例。随访12个月时,55例(75.3%)无复发,24个月时52例(71.2%)无复发。21例复发患者中,9例行第二次PAE手术治愈,2例行第三次PAE手术后治愈,1例行开放肾盂成形术,9例每3～6个月更换双J管或动态观察。结论:PAE可以作为原发性UPJO的一线治疗。继发性UPJO或其他成形术后再狭窄的UPJO复发率高,但是PAE适用范围广,可重复性好,仍然是微创腔内治疗的有效手段。     

Endoureteropyelotomy: percutaneous treatment of ureteropelvic junction obstruction

A total of 47 percutaneous operations (endoureteropyelotomy) was performed for treatment of 41 congenital and 6 secondary cases of ureteropelvic junction obstruction between September 1983 and April 1988. Evaluation was available in 39 cases with a followup of 4 to 56 months (mean 16 months). Good results were obtained in 28 of 39 cases (72 per cent) and there were 3 failures (8 per cent). Eight patients (20 per cent) were symptomatically improved but they had residual obstruction on a diuretic study. Only 1 multioperated patient with a good early postoperative result has shown radiological deterioration at 1 year. Complications were managed conservatively, except for 1 case of intravascular coagulopathy. Endoureteropyelotomy is an effective alternative treatment for ureteropelvic junction obstruction but further evaluation definitely is warranted to define better its indications and risk factors.     

Fistulas of the upper urinary tract: percutaneous management

We treated 40 patients with urinary fistulas by interventional radiology. The antegrade percutaneous route, catheterization of the ureter and bypassing of the fistula enabled ureteral stenting in 36 patients (90 per cent). Criteria for successful treatment were healing of the fistula, normal renal function (evaluated by excretory urography and radionuclide studies) and absence of secondary stenosis at 6 months. Of the patients 28 (70 per cent) were treated successfully. The number of nephrectomies after failure of percutaneous techniques (5 of 40, or 12.5 per cent) seems lower than in the case of surgery. The results were excellent for fistulas occurring after endourology (all 9 successful) or after ureterointestinal anastomoses (7 of 8). On the other hand, the results appear disappointing in patients with fistulas in transplanted kidneys (3 of 4 failures).     

Surgical options in the management of ureteropelvic junction obstruction

Ureteropelvic junction obstruction (UPJO) is a common cause of upper urinary tract obstruction that can be clinically silent or lead to symptoms such as pain, chronic urinary tract infections, and urinary stone disease. UPJO does not always mandate treatment, but when an indication for correction is present, there are several minimally invasive surgical options available. Surgical reconstruction represents the gold-standard treatment for UPJO, although endoscopic pyelotomy is a well established and efficacious alternative.