Failed pyeloplasty in children: our experience and clinical characteristics / 中华泌尿外科杂志

Objective:To summarize the clinical characteristics、diagnosis and treatment experience of children with reobstruction after pyeloplasty.Methods:A retrospective analysis was conducted on patients admitted to the Department of Urology, Beijing Children's Hospital from January 2015 to April 2022. Due to the unrelieved hydronephroplasty after the primary pyeloplasty, the anterior and posterior diameter of the pelvis was larger than that before the primary operation. Intravenous pyelography and diuretic renal radionuclide scanning confirmed the diagnosis of ureteropelvic reobstruction. Or underwent reoperation after undergoing puncture angiography for reobstruction. Fifty-four children were included in the study, 47 males (87.03%) and 7 females (12.96%), with a median age of 51.67(21.30, 117.24)month, and, 38 cases (70.37%) on the left side and 16 cases (29.63%) on the right side. The primary operation was open pyeloplasty (POP) in 20 cases and laparoscopic pyeloplasty (PLP) in 34 cases. 45 patients underwent primary operation in our hospital, and 9 patients were referred from other hospitals after primary operation. The interval between reoperation and initial operation was 7.25(6.15, 15.40)month. There were 28 cases with clinical symptoms before operation, and 26 cases without symptoms but reobstruction on imaging. 21 cases presented with recurrent abdominal pain, nausea and vomiting, and 7 cases presented with recurrent fever and urinary tract infection. All 54 patients underwent re-pyeloplasty after definite diagnosis of re-obstruction. In order to further study the feasibility of RLP, patients in the two groups were divided into RLP and ROP groups according to different surgical procedures. In the RLP group, there were 8 males (72.72%) and 3 females (27.28%). The median age was 82.21(49.83, 114.05) months, and obstruction was located on the left side in 8 cases (72.72%) and the right side in 3 cases (27.28%). There were 3 cases (27.28%) with POP and 8 cases (72.72%) with PLP. The time between the second operation and the primary operation was 12.83 (6.34, 16.86) months. APD before operation was 5.18 (4.25, 6.14) cm. There were 43 cases in the ROP group, including 38 males (88.37%) and 5 females (12.63%). The median age was 52.32 (26.62, 77.35) months; Obstruction was located on the left side in 31 cases (72.09%) and the right side in 12 cases (27.91%). The primary operation was performed in 19 cases (44.19%) with POP and 24 cases (55.81%) with PLP. The time between the second operation and the primary operation was 10.02 (8.03, 15.51) months. Preoperative APD was 5.42 (5.14, 5.90) cm. The causes of obstruction were found in the second operation: there were 28 causes (51.85%) of scar hyperplastic anastomotic stenosis, 7 cases (12.96%) of residual ectopic vascular compression, 8 cases (14.81%) of high ureteral anastomosis, 7 cases (12.96%) of ureteral adhesion distortion, and 4 cases (7.41%) of other causes (1 case of medical glue shell compression, 1 case of luminal polypoid hyperplasia, and 2 cases of complete luminal occlusion). Operation time, postoperative complications, APD, APD improvement rate (PI-APD), renal parenchyma thickness (PT), anteroposterior pelvis diameter/renal parenchyma thickness (APD/PT) at 3 and 6 months after operation were compared between RLP and ROP groups.Results:In this study, 54 patients were followed up with an average follow-up time of (34.41±20.20)month. APD of 3 months after pyeloplasty was 3.29(3.03, 3.52) cm, which was statistically significant compared with 5.45(5.13, 5.77)cm before pyeloplasty ( P=0.02). APD/PT changed from preoperative 21.71(21.08, 31.77)to 5.40(4.79, 6.79)3 months after surgery, and the difference was statistically significant ( P=0.03). The APD improvement rate was 37%(33%, 42%) 3 months after surgery and 49%(44%, 54%) 6 months after surgery. Among the 54 patients, 3 had lumbago and fever after clamping the nephrostomy tube, and 3(5.55%) had sinus angiography indicating that obstruction still existed and required reoperation. Therefore, the success rate of repyeloplasty in this group was 94.45%. Comparing RLP group and ROP group, operation time in RLP group was longer than that in ROP group [169.13(113.45, 210.66)]min vs. 106.83(103.14, 155.32)min, P=0.02]. The length of hospitalization in RLP group was shorter than that in ROP group [7.45(5.62, 9.28)d vs.11.64(10.45, 15.66)d, P=0.03], and the difference was statistically significant. The improvement rate of APD 3 months after surgery was compared between the two groups [30.48%(19.81%, 41.16%) vs.39.96%(35.16%, 47.76%), P=0.15], and the improvement rate of APD 6 months after surgery was compared between the two groups [48.00%(27.19%, 48.81%) vs.52.27%(46.95%, 56.76%), P=0.05], there was no significant difference in the success rate of operation between the two groups (90.90% vs. 95.34%, P=0.63). Conclusions:The common cause of reobstruction after pyeloplasty is cicatricial adhesion stenosis. The operation is challenging, but repyeloplasty can effectively relieve the obstruction and the overall success rate is 94.45%. RLP is a safe and effective surgical method for the treatment of reobstruction, which can achieve comparable surgical results with ROP.

Laparoscopic management of pelvi-ureteric junction obstruction caused by aberrant renal vessels in an adult

Pelvi-ureteric junction obstruction (PUJO) is not a rare clinical entity. It is indeed one of the common urological conditions presenting most commonly with hydronephrosis and pain. The most common etiology for patients suffering from acquired PUJO is the presence of calculus/calculi. An aberrant renal vessel (now termed as a vascular bar) is one of the causes in adults which are often missed on pre-operative investigations and is detected intraoperatively. We present herein the case of a 28 years old female who came with complaints of loin pain for 2 – 3 months. The workup investigations revealed only hydronephrosis without any calculi. Thus, a diagnosis of the primary PUJO was made. The patient was successfully managed by a laparoscopic pyeloplasty.

The initial experience of robotic-assisted laparoscopic pyeloplasty in the treatment of infant with ureteropelvic junction obstruction / 中华泌尿外科杂志

Objective To investigate the feasibility and safety of robotic-assisted laparoscopic pyeloplasty (RALP) in infant ureteropelvic junction obstruction.Methods Of 31 infants who underwent RALP between March 2017 and August 2017 were reviewed,including 25 boys and 6 girls.22 infants were found that the hydronephrosis was in the left kidney and 9 in the right kidney.The average age of the infants was (3.5 ± 0.7) months,ranged from 8 days to 6 months,including 7 infants less than 2 months.The average weight of the infants was (6.7 ± 1.2) kg,with a minimum weight of 3.3 kg.The diagnosis and outcomes of ureteropelvic junction obstruction (UPJO) were reviewed on clinical and imaging data.The ultrasound showed that the mean anteroposterior diameter of hydronephrotic kidney was (4.01 ±0.56)cm.The split renal function was (37.1 ± 3.2) ％ in infants who were more than 2 months.Patients with proximal defect were positioned in the lateral flank position with 50°-70° inclination and as close as possible to the edge of operating table.The trocars of robotic lens and No.1 robotic arm were placed on the middle of the umbilicus and the Pfannenstiel line respectively,and the trocar of No.2 robotic arm was placed on the supraumbilical symmetry point of the trocar No.1 robotic arm,and the auxiliary trocar was placed on the Pfannenstiel line outside the 3-4 cm of healthy side of the trocar of No.1 robotic arm.During operation,the ureteropelvic junction was dissected and tailored.Then the ureter was open longitudinally at the posterior lateral side and was anastomosed at the lowest part the renal pelvis.We assessed preoperative clinical data and outcomes,and analyzed the transition experience.Data are expressed as medians for continuous variables.Results All operations were successful with no serious intraoperative complication and traditional laparoscopic or open surgical conversion.The average operative time was 108 min,the average intraoperative blood loss was 9.5 ml.The average drain removal was 1.2 days,the average start oral of feeding was 3.2 hours days and the average postoperative hospital stay was 6.2 days.Postoperative pathological results showed smooth muscle hyperplasia,hypertrophy and fibrous tissue in the urothelium,accompanied by chronic inflammation of urothelial mucosa.Patients with Clavien Ⅰ and Ⅱ complications 22.6％ (7/31) postoperatively were managed conservatively.Among them,there were 1 cases of flank pain,1 cases of hematuria,2 cases of urinary leakage,and 3 cases of urinary tract infection.Patients' symptoms disappeared by conservative treatment.No patient suffered Clavien Ⅲ and Ⅳ complication postoperatively.The renal pelvis anteroposterior diameter was 1.58 cm at three months postoperatively,which was significantly smaller than that of peroperation (P ＜ 0.05).A diuretic T1/2 showed the improvement of split renal function without urinary obstruction in all patients at three months postoperatively.The postoperative split renal function was (39.2 ± 3.5) ％,which was slightly higher than that of preoperation (P ＞ 0.05).Conclusions Severe hydronephrosis in neonates can be acted as an indication for exploratory surgery when the surgeon's ability,anesthesia,monitoring and management conditions are available.Robotic-assisted laparoscopic pyeloplasty is a safe and feasible option for the treatment of UPJO in infant with less trauma,rapid recovery and good cosmetic result.We suggest that RALP is potentially a recommended feasible treatment option for infant with UPJO.

Initial experience of modified transperitoneal laparoscopic pyeloplasty combined with a rigid ureteroscope with a deflectable tip( Sun’s ureteroscope) for the treatment of ureteropelvic junction obstruction with renal calculi / 中华泌尿外科杂志

Objective@#To evaluate the efficacy and safety of Institution Urology of Peking University modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope(the Sun's ureteroscope) in ureteropelvic junction obstruction(UPJO) complicated with renal calculi.@*Methods@#From January 2018 to September 2018, eight patients, including five males and three females, were diagnosed as UPJO with coexistent ipsilateral renal calculi in Peking University First Hospital and Changzheng Hospital of Second Military Medical University. The age ranged from 14 to 50 years(mean 28 years). Four patients had flank pain and one patient had flank pain with hematuria, while the other three patients came without clinical symptom.The BMI ranged from 16.8 to 26.2 kg/m2(mean 22.0 kg/m2). The lesion located on the left side in 4 cases and on the right side in 4 cases. One patient suffered with multiple pelvis stones. Four patients suffered with multiple lower calyceal stones, and 3 patients had solitary lower calyceal stone. The stone size ranged from 2 mm to 10 mm (mean 6.4 mm). 3 cases had slight hydronephrosis and 5 cases had moderate hydronephrosis. Two patients combined with crossing vessels. All patients underwent modified transperotoneal laparoscopic dismembered pyeloplasty with pyelolithotomy. In cases with left lesion, an incision was made for the veress needle 5mm inferior to the costal margin in the left midclavicular line to establish pneumoperitoneum . A 12-mm camera port was placed 30 mm inferior to the umbilicus and 10 mm lateral to the border of left rectus muscle. Then, a 5 mm operative trocars was inserted at 30mm superior to the umbilicus 10 mm lateral to the border of left rectus muscle. Another 12 mm operative trocar was inserted at the opposite McBurney point. The last 5 mm operative trocar was placed at the veress needle point. After visualizing the pelvis and the proximal ureter at the lower pole of the kidney, a 1.0 cm transverse incision on the lower pole of the pelvis above the obstruction site was made. The Sun’s ureteroscope was introduced into the renal pelvis through the 1.0 cm transverse incision via the 12-mm trocar below the umbilicus. Stones in the renal pelvis and calyces were extracted with basket catheters and removed via the port. After the pyelo-nephroscopy, a modified transperitoneal laparoscopic pyeloplasty was made. A F6 double-J stent was inserted into the ureter during the surgery.@*Result@#All surgeries were finished successfully without conversion. The surgical duration ranged from 111 to 185 min(mean 135 min). The estimated blood ranged from 10 to 50 ml(mean 38.8 ml). The hospital stay ranged from 3 to 7 days(mean 4 days). The intraoperative stone free rate was 100%(8/8). No perioperative complications occured. With the follow-up from 6 to 14.4 months(mean 8.9 months), there was no evidence of obstruction in all patients, as confirmed by symptoms or radiological improvement of hydronephrosis, and two patients found recurrence of renal calculi.@*Conclusions@#Our modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope(the Sun′s ureteroscope) is a safe, effective method to manage ureteropelvic junction obstruction with renal calculi.

Initial experience of modified transperitoneal laparoscopic pyeloplasty combined with a rigid ureteroscope with a deflectable tip(Sun's ureteroscope) for the treatment of ureteropelvic junction obstruction with renal calculi / 中华泌尿外科杂志

Objective To evaluate the efficacy and safety of Institution Urology of Peking University modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope(the Sun's ureteroscope) in ureteropelvic junction obstruction (UPJO) complicated with renal calculi.Methods From January 2018 to September 2018,eight patients,including five males and three females,were diagnosed as UPJO with coexistent ipsilateral renal calculi in Peking University First Hospital and Changzheng Hospital of Second Military Medical University.The age ranged from 14 to 50 years(mean 28 years).Four patients had flank pain and one patient had flank pain with hematuria,while the other three patients came without clinical symptom.The BMI ranged from 16.8 to 26.2 kg/m2 (mean 22.0 kg/m2).The lesion located on the left side in 4 cases and on the right side in 4 cases.One patient suffered with multiple pelvis stones.Four patients suffered with multiple lower calyceal stones,and 3 patients had solitary lower calyceal stone.The stone size ranged from 2 mm to 10 mm (mean 6.4 mm).3 cases had slight hydronephrosis and 5 cases had moderate hydronephrosis.Two patients combined with crossing vessels.All patients underwent modified transperotoneal laparoscopic dismembered pyeloplasty with pyelolithotomy.In cases with left lesion,an incision was made for the veress needle 5mm inferior to the costal margin in the left midclavicular line to establish pneumoperitoneum.A 12-mm camera port was placed 30 mm inferior to the umbilicus and 10 mm lateral to the border of left rectus muscle.Then,a 5 mm operative trocars was inserted at 30mm superior to the umbilicus 10 mm lateral to the border of left rectus muscle.Another 12 mm operative trocar was inserted at the opposite McBurney point.The last 5 mm operative trocar was placed at the veress needle point.After visualizing the pelvis and the proximal ureter at the lower pole of the kidney,a 1.0 cm transverse incision on the lower pole of the pelvis above the obstruction site was made.The Sun's ureteroscope was introduced into the renal pelvis through the 1.0 cm transverse incision via the 12-mm trocar below the umbilicus.Stones in the renal pelvis and calyces were extracted with basket catheters and removed via the port.After the pyelo-nephroscopy,a modified transperitoneal laparoscopic pyeloplasty was made.A F6 double-J stent was inserted into the ureter during the surgery.Result All surgeries were finished successfully without conversion.The surgical duration ranged from 111 to 185 min(mean 135 min).The estimated blood ranged from 10 to 50 ml(mean 38.8 ml).The hospital stay ranged from 3 to 7 days(mean 4 days).The intraoperative stone free rate was 100％ (8/8).No perioperative complications occured.With the follow-up from 6 to 14.4 months(mean 8.9 months),there was no evidence of obstruction in all patients,as confirmed by symptoms or radiological improvement of hydronephrosis,and two patients found recurrence of renal calculi.Conclusions Our modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope (the Sun's ureteroscope) is a safe,effective method to manage ureteropelvic junction obstruction with renal calculi.

Minimally Invasive Approaches to Ureteropelvic Junction Obstruction / Монголын Анагаах Ухаан

@#There are many treatment options for the management of ureteropelvic junction obstruction (UPJO). Open pyeloplasty has a high success rate and has been considered as a gold standard. Minimally invasive surgical techniques are associated with reduced morbidity, improved cosmetic result and better convalescence than open pyeloplasty. For endopyelotomy, these advantages for minimally invasive surgery such as laparoscopic pyeloplasty and robot assisted pyeloplasty have superior success rate than open pyeloplasty. However, the success rate for laparoscopic surgery could potentially be improved by careful selection of patients, using the criteria of stricture <2 cm, renal function >25% and the absence of severe hydronephrosis. Laparoscopic pyeloplasty and robot-assisted pyeloplasty have similar success rates to open pyeloplasty (>90%) and the best outcomes have been reported for robot-assisted pyeloplasty although this treatment option is less readily available than laparoscopic pyeloplasty. Retrograde endopyelotomy is a simple, safe, and effective therapeutic option for primary and secondary symptomatic UPJO. </br> Retrograde endopyelotomy should be considered a viable first-line treatment option for the management of patients with UPJO. These include balloon dilation, antegrade endopyelotomy, retrograde endopyelotomy, Acucise endopyelotomy and laparoscopic pyeloplasty. During last decade, advances in endourological techniques have resulted in significant progress in the development of minimally invasive surgical procedures to treat UPJO. </br> Surgeons described their modification of Kusters dismembered procedure that involved anastomosis of the spatulated ureter to a projection of the lower aspect of the pelvis after a redundant portion was excised. Laparoscopic pyeloplasty was first reported in 1993 both by Schuessler and others and by Kavoussi and Peters, who utilized dismembered pyeloplasty technique. During last decade, advances in endourological techniques have resulted in significant progress in the development of minimally invasive surgical procedures to treat UPJO. The combination of less postoperative morbidity, improved cosmesis, shorter convalescence and comparable operative success rates has lured many patients away from gold standard of open pyeloplasty. Only few retrospective studies have been conducted regarding laparoscopic versus open pyeloplasty. Success rates are comparable for laparoscopic pyeloplasty.</br> The number of minimally invasive surgeries performed by us increased from year to year. Therefore the characteristics and performance of the surgeries should be studied in detail and based on the finding the evidence based medicine should be placed in.

Application of Da Vinci Robot System in Pediatric Hydronephrosis / 中山大学学报(医学科学版)

[Objective] To explore the application of Da Vinci robot in laparoscopic pyeloplasty treatment for pediatric hydronephrosis and to improve the effect of operation and shorten the operation time effectively.[Methods] A summary and analysis was performed on the intraoperative cooperation about the clinical data of 14 pediatric hydronephrosis cases (16 sides) whom were performed RALP from November 2015 to July 2016.The intraoperative cooperation includes preoperative education,adequate preparation of surgical instruments,ensuring the normal operation of robot system before surgery and also,the proper body positions,the protection for patients,the establishment of aseptic barrier during operation as well as the maintenance of robot after operation.[Results] All procedures were performed via transperitoneal approach.Docking time was shortened from 40 to 20 min,operation time lasted (115± 38) min.One severe case presented with anastomasis stenosis even after PCN dilatation,and was redid dismembered pyeloplasty half a year later and the ultimate result was good.The other cases recovered well and the overall success rate was 93.75％.There were no robot failure caused by improper cooperation and no complications caused by improper nursing among the 14 pediatric hydronephrosis cases (16 sides) in pediatric hydronephrosis operations.[Conclusion]Da Vinci robot performed well in assisting laparoscopic pyeloplasty treatment for pediatric hydronephrosis,for it leaves light surgical trauma and short duration of operation.Adequate preoperative preparation,medical staff's formal professional technical training and professional cooperation team can not only improve the operation efficiency,but also be the key to the success of the operation.

Concomitant hybrid robotic-assistant laparoscopic pyeloplasty and flexible ureteroscopy for ureteropelvic junction obstruction combined with renal stones / 第二军医大学学报

Objective To evaluate the efficacy and safety of the robotic-assistant laparoscopic pyeloplasty(RALP) combined with flexible ureteroscopy(f-URS) for treatment of ureteropelvic junction obstruction(UPJO) with renal stones. Methods We retrospectively reviewed the records of 5 patients who underwent RALP and f-URS for UPJO combined with renal stones from May 2012 to August 2013.Three cases had solitary stones located at the lower calyx, and the other two had multiple stones. Results The operation was successful in all the 5 patients with no severe complications. The average total operation time was (132.4±24.8) min and the average f-URS time was (25.4±11.9) min. f-URS had full views of the collecting system with no blind area in all cases. Post-operative KUB and CT scan showed no residual stone fragments. The symptoms were greatly relieved in all patients after a 6-month follow-up postoperatively, with one patient still having 2 cm hydronephrosis; and the UPJO outcomes were satisfactory in the others. Conclusion Hybrid RALP combined with f-URS is safe and feasible for treatment of UPJO complicated with renal stones.