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【Objective】 To evaluate the efficacy and safety of 3-dimensional laparoscopic pyeloplasty and ultrasound-guided flexible ureteroscopy lithotripsy (3DLP-UGFURL) in the treatment of ureteropelvic junction obstruction (UPJO) and renal calculi. 【Methods】 The clinical data of 29 patients of UPJO complicated with renal calculi treated with 3DLP-UGFURL during Dec.2017 and Jul.2022 were retrospectively analyzed. There were 23 males and 6 females with average age of (35.3±13.6) years. The lesions were on the left side in 20 cases, on the right side in 9 cases, and all were unilateral. One case was complicated with horseshoe kidney. The body mass index (BMI) was 23.6±3.9. Multiple calculi of renal pelvis or calyces occurred in 16 cases, and the rest were single calculi. The maximum diameter of calculi was (1.2±0.6)cm. There were 2 cases of mild hydronephrosis, 19 cases of moderate hydronephrosis and 8 cases of severe hydronephrosis. 【Results】 All operations were successful. The operation time of 3DLP was (84.2±15.4)min. Operation time of UGFURL was (42.8±15.7)min. Estimated blood loss was (36.9±13.6)mL. Indwelling time of drainage tube was (3.6±1.6)d. Indwelling time of urinary catheter and postoperative hospital stay was (6.8±1.2)d. One month after operation, the stone removal rate was 97.4%. The retention time of ureteral stent was 2.7 months. During the follow-up of (24.5±10.0)months, there were 45 Clavien Dindo grade 1 complications. 【Conclusion】 3DLP-UGFURL is safe and effective in the treatment of UPJO complicated with renal calculi, but it still needs long-term follow-up data.
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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.
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Objective:To compare the efficacy of modified "double flaps" pyeloplasty and traditional dismembered pyeloplasty in the treatment of special types of hydronephrosis with small pelvis and long proximal ureteral stricture in children.Methods:The data of 39 children with special types of hydronephrosis treated in Seventh Medical Center, General Hospital of PLA from June 2018 to June 2019 were retrospectively analyzed. Among them, 33 were boys and 6 were girls. The median age of the patients was 12.0(4.5, 63.5) months. Nine of them had left hydronephrosis and four children had right hydronephrosis. These patients with small pelvis existed the characteristics that the anteroposterior diameter of pelvis was smaller than 2.5 cm and these patients existed the symptom of hematuria, flank pain or recurrent urinary tract infection with the imaging revealing ureteral obstruction. The length of proximal ureteral stenosis ranged from 2.0 to 4.0 cm. Among 39 cases, 19 cases were operated with modified "double flaps" pyeloplasty, which was the modified "double flaps" pyeloplasty group. 20 cases were operated with traditional Anderson-Hynes pyeloplasty, which was traditional pyeloplasty group. The technique of modified "double flaps" pyeloplasty mainly included that the renal pelvis was cut into double flaps, the inferior flap was anastomosed with the spatulated ureter and the superior was covered, so that the length and caliber of the ureter were partial extended. The median age of two groups were 12.0 (6.0, 44.0) months and 12.0 (4.8, 62.8) months respectively, the anterior and posterior diameter of renal pelvis were (2.8±0.8)cm and (2.6±0.6)cm respectively, and split renal function were (36.7±5.1)% and (36.0±6.8)% respectively. There were no statistically significant differences in above parameters between the two groups( P>0.05). The clinical efficacy of the two groups were compared by collecting and comparing the operation related data and postoperative follow-up data. Results:The operation of 39 children in this study was successfully completed without conversion to open surgery.The operation time of "double flap" pyeloplasty group and traditional pyeloplasty group were (142.6±9.6) min and (124.5±8.6) min respectively, and the intraoperative anastomosis time were (56.1±7.2) min and (47.6±4.8) min respectively. There were significant difference in operation time and intraoperative anastomosis time between the two groups( P<0.05). Thirty-nine children were followed up normally without loss. The mean follow-up time was (27.7±2.5) months after surgery. In the "double flaps" pyeloplasty group, 2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment. In the traditional pyeloplasty group, 2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment. Two children had flank pain during follow-up to more than one year and the examination revealed that the anteroposterior diameter of the renal pelvis gradually increased. So surgery were performed again and the two children recovered. There were no significant differences in complication rate (2/19 and 4/20) and short-term surgical success rate(19/19 and 18/20) between the two groups ( P>0.05). Conclusions:The operation time and anastomosis time of the modified "double flap" technique for treating hydronephrosis are longer than those of the traditional method. But in the treatment of special types of hydronephrosis with small renal pelvis or long proximal ureteral stricture, it may have application prospects in reducing complications.
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Objective:Objectives To investigate the predictive value of color Doppler flow imaging (CDFI) for the proteinuria following pyeloplasty for congenital ureteropelvic junction obstruction (UPJO) in children.Methods:We identified a series of 206 children with a mean age of (20.0±28.8) months (1-132 months), consisted of 171 males and 35 females, diagnosed with congenital UPJO accepted pyeloplasty from January 2014 to September 2018, the preoperative mean urinary Albumin/Creatinine Ratio (ACR) was (17.3±160.1) mg/mmol and the mean β2-microglobulin/Creatinine Ratio (β2-MG/Cr) was (135.6±383.8) μg/mmol, ultrasound showed a mean renal pelvis dilatation of (3.1±1.5) cm and a mean cortical thickness of (0.3±0.1) cm, and classified as grade Ⅰ-Ⅴ according to the blood flow distribution in renal by CDFI, these children were divided into three groups of increased, decreased and unchanged blood flow according to the postoperative CDFI within 1 week, the postoperative urinary protein and renal function indexes within 1 week and 2 years were retrospectively analysed among groups.Results:Within 1 week postoperatively, an increased, decreased and unchanged blood flow occurred in 113 (54.9%), 31(15.0%), 62(30.1%) children, respectively. Urinary ACR in above mentioned groups was (112.3±400.7), (16.1±29.3), (32.7±48.4) mg/mmol, β2-MG/Cr was (887.4±6061.0), (50.2±62.7), (51.9±57.8)μg/mmol, there were significant differences among groups ( P<0.01). Contralateral hydronephrosis occurred in 21(18.6%), 4(12.9%), 8(12.9%) children, urinary N-Acetyl-β-D-glucosaminidase (NAG) was (7.5±5.2), (7.0±5.4)、(5.7±4.5) U/L, these indexes showed no significant differences among groups. There was a positive correlation between the increased blood flow level and the decreased renal pelvis dilatation (Spearman’s correlation coefficient 0.2, P<0.01), ACR (Spearman’s correlation coefficient 0.4, P<0.01) and β2-MG/Cr (Spearman’s correlation coefficient 0.3, P<0.01). After a follow up of 2 years, 67 children were diagnosed with proteinuria in this series, 51 cases of them with an increased blood flow, which had significantly higher percentage than children with a decreased (4 cases, 12.9%) or unchanged blood flow (12 cases, 19.3%). Logistic multivariate analysis indicated that early postoperative (within 1 week) increased blood flow ( OR=1.9, 95% CI 1.5-2.6), contralateral hydronephrosis ( OR=2.2, 95% CI 1.1-4.8) and urinary NAG ( OR=1.1, 95% CI 1.0-1.1) were predictive of proteinuria, the increased blood flow was independent predictor of proteinuria (Ⅰ level increased: OR=1.9, 95% CI 1.5-2.6). Conclusions:The CDFI reveals good predictive value for the postoperative proteinuria, an early marked increased blood flow postoperatively indicated risk of proteinuria in the long term.
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Objective:To compare the advantages and disadvantages of laparoscopic robot-assisted transmesenteric approach and retrocolic approach disconnected pyeloplasty in the treatment of children with hydronephrosis.Methods:From October 2020 to March 2021, 19 children with hydronephrosis were divided into two groups: intra-renal type and extra-renal type. Among them, 15 were males and 4 were females. The average age of the patients was 3.5 years old (0.2 years old to 16.8 years old), and the average weight was 18.4 kg (5.5 kg to 67.0 kg). The average ERPF of affected kidney before surgery was 35.4%(23.0%-49.8%). All of them were treated with laparoscopic robot-assisted transmesenteric approach and retrocolic approach disconnected pyeloplasty. The operation was performed in accordance with the standard surgical procedures of the guidelines. After the insertion of the trocar, the children in the transmesenteric group were exposed to the renal pelvis by incising the colonic mesangium into the retroperitoneal space, while in the retrocolic group, the peritoneum was cut into the retroperitoneal space to expose the renal pelvis. After that, the steps of incision, cutting, tube placement, and suture of the renal pelvis and ureter were the same in the two groups. Among the 10 cases of the extrarenal type, 6 cases were in the transmesenteric group and 4 cases were in the retrocolic group; among the 9 cases of the intrarenal type, 5 cases were in the transmesenteric group and 4 were in the retrocolic group. There was no statistically significant difference in age, weight, and renal function of the affected side before operation in different surgical approach groups ( P>0.05). The operation time, intraoperative anastomosis time, intraoperative blood loss and postoperative hospital stay were recorded and compared. There was no statistical difference in the age, weight, and renal function of the affected side before the operation. Results:19 cases were followed up for 6 months, no complications such as fever or wound infection occurred. The operation was successfully completed in all patients, no patients were transferred to open surgery, and the hydronephrosis was significantly reduced. Symptoms disappeared in both groups. Of the 19 children. In children with extrarenal type, the operation time of the transmesenteric group and the retrocolic group were (108.8±15.5) min and (132.8±7.6) min, and the intraoperative anastomosis time was (40.7±6.1) min and (51.5±5.5)min, the estimated intraoperative blood loss was (9.5±2.1) ml and (9.3±0.8) ml, respectively, and the postoperative hospital stay was (9.0±1.6) d and (9.3±2.9) d. The operation time and the difference of intraoperative anastomosis time was statistically significant ( P<0.05). In children with intrarenal type, the operation time of the transmesenteric group and the retrocolic group were (136.6±7.9) min and (116.5±13.5) min, and the intraoperative anastomosis time was (52.8±6.9) min and (40.8±6.2), min, the estimated blood loss during the operation was (11.4±2.3) ml and (10.5±0.9) ml, and the postoperative hospital stay was (8.8±1.7) d and (8.0±1.6) d. The operation time and The difference of intraoperative anastomosis time was statistically significant ( P<0.05). The 19 cases were followed up for 6 months, and there was no complications such as fever or wound infection. The volume of hydronephrosis was significantly reduced compared with that before operation, and the renal blood perfusion increased compared with that before operation. The difference was statistically significant ( P<0.05). Conclusion:In terms of shortening the operation time and suture time, for laparoscopic robot-assisted transmesenteric approach and retrocolic approach disconnected pyeloplasty in the treatment of children with hydronephrosis, the transtransmesenteric approach is more advantageous in the treatment of extrarenal hydronephrosis, while the retrocolic approach is more advantageous in the treatment of intrarenal hydronephrosis.
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This paper reports a rare clinical case of 46 X, i(X)(q10)TS in a female patient with horseshoe kidney and right duplication kidney with renal pelvic and ureteral junction stenosis and double kidney cysts, secondary to right renal calculi and hydronephrosis. After open surgical treatment, the curative effect was definite, which effectively relieved the stenosis at the junction of the renal pelvis and ureter and relieved the clinical symptoms of the patient. The patient was followed up for 3 months and recovered well. When TS is combined with horseshoe kidney with UPJO, open pyeloplasty with partial isthmus and renal fixation are still classic surgical procedures.
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Ureteropelvic junction obstruction (UPJO) is characterized by decreased flow of urine down the ureter and increased fluid pressure inside the kidney. Open pyeloplasty had been regarded as the standard management of UPJO for a long time. Laparoscopic pyeloplasty reports high success rates, for both retroperitoneal and transperitoneal approaches, which are comparable to those of open pyeloplasty. However, open and laparoscopic pyeloplasty have yielded disappointing failure rates of 2.5%-10%. The main causes for recurrent UPJO are severe peripelvic and periureteric fibrosis due to urinary extravasation, ureteral ischemia, and inadequate hemostasis. In addition, failing to diagnose lower pole crossing vessels before or during the primary procedure is also responsible for recurrent UPJO. In addition, poor preoperative split renal function, hydronephrosis, presence of renal stones, patient age, diabetes, prior endopyelotomy history, and retrograde pyelography history were considered as predictors of pyeloplasty failure. The failure is usually defined by persistent pain, persistent radiographic obstruction (infection or stones), continued decline in split renal function, or a combination of the above. And the failure of pye-loplasty often occurs in the first 2 years after the surgery. The available options for managing recurrent UPJO with a salvageable renal unit include endopyelotomy, re-do pyeloplasty, stent implantation, percutaneous nephrostomy, ureterocalicostomy, and nephrectomy. Re-do pyeloplasty has such merits as high successful rates and rare complications, compared with endopyelotomy or ureterocalicostomy. And some investigators think that re-do pyeloplasty should be regarded as the gold standard for secondary therapy if feasible. Open pyeloplasty can enlarge the operating field, facilitate the exposure of the ureteropelvic junction, reduce the difficulty of operation, and thus reduce the occurrence of complications. There are no significant differences among the success rates of re-do pyeloplasty under open approach, traditional laparoscopy and robot-assisted laparoscopy, according to previous reports. However, traditional laparoscopic and robot-assisted pyeloplasty give advantages of cosmetology, small trauma, less postoperative pain, speedy recovery and shorter hospitalization, fewer complications and lower recurrent rates. If the primary pyeloplasty is an open operation in retroperitoneal approach, the traditional laparoscopic and robotic operation with retroperitoneal approach should be considered for secondary repair. The cause of recurrent UPJO should be evaluated before surgery and identified intraoperatively to minimize the possibility of recurrence.
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Humans , Hydronephrosis , Kidney Pelvis , Laparoscopy , Ureter , Ureteral Obstruction/surgery , Urologic Surgical ProceduresABSTRACT
OBJECTIVE@#To investigate the value of preoperative three-dimensional image reconstruction in the treatment of ureteropelvic junction obstruction (UPJO).@*METHODS@#We reviewed data on 40 patients (22 male cases, and 18 female cases) diagnosed with UPJO in Peking University First Hospital from May 2017 to April 2019. The median age was 26.5 years (IQR 23.25-38.75) years. There were 11 patients complicated with ectopic vessels, 14 patients with kidney stones, 3 patients with horseshoe kidney, and 6 patients with obstruction after pyeloplasty. All the patients underwent preoperative enhanced CT scan, and the CT data were reconstructed into three-dimensional image models. The obstruction position of ureteropelvic junction and the relationship between ureteropelvic junction and blood vessels and organs were observed by three-dimensional models to assist planning surgery. Thirty-seven patients underwent laparoscopic pyeloplasty (including 3 cases combined with pyelolithotomy with flexible cystoscope, 1 case combined with pyelolithotomy by sun-style cystoscope, 1 case with laparoscopic ureter resection and anastomosis, 3 cases of laparoscopic pyeloplasty of horseshoe kidney), 2 patients underwent laparoscopic ventral onlay lingual mucosal graft ureteroplasty, and 1 patient underwent robot-assisted laparoscopic pyeloplasty.@*RESULTS@#Three-dimensional CT image clearly showed the relationship between the obstruction of ureteropelvic junction and blood vessels and organs after three-dimensional reconstruction. The type, diameter, position and direction of the ectopic vessels could be observed clearly before operation according to the three-dimensional reconstruction model, and the number, size, location and shape of renal calculi or other masses, the number of involved renal calyces and the anatomical distribution in the renal pelvis and calyces could be also evaluated preoperatively. After comprehensive analysis of the above information, individualized operation plans were performed on the patients, all the 40 cases were successfully completed with the surgery without any transfer to open surgery. The average operative time was (129.91±37.90) min (range: 75 to 273), the average blood loss was (48.1±78.0) mL (range: 10 to 400), the average hospitality was (5.04±1.99) d (range: 2 to 10), and the average postoperative drainage time was (3.8±1.4) d (range: 2 to 8).@*CONCLUSION@#The preoperative three-dimensional image reconstruction has a high clinical value in the treatment of ureteropelvic junction obstruction, and it is of great help to assist surgery planning and is worthy of further clinical promotion and application.
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Adult , Female , Humans , Male , Young Adult , Imaging, Three-Dimensional , Kidney Pelvis , Laparoscopy , Retrospective Studies , Treatment Outcome , Ureteral Obstruction/diagnostic imaging , Urologic Surgical ProceduresABSTRACT
ABSTRACT We describe the rare case of a 61-year-old female with right ureteropelvic junction (UPJ) obstruction caused by metastatic cholangiocarcinoma. Her past medical history was notable for cholangiocarcinoma treated with neoadjuvant chemoradiation and two orthotopic liver transplants six years earlier. Urology was consulted when she presented with flank pain and urinary tract infection. Diagnostic workup demonstrated right UPJ obstruction. She was managed acutely with percutaneous nephrostomy. She subsequently underwent robotic pyeloplasty and intrinsic obstruction of the UPJ was discovered. Histological examination revealed adenocarcinoma, consistent with systemic recurrence of the patient's known cholangiocarcinoma.
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Humans , Female , Pelvic Neoplasms/complications , Ureteral Neoplasms/complications , Ureteral Obstruction/etiology , Cholangiocarcinoma/complications , Pelvic Neoplasms/secondary , Ureteral Neoplasms/secondary , Ureteral Obstruction/pathology , Ureteral Obstruction/diagnostic imaging , Bile Duct Neoplasms/pathology , Urography , Tomography, X-Ray Computed , Cholangiocarcinoma/secondary , Hydronephrosis/etiology , Hydronephrosis/diagnostic imaging , Middle AgedABSTRACT
OBJECTIVE: To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure. METHODS: Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve. RESULTS: The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction. CONCLUSIONS: Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.
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Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Young Adult , Ureteral Obstruction/surgery , Laparoscopy/education , Learning Curve , Robotic Surgical Procedures/education , Surgeons/education , Kidney Pelvis/surgery , Postoperative Complications , Analysis of Variance , Treatment Outcome , Laparoscopy/methods , Statistics, Nonparametric , Operative Time , Robotic Surgical Procedures/methods , Length of StayABSTRACT
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.
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Objective To observe the therapeutic effect of discontinuation pyeloplasty in children with hydronephrosis.Analyze the factors that affect the recovery of postoperative renal function.Methods A retrospective analysis was performed on 125 children with hydronephrosis caused by unilateral ureteropelvic junction obstruction from January 2014 to December 2015 in Hunan Children's Hospital.Preoperative and postoperative renal pelvis anteroposterior diameter,renal parenchymal thickness,segmental artery resistance index,glomerular filtration rate (GFR),blood urea nitrogen,serum creatinine and other indicators were observed.The measurement data were expressed as mean ± standard deviation (Mean ± SD),and paired t-test was used for inter-group comparison,and Chi-square test was used for inter-group comparison of counting data.Logistic regression analysis was performed on the factors such as sex,age,hydronephrosis location and hydronephrosis degree before operation,and the important factors affecting postoperative renal function recovery were screened out.Results Postoperative renal pelvis anteroposterior diameter (1.87 ± 1.02) cm,renal parenchyma thickness (6.34 ± 1.41) mm,segmental arterial resistance index (0.68 ± 0.05),GFR (40.54 ± 3.25) ml/min,blood urea nitrogen (2.18 ± 1.24) mmol/L and serum creatinine (27.54 ± 6.21) μg/ml and other indicators were better than preoperative,the difference were statistically significant (P ＜ 0.05).Multivariate logistic regression analysis showed that the degree of hydronephrosis,age and level of renal function were the influencing factors of renal function recovery (P ＜ 0.05).The postoperative recoveryof renal function was not related to gender,location of hydronephrosis,surgical methods and other factors (P ＞ 0.05).Conclusions Pyeloplasty is good for children with hydronephrosis,it can improve the degree of patients with hydronephrosis,improve renal function recovery.Preoperative patients with age,degree of hydronephrosis and sub-renal function levels affect postoperative renal function recovery.
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Objective@#To analyze the clinical features of spontaneous rupture of the renal pelvis (SRRP) in infants caused by UPJO.@*Methods@#A retrospective analysis of 7 cases of SRRP in infants caused by UPJO in our hospital from October 2013 to October 2018 was performed. All the patients included 5 males and 2 females. The average age was(12.0±6.1) months(ranging 2 days-25 months). 3 cases suffered renal rupture in left side and 4 cases suffered renal rupture in right side. 2 cases had grade Ⅲ hydronephrosis and 5 cases had grade Ⅳ hydronephrosis. Other symptoms included fever in 4 cases, digestive symptoms in 3 cases, oliguria in 2. 7 cases were revealed RBC(+ + + )with urinary occult blood positive in urine test. 6 cases were found the white blood cells in urine was more than 8/μl. 3 cases had the elevated blood C-reactive protein.3 cases suffered with renal function insufficiency, which the creatinine was more than 110 μmol/L. The 2 cases of urinary extravasation was found in the posterior abdominal cavity and 2 in posterior abdominal cavity and abdominal cavity by CT enhanced scan. 4 cases performed open pyeloplasty, nephrostomy and perirenal drainage.2 cases performed pyeloplasty, nephrostomy, abdominal and perirenal drainage. 1 case performed perirenal drainage and retrograde indwelling Double-J stents.@*Results@#All operation performed successfully. The median operation time was 84 min (ranging 45-90 min). The estimate blood loss was 15 ml (ranging 10-35 ml)without any transfusion. The median time of postoperative perirenal drainage tube was 3 d (ranging 2-5 d), The median time of the abdominal drainage tube was 5 d (ranging 3-7 d), the median time of nephrostomy was 12 d (ranging 10-14 d). The median hospital stay was 14 d (ranging 10-21 d). The median follow-up was 18 months (ranging 3-36 months). One performed the second stage pyeloplasty after double-J stents removed, and the renal function gradually recovered.@*Conclusions@#The SRRP in infants caused by UPJO is rare and easily misdiagnosed. The degree of hydronephrosis and inflammation may be important factors affecting the spontaneous rupture of pediatric renal pelvis. When it occurs, it requires active intervention by the operation, while treating the stenosis of the UPJ and draining the extravasation of urine.
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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.
ABSTRACT
Objective To analyze the clinical features of spontaneous rupture of the renal pelvis (SRRP) in infants caused by UPJO.Methods A retrospective analysis of 7 cases of SRRP in infants caused by UPJO in our hospital from October 2013 to October 2018 was performed.All the patients included 5 males and 2 females.The average age was(12.0 ± 6.1) months(ranging 2 days-25 months).3 cases suffered renal rupture in left side and 4 cases suffered renal rupture in right side.2 cases had grade Ⅲ hydronephrosis and 5 cases had grade Ⅳ hydronephrosis.Other symptoms included fever in 4 cases,digestive symptoms in 3 cases,oliguria in 2.7 cases were revealed RBC (+ + +)with urinary occult blood positive in urine test.6 cases were found the white blood cells in urine was more than 8/μl.3 cases had the elevated blood C-reactive protein.3 cases suffered with renal function insufficiency,which the creatinine was more than 110 μmol/L.The 2 cases of urinary extravasation was found in the posterior abdominal cavity and 2 in posterior abdominal cavity and abdominal cavity by CT enhanced scan.4 cases performed open pyeloplasty,nephrostomy and perirenal drainage.2 cases performed pyeloplasty,nephrostomy,abdominal and perirenal drainage.1 case performed perirenal drainage and retrograde indwelling Double-J stents.Results All operation performed successfully.The median operation time was 84 min (ranging 45-90 min).The estimate blood loss was 15 ml (ranging 10-35 ml)without any transfusion.The median time of postoperative perirenal drainage tube was 3 d (ranging 2-5 d),The median time of the abdominal drainage tube was 5 d (ranging 3-7 d),the median time of nephrostomy was 12 d (ranging 10-14 d).The median hospital stay was 14 d (ranging 10-21 d).The median follow-up was 18 months (ranging 3-36 months).One performed the second stage pyeloplasty after double-J stents removed,and the renal function gradually recovered.Conclusions The SRRP in infants caused by UPJO is rare and easily misdiagnosed.The degree of hydronephrosis and inflammation may be important factors affecting the spontaneous rupture of pediatric renal pelvis.When it occurs,it requires active intervention by the operation,while treating the stenosis of the UPJ and draining the extravasation of urine.
ABSTRACT
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.
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Objective To evaluate the observation period and association between the initial visit data including initial APD measured by ultrasonography (USG) and outcome of unilateral hydronephrosis caused by ureteropelvic junction obstruction (UPJO) in children.Methods One hundred and ninety-three children with UPJO,who underwent the USG at the initial visit time.There were 155 boys and 38.166 cases in left side and other 27 cases in right side.All cases were divided by initial visit time and initial APD respectively.There were 109 infancy(≤ 12 months),36 toddler(12-36 months),19 preschooler(36-60 months),29 school-age children(＞ 60 months)and 11 cases in normal group (APD ＜ 0.5 cm),47 in mild (0.5 cm≤APD ＜ 1.0 cm),54 in moderate(1.0 cm≤ APD≤ 1.5 cm),81 in sever(APD ＞ 1.5 cm).All the patients were follow up for at least 24 months and divided into two groups depended on whether the patients received the surgery.Results Areas under the receiver operating characteristic plots were 0.924 (95％ CI 0.870-0.977,P ＜ 0.01);sensitivity,specificity,positive predictive value,and negative predictive value were 87.2％,88.9％,87.5％,and 95.5％,respectively,for the cut of APD is ≥ 1.85 cm.Infancy and initial APD ＞ 1.5 cm was the risk factors predicting operation with the hazard ratio of 2.991 (95％ CI 1.328-6.734,P =0.008) and 16.593 (95％ CI 5.893-46.719,P ＜ 0.01),respectively.Operation rate at one year of UPJO,for initial APD ＞ 1.5 cm,initial APD ≤ 1.5 cm,infancy and after infancy,were 43.20％(35/81),2.67％ (3/112),30.27％ (33/109),5.95％ (5/84),respectively.Conclusions Initial USG is an efficient diagnostic tool to detect pathologic hydronephrosis.Initial APD predicts the clinical outcome of UPJO in pediatrics accurately.Further investigation is recommended when initial APD ＞ 1.5 cm.Close observation is needed during the one year after initial visit to detect the deterioration of UPJO,especially in infancy.
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Hydronephrosis caused by ureteropelvic junction obstruction(UPJO)is a common urinary abnormality in children which involves dilation in the urinary tract due to limitation in urinary drainage. most cases would resolve spontaneously,but the others who were short of adequate treatment would lead to irreversible renal damage. Ultrasonog_raphy is the most common examination for UPJO. However,there exists disagreement in the way to define obstruction accurately or to predict which patient will benefit from surgical intervention by ultrasonography. By reviewing the related national data the authors analyzed the advance on prognosis of ultrasonography and the non _ surgical outcomes of UPJO.
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Congenital ureteropelvic junction obstruction(UPJO)is a common urinary tract obstructive disease and it is one of the common causes of hydronephrosis in children and adolescents. Untreated UPJO may cause aggrava﹣tion of hydronephrosis,chronic infection,urinary calculi,or even Worsening of renal function. UPJO＇s treatment includes conservative and surgical treatment,and surgical treatment not only includes endoscopic surgery and classic open pyelo﹣plasty,it also includes minimally invasive techniques such as laparoscopy and robot－assisted laparoscopic surgery. In recent years,the application of minimally invasive techniques in pyeloplasty has been greatly improved and developed, noW the research progress of UPJO in treatment is revieWed.
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Objective@#Comparison of the efficacy of mini flank incision and laparoscopy in the treatment of infants with ureteropelvic junction obstruction.@*Methods@#We retrospectively analyzed 85 cases of infants with ureteropelvic junction obstruction in our hospital from Jan. 2016 to Jan. 2018, all the patients underwent dismembered pyeloplasty. According to the surgical approach, they were divided into two groups: There were 45 cases in the mini flank incision group, including 39 males and 6 females, aged from 1 month to 3 years, with a median age of 4 months, and 40 patients in the laparoscopy group, including 33 males and 7 females, aged from 2 months to 3 years, with a median age of 9 months. The clinical effects of the two groups were compared.@*Results@#The patients were followed up for 12-24 months. The operation time[(68.0±15.3)min vs.(79.6±18.8)min], fasting time[(5±1)h vs.(14±8)h] and indwelling time of peri-renal drainage tube[(3.1±1.4)d vs.(4.3±2.2)d] in the mini flank incision group were shorter than those in the laparoscopy group (P<0.01), but there was no significant difference in the amount of blood loss[(2.1±0.9)ml vs.(2.2±0.6)ml] during the operation (P>0.05). The recurrence rate[0 vs.5%(2/40)] and the incidence of complications[11.1%(5/45)vs. 17.5%(7/40)] in the mini flank incision group were lower than those in the laparoscopy group, but there was no statistical difference (P>0.05).@*Conclusions@#Pyeloplasty via mini flank incision or laparoscopy are both safe, effective and cosmetic.Mini flank incision surgery has the advantage of short operation time, easy to master and less disturbance of physiological function. Pyeloplasty via mini flank incision it is one of the reasonable options for the treatment of infants with ureteropelvic junction obstruction.