重复肾合并肾盂输尿管连接部梗阻的诊治特点分析

目的 探讨重复肾畸形合并肾盂输尿管连接部梗阻的诊治特点.方法 1993-2010年共收治肾盂输尿管连接部梗阻患者752例,伴重复肾畸形18例(2.4%).男7例,女11例.平均年龄23(1～47)岁.18例患者均行泌尿系B超检查,15例行泌尿系增强CT检查,11例行IVU检查,10例行逆行造影检查.完全性重复肾畸形3例,不完全性15例;梗阻发生在左侧11例,右侧7例,重复肾肾上极5例,下极13例.结果 18例患者行手术治疗16例,其中肾盂输尿管成形术9例,重复肾半肾切除术7例.术后病理报告示肾盂输尿管连接部肌层结构紊乱,间质内炎症细胞浸润.18例患者平均随访24(6～36)个月.16例手术者症状消失,泌尿系B超及IVU影像学评估肾积水情况明显缓解,SCr水平稳定,肾功能无恶化;2例观察随访者肾积水无加重,肾功能正常.结论重复肾畸形合并肾盂输尿管连接部梗阻临床少见,梗阻多发生于重复肾下极,确诊需结合多种影像学检查手段.膀胱输尿管逆行造影的特异性高,对于疑难病例具有重要意义.手术仍是主要的治疗手段,应根据分肾及半肾功能选择手术方案.

Abstract：

Objective To evaluate the clinical features and treatment of pelvi-ureteric junction obstruction (PUJO) in a duplex kidney. Methods From 1993 to 2010, 752 patients were diagnosed as PUJO in our hospital and 18 patients (2.4%) with PUJO in duplex kidneys. Three patients had obstruction in the complete duplicated systems and 15 in the incomplete duplicated systems. Five patients had obstruction of the upper moiety and 13 of the lower moiety. All of the 18 patients underwent B-ultrasonography, with 15 enhanced CT scan, 11 intravenous urography and 10 retrograde pyelography.All patients had serum creatinine test after admission and during the follow-up. Results Sixteen patients underwent operations and 2 patients were treated conservatively. Nine patients underwent pyeloplasty and 7 patients underwent heminephroureterectomy. Pathology shows derangement of the lamina muscularis at pelvi-ureteric junction and infiltration of inflammatory cells in mesenchymal. They were followed up from 6 months to 3 years with a mean of 24 months. The clinical symptoms of patients who underwent surgery were cured in all cases. B-ultrasound and IVU showed that hydronephrosis was obviously relieved and the levels of serum creatinine remained the same or decreased. The hydronephrosis and serum creatinine of patients who underwent conservative treatment remained stabilized. Conclusions PUJO in duplicated system is a rare condition. Careful preoperative evaluation is needed to reach the final diagnosis and retrograde pyelography has high specificity. Treatment should be individualized according to split and partial renal function.     

Urological emergency in neonates with congenital hydronephrosis

OBJECTIVE: It is well described that unilateral pelviureteric junction obstruction (PUJO) is a benign condition, because the dilatation resolves spontaneously and the function does not decrease in most of the kidneys. However, there is exceptional PUJO that requires emergent treatment in neonatal periods. The aim of this article is to report the urological emergency and management in neonates with PUJO. MATERIALS AND METHODS: Nine children (seven boys and two girls) with PUJO who underwent neonatal emergent treatment during the last 13 years were reviewed. Renal function was evaluated according to decay curve of serum creatinine (SCr) levels corresponding to gestational age (GA) at delivery. Physical examination, ultrasonographic monitoring, and chest and abdominal plain radiographs were repeated in each neonate. RESULTS: Eight patients were detected prenatally. In five patients, multicystic dysplastic kidney (MCDK) was demonstrated on the contralateral side. Three patients underwent percutaneous puncture of fetal hydronephrosis. Decrease of amniotic fluid was evident in three fetuses. Indications for emergent treatment included mass effect from hydronephrosis in three patients, renal dysfunction in five, and severe urinary tract infection in one. During neonatal periods, a percutaneous nephrostomy tube was placed in seven, and open nephrostomy in one with anorectal malformation. Repeated punctures of the dilated renal pelvis were done in one patient. Renal function after pyeloplasty was stable in eight patients, while it was moderately decreased in one who was associated with oligohydramnios in utero. CONCLUSION: Indications for emergent treatment in neonates with PUJO included mass effect from giant hydronephrosis, renal dysfunction and severe urinary tract infection. At birth, respiratory and circulatory conditions must first be stabilized. In neonates with hydronephrosis of the solitary kidney or severe bilateral PUJO, serial SCr should be monitored to evaluate renal function. Decrease of amniotic fluid suggested renal functional compromise that would not recover after urological management.     

Magnetic resonance imaging in the evaluation of pelvi-ureteric junction obstruction: an all-in-one approach

OBJECTIVE: To study the ability of comprehensive magnetic resonance imaging (MRI) to replace multiple imaging methods in the evaluation of patients with pelvi-ureteric junction obstruction (PUJO). PATIENTS AND METHODS: Between May 2003 and November 2005, 46 consecutive patients (22 male and 24 females; mean age 31.6 years) with symptomatic primary PUJO were included. All had comprehensive MRI, including MR urography (MRU), dynamic MRI and MR angiography (MRA). Morphological results of MRU were compared with that of renal ultrasonography or intravenous urography, while the anatomical results of MRA were compared with the operative findings. A correlation between MR clearance and radioisotope clearance was done using linear regression analysis. RESULTS: MRU showed the morphology of the collecting system in all patients, and the ureter below the PUJ in 31 of 46 (67%), but renal stones were missed in three of 10 patients. MRA showed crossing vessels in 22 patients (48%). There was a strong correlation between MR clearance and radioisotope clearance (r = 0.823, P < 0.001). From the MRI results, 35 patients (19 with crossing vessels and 16 with marked hydronephrosis) had pyeloplasty and 11 had an endopyelotomy. Findings during pyeloplasty showed one false-negative and one false-positive result of the preoperative MRI. Therefore, the sensitivity, specificity and accuracy of MRA were 95%, 94% and 94%, respectively. The outcome was successful in 44 (96%) patients. One failure after pyeloplasty was managed with endopyelotomy and the other was treated with pyeloplasty after endopyelotomy. CONCLUSION: Comprehensive MRI is a valuable and accurate single-imaging method for evaluating patients with PUJO.     

Concomitant management of renal calculi and pelvi-ureteric junction obstruction with robotic laparoscopic surgery

OBJECTIVE: To present technical recommendations for robotic-assisted laparoscopic pyeloplasty (RALP) and stone extraction, as patients with kidney stones proximal to a pelvi-ureteric junction obstruction (PUJO) present a technical challenge, and have traditionally been managed with open surgery or percutaneous antegrade endopyelotomy. PATIENTS AND METHODS: From November 2002 to April 2005, 55 patients had RALP for PUJO; eight of these had concomitant renal calculi. Stone burden and location were assessed with a preoperative radiological examination. Before completing the PUJO repair, one robot working arm (cephalad one) was temporarily undocked to allow passage of a flexible nephroscope into the renal pelvis and collecting systems under direct vision. Stones were extracted with graspers or basket catheters and removed via the port. The surgical-assistant port in the subxiphoid area was used to introduce laparoscopic suction and other instruments. RESULTS: The Anderson-Hynes dismembered pyeloplasty was the preferred reconstructive technique in all patients. Operations were completed robotically with no conversions to open surgery. All patients were rendered stone-free, confirmed by imaging, and there were no intraoperative or delayed complications during a mean (range) follow-up of 12.3 (4-22) months. The mean operative time was 275.8 min, 61.7 min longer than in patients who did not have concomitant stone removal. CONCLUSIONS: Concurrent stone extraction and PUJO repair can be successful with RALP. Operative times are longer than in patients with isolated PUJO repair, but this is to be expected as there is an additional procedure.     

肾盂输尿管成形术及其辅助治疗

目的：探讨肾盂输尿管连接部（UPJ）梗阻的最佳治疗方法。方法报告63例（70例）UPJ梗阻的治疗情况,48侧行Anderson-Hynes肾盂成形术,其中8例巨大及重度肾积水者加作肾内翻折叠及肾固定术,6例行肾盂瓣输尿管成形术,5侧行Y－V成形术,11例行肾切除术,全部病例均放置输尿管支架引流,其中11例患儿应改良式双J管内引流。结果。48侧行Anderson-Hytes肾盂成形术者术后复查IVU显示肾盂明显缩小,肾功能改善,UPJ处蠕动良好,1例吻合口处狭窄,扩张后再次放置双J管8周后治愈。6侧行肾盂瓣成形术及5侧行Y－V成形术者术后复查肾积水有改善,但肾盂缩小不明显,UPJ处蠕动幅度、频率改善不明显。11侧应用改良双J管的患儿术后4周门诊拔管,均获治愈。停顿上以往外引流的18－20d缩短至6－7d.51例随访6个月5－年,1例吻合口处狭窄者扩张置管后治愈,余无复发。结论Anderson-Hynes肾盂成形术为最佳术式。巨大肾积水者行Anderson-Hynes肾盂成形术加肾内翻折叠及肾固定术不仅改善外观,更利于引流及功能恢复,改良式双J管可用于儿童患者内引流。     

Laparoskopische Nierenbeckenplastik bei komplizierter Doppelniere

Laparoscopic pyeloplasty has been established as an effective and minimally invasive technique for treating ureteropelvic junction obstruction. Only case reports are available describing the use of laparoscopic pyeloplasty in patients with duplicated collecting systems. We report the case of a patient presenting with a short stenotic connection between the hydronephrotic lower pole system and a solitary ureter coming from the upper pole. In this patient, a side-to-side anastomosis between the renal pelvis and the ureter was successfully performed. The present data demonstrate that laparoscopic pyeloplasty is an applicable tool even in patients with upper urinary tract anomalies such as duplicated collecting systems.     

Laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction in patients with horseshoe kidneys: technique and 1-year follow-up

OBJECTIVE: To report our experience with laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction (PUJO) in patients with horseshoe kidneys. PATIENTS AND METHODS: Between January 2002 and May 2003, two men and a woman with horseshoe kidneys (mean age 44.6 years) had laparoscopic dismembered pyeloplasty with robotic assistance for PUJO with no division of the isthmus. Two patients had renal stones which were extracted during surgery. None of the patients had had previous abdominal surgery. RESULTS: The mean operative duration was 148.3 min, the mean estimated blood loss was <100 mL and the mean hospital stay was 7.6 days. Renal function was preserved in all three patients during the immediate and long-term follow-up as measured by intravenous urography. The three patients had durable clinical and radiographic success during a mean follow-up of 21 months. One patient needed complementary extracorporeal shockwave lithotripsy, and one had an episode of pyelonephritis, which was treated successfully. There were no other significant complications before or after surgery. CONCLUSION: Laparoscopic robotic-assisted pyeloplasty for horseshoe kidney is safe and feasible, offering the advantages of minimally invasive surgical procedures with enhanced laparoscopic skills related to the use of the robot.     

Pelvi-ureteric junction obstruction in children: the role of urinary transforming growth factor-beta and epidermal growth factor

OBJECTIVES: To investigate the role of transforming growth factor beta(1) (TGF-beta(1)) and epidermal growth factor (EGF) in voided urine for the diagnosis and follow-up of children with pelvi-ureteric junction obstruction (PUJO). PATIENTS, SUBJECTS AND METHODS: The study included 35 children with unilateral PUJO who had a pyeloplasty, and 30 healthy control children. Urine samples were obtained from the bladders of patients before surgery, and as voided samples at 1, 2, 3, 6, 9 and 12 months after surgery. Bladder urine samples were also collected from all 30 children in the control group. TGF-beta(1) and EGF were then measured in all the urine samples. RESULTS: The level of bladder TGF-beta(1) before surgery in the patients was significantly higher than that in the healthy control group. A threshold of 190 pg/mg creatinine gave a sensitivity of 100%, a specificity of 80%, a positive predictive value of 85.4%, negative predictive value of 100% and an overall accuracy of 90.8%. Compared with the value before surgery, urinary TGF-beta(1) was significantly lower at 1 year after pyeloplasty. There was no significant difference between the level of EGF before surgery in the patients and that in the control group, and no significant difference in the level of EGF before and after surgery over the follow-up. CONCLUSION: We do not recommend using EGF levels in voided urine in the routine diagnosis of children with hydronephrosis. The urinary level of TGF-beta(1) is a useful noninvasive tool for the long-term follow-up of children with PUJO treated by pyeloplasty. Further studies with various controls are required to confirm the diagnostic accuracy of TGF-beta(1) in children with PUJO.     

Minimal invasive approach for lower pole uretero-pelvic junction obstruction (UPJO) in duplication anomaly: A multi-institutional study

Purpose: We present a multi-institution experience of laparoscopic and robotic-assisted reconstruction approach of lower-pole UPJO (ureteropelvic junction obstruction) in duplicated collecting systems.Methods: Retrospective review of patients who underwent laparoscopic or robotic pyeloplasty for lower pole UPJO between 2011 and 2020. Patient demographics, perioperative surgical data, complications and outcomes are described.Surgical approach was adjusted to the anatomic variant.Success was defined as improved hydronephrosis, indicated by improved Society of Fetal Urology classification at 9 months follow up.Results: Forty-one patients underwent MIS reconstruction surgery of lower pole UPJO (38- laparoscopy, 3- robot assisted). Median age at surgery was 13 months (IQR, 5–32). Mean operative time was 80 min (IQR, 70–110). There were no intraoperative complications, no conversions and estimated blood loss was negligible.Lower pole dismembered pyeloplasty was performed in 19 (46%) patients, uretero-pyelostomy (lower pole pelvis to upper pole ureter) in 15 (36.5%), concomitant obstruction of the upper pole moiety was encountered in 4 (10%) patients; lower pole dismembered pyeloplasty and upper pole ureter to lower pole pelvis (end-to-side uretero-pyelostomy) was performed and concomitant ipsilateral upper pole partial nephrectomy was carried out in 3 (7%) patients.Overall, 3 patients had grade 1 or 2 Clavien-Dindo postoperative complications and one patient developed a grade 3 complication.Surgical success was achieved in 38/41 (93%), 3 patients required an additional procedure.Conclusions: UPJO of lower pole of duplication anomaly is highly variable anatomically; therefore, an individualized surgical approach is mandatory. The minimal invasive approach is feasible and safe with good outcomes.     

The change in renal function in the supranormal hydronephrotic kidney after pyeloplasty

OBJECTIVE: To investigate changes in the differential renal function (DRF) before and after pyeloplasty in renal units with unilateral pelvi-ureteric junction obstruction (PUJO) with supranormal function, and to evaluate the clinical significance. PATIENTS AND METHODS: We reviewed the medical and radiographic records of 29 children (26 boys and three girls) with unilateral PUJO with a DRF (estimated by (99m)Tc-mercaptoacetyltriglycine renal scintigraphy) of >/= 50% in the affected renal unit, who had pyeloplasty and were followed for >1 year after surgery. Patients were divided into two groups according to the degree of change in their DRF to compare the clinical variables, anteroposterior pelvic diameter and parenchymal thickness measured by renal ultrasonography. The mean (range) follow-up after pyeloplasty was 35 (12-89) months. RESULTS: After pyeloplasty, although the mean DRF reduced from 53.8% to 51.4%, in seven (24%) patients the DRF decreased significantly (>5%) while most (76%) showed a change of /= 55% before surgery, the DRF afterward was >55% in four and 50-55% in one. Between those with and with no significant reduction in DRF, only the preoperative renal parenchymal thickness differed significantly (2.78 vs 5.00 mm, P = 0.006). CONCLUSION: Supranormal DRF exists and represents the true split function of the affected renal unit in patients with adequate renal parenchyma; these units maintained the supranormal function after pyeloplasty. Parenchymal thickness might be useful to differentiate between the true and false estimates and predict surgical outcome before surgery.     

不同术式治疗肾盂输尿管连接部梗阻63例报告

目的　探讨肾盂输尿管连接部梗阻的最佳治疗方案。　方法　报告 6 3例 (70侧 )肾盂输尿管连接部梗阻的治疗 ,48侧行Anderson -Hynes肾盂成形术 ,6侧行肾盂瓣输尿管成形成 ,5侧行Y -V成形术 ,11例行肾切除术。 8例巨大及重度肾积水病人在A -H肾盂成形术基础上加肾内翻折叠及肾固定术 ,全部病例均放置输尿管支架引流。 11例患儿应用改良式双J管内引流。　结果　 5 1例随访 6个月～ 5年 ,均治愈。　结论　A -H肾盂成形术为最佳术式 :巨大肾积水A -H肾盂成形术加肾内翻折叠及肾固定术不仅改善外观 ,更利于引流及功能的恢复。改良后的双J管也可用于儿童患者内引流     

Pediatric laparoscopic pyeloplasty: 4-year experience

BACKGROUND AND OBJECTIVE: Laparoscopic dismembered pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in the pediatric population is comparable to open dismembered pyeloplasty in success rates. Experience with this procedure however remains limited. We review our experience with this technique. PATIENTS AND METHODS: The hospital records of consecutive patients undergoing surgery for UPJO between May 2001 and May 2005 were reviewed. Only those who underwent laparoscopic pyeloplasty for single system UPJO were included in the study. Indications for surgical correction were T(1/2) > or = 20 minutes by diethylene triamine pentaacetic acid Lasix renography or symptomatology with hydronephrosis seen on renal ultrasonography (US). RESULTS: Fifty-nine patients were identified, all of whom were treated surgically for salvageable UPJO. Four underwent percutaneous endopyelotomy for concomitant urolithiasis, 27 underwent open dismembered pyeloplasty (parent choice or under 18 months of age), and 28 underwent laparoscopic dismembered pyeloplasty. One patient had bilateral laparoscopic repairs at different times, resulting in 29 renal units that were reconstructed laparoscopically. Of these, 28 were completed. Eighteen procedures were performed on boys and 11 on girls. The mean age was 8.1 (1.6-18.9) years. The mean operating room time was 255 (157-396) minutes. Estimated blood loss was <10 mL in every patient. One patient required hospitalization longer than 23 hours because of postoperative ileus. A retroperitoneal urinoma developed in another patient, despite having a ureteral stent; it resolved with urethral catheter drainage. The first laparoscopic pyeloplasty resulted in open conversion because of failure of progression of the ureteropelvic anastomosis. At a mean follow-up of 27.9 (7.6-58.0) months, all patients demonstrated improvement of symptoms and drainage on nuclear renography or a decrease in the grade of hydronephrosis on renal US. CONCLUSION: Our series of patients undergoing laparoscopic pyeloplasty had excellent results with low morbidity. We consider this our primary technique for surgical correction of UPJO in patients older than 18 months.     

How successful is the conservative management of pelvi‐ureteric junction obstruction in adults?

OBJECTIVE

To assess the conservative management of pelvi‐ureteric junction obstruction (PUJO), according to severity, accepted in paediatric urology but rarely reported in adults.

PATIENTS AND METHODS

A series of 23 patients (median age 58 years, 17 men and six women) with asymptomatic or minimally symptomatic PUJO were managed conservatively. The patients’ age, preference and comorbidities were considered. The diagnosis of PUJO was based on intravenous urography and isotopic renography. After stringently reviewing the renograms based on relative renal function (RRF) and output efficiency (OE), 15 patients had an OE consistent with definitive PUJO. One patient had no further imaging due to associated comorbidities. Ten patients had right PUJO, three left and one with bilateral PUJO, with unilateral conservative management. The follow‐up included annual renography and clinical consultation. Laparoscopic pyeloplasty was considered for patients with a >10% loss of RRF and/or <40% RRF during the follow‐up.

RESULTS

Overall, 14 of 15 patients had renograms during the follow‐up. The mean RRF of the affected kidney at diagnosis was 48.6% which marginally decreased to 46.7% after a median (range) follow‐up of 44 (23–75) months. The RRF of 11 patients remained stable and in three decreased significantly (median 11% RRF), requiring pyeloplasty. None of the patients became symptomatic throughout the follow‐up.

CONCLUSION

In asymptomatic adults the conservative management of PUJO appears to be safe during a short‐ to medium‐term follow‐up. We recommend that patients are regularly followed with renography and seen promptly should they become symptomatic. A longer follow‐up is needed in a larger group to confirm these findings.     

Our experience with retroperitoneal and transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction obstruction

OBJECTIVE: Laparoscopic dismembered pyeloplasty has been quoted to have equivalent success rates to the traditional open procedure in the treatment of pelvi-ureteric junction obstruction (PUJO). The aim of this study was to report our experience with laparoscopic pyeloplasty. PATIENTS AND METHODS: All patients with PUJO are entered into a database to record patient, operative and post-operative details. Over an eleven-year period, 176 procedures were performed. Eighty-three procedures were dismembered laparoscopic pyeloplasties, of which two retroperitoneal procedures were converted to open. The first 17 procedures were performed via the retroperitoneal approach and the following 66 via the transperitoneal route. Thirty-one procedures were open pyeloplasty. RESULTS: The retroperitoneal group had a mean follow up of 35 (16-66) months. Five patients (33%) developed recurrent symptoms with evidence of obstruction seen on the renogram within 4 months and required further surgery. The transperitoneal group had a mean follow up of 15 (3-38) months. Five patients were classified as failures (mean time to failure 4.6 months) resulting in a success rate of 92% for the transperitoneal route. Both groups had a mean post-operative hospital stay of 3.6 days. Open pyeloplasty at our institution has a success rate of 88% at a mean follow up of 85 months (range 3-260 months) and a mean length of post-operative stay of 6 days. CONCLUSION: Overall our success rate following laparoscopic pyeloplasty is 88%. However, our preferred approach is transperitoneal, which is associated with a success rate of 92%. This is equivalent, if not better than that seen following open pyeloplasty with the additional benefits of reduced hospital stay and time to recovery. There are many possible explanations for this difference in success rates between approaches, however equivalent results are reported in the literature and therefore the learning curve is likely to be the major factor in this series.     

Dismembered pyeloplasty in children: A review of 5 years single center experience

AIM: Dismembered pyeloplasty is the treatment of choice for significant ureteropelvic junction obstruction in children. In the present study, we review our experience in 103 pediatric patients and present the clinical characteristics, the surgical treatment and its complications and the long term results. METHODS: We have reviewed the medical charts of 103 consecutive patients who underwent dismembered pyeloplasty in a 5-year period, from 1997 to 2002. Preoperative data, short- and long-term complications and outcome were recorded. Imaging studies included urinary tract sonography and dynamic renal scans, the results of which were compared pre- and postoperatively. RESULTS: Most of our patients were boys (81%), diagnosed prenatally (78%). We had no major complications and acceptable incidence of minor complications. Postoperative outcome was excellent, with decreased hydronephrosis (81%), improved renal drainage (87%) and preserved or improved renal function (89%). CONCLUSION: Dismembered pyeloplasty can be performed with a low incidence of minor complications, no major complications and excellent long-term outcome.     

Elastin content of the renal pelvis and ureter determines post-pyeloplasty recovery

PURPOSE: We evaluated the collagen-to-smooth muscle tissue matrix ratio and percentage of elastin in the renal pelvis, ureteropelvic junction (UPJ) and ureter, and compared these findings with the degree of obstruction, patient age and post-pyeloplasty renal recovery. MATERIALS AND METHODS: We analyzed histological sections from 75 patients with UPJ obstruction. Nine patients were excluded owing to bilateral UPJ obstruction and an improper specimen. We divided the specimen obtained from pyeloplasty into 3 parts, namely the renal pelvis above the obstruction, the obstructed UPJ portion and the ureter below the obstruction. To examine the collagen and smooth muscle, sections were stained using Masson's trichrome, and elastic van Giesson stain was used for elastin, smooth muscle and collagen. Collagen, smooth muscle and elastin populations were identified, and the tissue matrix ratio and percentage of elastin were calculated by color image analysis. RESULTS: In patients with lower ratios of collagen-to-smooth muscle in the UPJ proper hydronephrosis was more improved postoperatively (p = 0.049). In patients with a lower percentage of elastin in the renal pelvis, UPJ and ureter hydronephrosis was more improved postoperatively (p <0.0001). CONCLUSIONS: Because the UPJ portion was resected during pyeloplasty, the renal pelvis and the ureter remaining after pyeloplasty are likely to be related to improved hydronephrosis. A higher percentage of elastin in the renal pelvis and ureter contributes to inelasticity and low compliance, and results in a slower recovery from hydronephrosis after pyeloplasty.     

Robotic Anderson-Hynes pyeloplasty: 5-year experience of one centre

OBJECTIVE: To present our 5-year experience with robotically assisted laparoscopic pyeloplasty (RALP), as LP has been shown to have similar success rates as open surgery, but standard LP requires high operative skills and a correspondingly long period of training, limiting its widespread availability, and RALP is easier and quicker to learn due to facilitated intracorporeal suturing. PATIENTS AND METHODS: In all, 92 patients had transperitoneal RALP for pelvi-ureteric junction obstruction (PUJO) using the daVinci system (Intuitive Surgical, Sunnyvale, CA, USA). A transperitoneal dismembered Anderson-Hynes procedure was used in all cases. Three robotic ports and one assistant port were used in all cases while a JJ stent was left indwelling for 6 weeks. Both primary PUJO (including horseshoe kidneys in 80 cases) and secondary (in 12 cases) were considered eligible. The follow-up included ultrasonography, excretory urography and renal scintigraphy. RESULTS: The mean follow-up was 39.1 months; PUJO was successfully resolved in 89 patients (96.7%) while three required additional procedures. Haemorrhage into the collecting system and urine extravasation occurring early after surgery were the causes of failure. The mean (range) operative duration, including the set-up of the robot, was 108.34 (72-215) min; the mean duration of docking and surgery significantly decreased with experience (P < 0.001). The mean hospital stay was 4.57 days. Split renal function improved from 37.6% to 41.9%. No cases of secondary PUJO were recorded during extended follow-up. CONCLUSIONS: RALP using the daVinci system is safe and effective, achieving similar long-term success rates to open surgery. The three-dimensional versatility of the robot enables the surgeon to recapitulate the open procedure. The results were durable with no cases of late complications, corroborating the accuracy of robot-assisted intracorporeal suturing and the subsequent quality of the pelvi-ureteric anastomosis. Moreover, the robotic approach was easy and quick to learn for both the surgical and the technical staff. Therefore, RALP is our preferred technique to treat PUJO.     

Doppelniere mit Nierenbeckenabgangsstenose im Kindesalter

Laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction (UPJO) in children is still one of the most demanding operations in urology. We report on a 12-year-old boy with UPJO in a duplicated collecting system with high ureter fissus. He was admitted with a 1-year history of recurrent flank pain and dilation of the lower duplicated collecting system. We performed a retroperitoneoscopic Anderson-Hynes pyeloplasty.     

Renal pelvis cuff pyeloplasty for ureteropelvic junction obstruction for the high inserting ureter: an initial experience

PURPOSE: Ureteropelvic junction (UPJ) obstruction can result from a high inserting ureter without intrinsic ureteral obstruction. We describe our initial experience using a renal pelvis cuff pyeloplasty technique to treat this cause of UPJ obstruction. MATERIALS AND METHODS: We reviewed our experience regarding all children who underwent renal pelvis cuff pyeloplasty. All patients had Society for Fetal Urology grade 3 to 4 hydronephrosis on ultrasonography and radiographic confirmation of UPJ obstruction by diuretic mercaptoacetyltriglycine renography. Pyeloplasty was performed through a flank incision. A circumferential incision was made of the renal pelvis proximal to the insertion site of the ureter into the renal pelvis. Next, a catheter was passed through the UPJ to ensure uniform patency. The cuff of pelvis with the attached ureter was then sutured to the dependent portion of the pelvis. Postoperative resolution of the obstruction was evaluated by ultrasonography and mercaptoacetyltriglycine renography. RESULTS: A total of 11 children (6 boys and 5 girls) underwent renal cuff pyeloplasty for UPJ obstruction due to a high inserting ureter. Median patient age was 6 months (range 2.5 months to 2.4 years) and median followup was 11 months (8 months to 3.4 years). All patients were discharged home within 2 days postoperatively. No intraoperative or postoperative complications were noted. All patients exhibited resolution of UPJ obstruction on followup radiographs. CONCLUSIONS: Renal pelvis cuff pyeloplasty is a surgical technique for UPJ obstruction resulting from a high inserting ureter without intrinsic ureteral obstruction. The procedure was straightforward with good results and without complications in this initial experience.     

小儿后腹腔镜下离断性肾盂成形术

目的 探讨小儿后腹腔镜下离断性肾盂成形术的临床效果.方法 肾盂输尿管连接部梗阻(UPJO)患儿24例.平均年龄7(3～14)岁.经B超、IVU、CT,磁共振水成像检查临床确诊,轻度肾积水4例、中度10例、重度10例.均采用后腹腔镜下离断性肾盂成形术治疗.结果 24例手术均获成功,无中转开放手术.手术时间平均180(150～200)min,出血量平均60(40～100)ml,术后住院平均7(5～9)d.随访平均14(6～24)个月,吻合口无狭窄,肾积水消失18例,肾积水明显减轻6例.结论 后腹腔镜下离断性肾盂成形术治疗小儿 UPJO安全、有效,可以替代开放手术.