Robotic management of complicated ureteropelvic junction obstruction

Purpose  

To assess the feasibility and outcomes of robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO).     

Surgical management of ureteropelvic junction obstruction in adults

Ureteropelvic junction (UPJ) obstruction is a well-recognized entity that may present at any time - in fetal life, infancy, childhood, or early or late adulthood. As the most common site of obstruction in the upper urinary tract, the UPJ is an area with which urologists should be well familiar. There has been an improved understanding of the pathophysiology of primary congenital UPJ obstruction that has been reflected in the evolution of surgical options, from open surgical repair to minimally invasive surgery. Although the primary scope of this review is the surgical management of this condition, we will briefly review the pathogenesis, clinical presentation, and diagnosis of UPJ obstruction.     

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.     

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.     

Results of selective management of ureteropelvic junction obstruction

BACKGROUND AND PURPOSE: Controversy continues over the need to image the ureteropelvic junction (UPJ) before endopyelotomy to detect crossing vessels. We evaluated a selective management model for UPJ obstruction. PATIENTS AND METHODS: Intraoperative ultrasonography was performed before endopyelotomy in 19 men and 16 women. Patients with large (>4-mm) crossing vessels underwent open or laparoscopic pyeloplasty; the others had ureteroscopic or percutaneous endopyelotomy with electrocautery or the holmium laser. RESULTS: Crossing vessels were found in 25 of the 35 patients and a high-inserting ureter in 4. The vessels were >4 mm in nine patients, seven of whom had successful pyeloplasty and two of whom were managed expectantly with good results. Endopyelotomy was successful in 94% without a crossing vessel and 70% of those with a crossing vessel. The overall success rate (absence of symptom and resolution of obstruction on renal scintigraphy) was 89%. CONCLUSION: Selective management of UPJ obstruction, avoiding endopyelotomy in the presence of a large crossing vessel, appears to improve the success rate.     

金属网状支架在继发性肾盂输尿管连接部梗阻中的应用

目的　总结应用金属网状支架治疗继发性肾盂输尿管连接部梗阻的临床疗效。　方法　回顾性分析 1 3例应用金属网状支架治疗继发性肾盂输尿管连接部梗阻患者资料。男 1 0例 ,女 3例 ;平均年龄 4 1岁。术后采用B超、IVU、肾图及输尿管镜检复查。　结果　 1 3例患者平均随访 2 6个月 ,其中 8例治愈 ,3例好转 ,2例失败。术后发生支架腔内纤维化狭窄 5例 ,需输尿管镜下去除增生纤维组织。　结论　金属网状支架可用于治疗继发性肾盂输尿管连接部梗阻 ,尤其适宜于多次手术失败、不适宜开放手术者 ,可明显降低输尿管狭窄的复发率     

Urinary proteome analysis and the management of ureteropelvic junction obstruction

Ureteropelvic junction obstruction (UPJO) detected prenatally may over time deteriorate and require surgery, improve, or remain stable, and it may take upwards of 3 years for its natural history to unfold. Clinical decisions for or against operative corrections are usually based on scintigraphy follow-up studies. A non-invasive method for facilitating clinical decisions has recently been presented: urinary proteome analysis utilizing capillary electrophoresis mass spectrometry (CE-MS) has been shown to predict the outcome of UPJO in newborns. The group that developed this assay has now validated their seminal findings and extended the investigations to older age groups (this issue). The results of the blinded analysis correctly identified patients with UPJO who underwent surgery with a sensitivity of 83% (5 of 6 patients) and a specificity of 92% (12 of 13 patients) in infants up to 1 year of age. The validity of the analysis was poor in children >1 year of age with unilateral UPJO. A large number of patients will be needed to answer the question of to what extent the normal variability of urinary proteomes overlap with the variability of the pattern in UPJO beyond early infancy.     

肾盂输尿管交界部功能性梗阻

自１９８５～１９９１年间共收治先天性肾盂输尿管交界部（ＵＰＪ）功能性梗阻患者３７例，病理检查而确诊，均经手术治疗。其中近期７例手术标本作了电镜检查，结果证实本病的病因为ＵＰＪ处平滑肌细胞之间有大量胶原纤维组织堆积，平滑肌细胞本身发育不良所致传导功能障碍。治疗应尽量切除病变的ＵＰＪ组织。     

Outcome of antenatally diagnosed pelviureteric junction hydronephrosis

Over a 6-year period, in a series of 107 consecutive patients with antenatally detected urological anomalies, 45 had pelviureteric junction (PUJ) hydronephrosis (66 units). Of these, 24 units (36%) had obstructive (group I) and 42 (64%) non-obstructive hydronephrosis (group II). Significantly compromised renal function was found only in group I. Treatment in group I was by an early pyeloplasty; in group II the patients were kept under close review. During the 6-year period, 2 units (5%) in group II, deteriorated, 13 (31%) improved and 27 (64%) were unchanged. These results suggest that early in life, antenatally diagnosed PUJ hydronephrosis without obstruction may be a relatively benign condition but will require long-term follow-up in order to determine the natural history of the condition.     

Dominantly inherited ureteropelvic junction obstruction

We report on siblings from two families with unilateral ureteropelvic junction obstruction. HLA studies were undertaken and found to be a useful marker between affected members. We believe that incomplete penetrance with variable expression is the most probable mode of transmission of this disorder.     

The minimally invasive management of ureteropelvic junction obstruction in horseshoe kidneys

Purpose  

Data regarding the treatment of ureteropelvic junction obstruction (UPJO) in horseshoe kidneys are limited. We performed a retrospective analysis of our experience with minimally invasive treatment of UPJO in patients with this anomaly.     

Contemporary management of ureteropelvic junction obstruction: practice patterns in Minnesota

BACKGROUND AND PURPOSE: Ureteropelvic junction (UPJ) obstruction can be addressed surgically by an open, laparoscopic, endoscopic, or fluoroscopic procedure. Our objective was to establish what surgical alternatives are currently offered by urologists in Minnesota. MATERIALS AND METHODS: A questionnaire was sent to 174 members of the Minnesota Urological Society. Practice settings were characterized as rural, urban, or metropolitan on the basis of the ZIP-code classifications of the Minnesota Ambulance Association and state geographic legislation. Respondents were asked to select initial treatment options for an adult patient with flank pain, decreased renal function, and hydronephrosis secondary to UPJ obstruction. RESULTS: Whereas 60% of the respondents would offer open pyeloplasty, only 12% would offer it as the only treatment option. The two most common minimally invasive therapies offered were the Acucise balloon (48%) and percutaneous antegrade endopyelotomy (48%). Rural urologists were more likely to offer Acucise balloon incision (71%) than were urban (28%; P=0.045) or metropolitan (55%; P=0.412) urologists. CONCLUSIONS: The majority of urologists still offer open pyeloplasty as first-line therapy for UPJ obstruction. Further emphasis should be placed on increasing the availability of endoscopic and laparoscopic procedures.     

腹腔镜手术治疗肾盂输尿管连接部狭窄19例

目的 评价腹腔镜手术治疗肾盂输尿管连接部狭窄（ureteropelvic junctiono bstruction，UPJO）的疗效。方法 采用经腹路径对19例UPJO行离断式。肾盂输尿管成形术。打开侧腹膜，以。肾下极为标志游离出。肾盂输尿管连接部，切除狭窄部分，端端吻合肾盂输尿管并留置双J管。结果 19例手术全部成功，手术时间110～240min，平均150min。术中出血量50～100ml，平均80ml，无严重并发症发生。术后住院6～10d，平均7．8d。19例随访3～15个月，平均6个月，14例静脉尿路造影（intrarenous urography，IVU）无吻合口狭窄。结论 腹腔镜下离断式肾盂输尿管成形术治疗UPJO有效、可行，可以替代开放手术。     

Management of ureteropelvic junction obstruction in neonate

Fetal hydronephrosis demonstrated by maternal ultrasonography should lead to early investigation during the neonatal period. Postnatal confirmation of the diagnosis of ureteropelvic junction obstruction usually can be established by combining the radiologic modalities of ultrasound, diuretic isotope renal scan, and voiding cystourethrography. Rarely should intravenous urography, antegrade pyelography, or cystoscopy and retrograde pyelography be necessary. Findings of high-grade obstruction and/or significantly diminished function on the affected side(s) should prompt early neonatal reconstruction. Pyeloplasty was performed within the first month of life in 17 infants (20 kidneys) diagnosed as having significant ureteropelvic junction obstruction. Early reconstruction in the neonatal period can be performed successfully with minimal complications and a relatively brief period of hospitalization. This may ultimately achieve maximal preservation of renal function.     

Management of neonatal ureteropelvic junction obstruction

No topic in urology is more contentious than the management of neonatal ureteropelvic junction obstruction. Those favoring early diagnosis and correction of obstruction in early infancy cite excellent return of function and superior surgical results compared with delayed repair. Others believe that hydronephrosis improves or resolves with growth in many instances. In the most widely quoted series, almost all such patients improved. This article attempts to separate opinion from fact. The arguments for early surgery and for observation, even when obstruction has been diagnosed, are reviewed. Several experiences with long-term surveillance are summarized.