Protocolo prospectivo de pieloplastia laparoscópia pediátrica; del estrés a la tranquilidad / Prospective protocol for laparoscopic pyeloplasty in pediatrics; from stress to tranquility

La resolución quirúrgica de una obstrucción pieloureteral (OPU), con mayor frecuencia se realiza de forma laparoscópica. Siendo un procedimiento difícil per-se, consideramos que para optimizar tiempos, materiales y esfuerzo es necesario involucrar a todo el equipo quirúrgico. Se evalúa protocolo quirúrgico prospectivo, con ajuste de protocolo a mitad del estudio en post de mejorar los tiempos quirúrgicos. Método: Estudio prospectivo de 12 casos de pacientes >5kg con OPU y MA G3 con dificultad de vaciamiento; en quienes se aplicó el protocolo quirúrgico para pieloplastia laparoscópica (pasos quirúrgicos, características de suturas, pig-tail y material quirúrgico). Todos los casos fueron operados por 2 cirujanos con experiencia laparoscópica urológica avanzada (>5 años); un mismo ayudante y dos instrumentistas. Después de los primeros 6 pacientes (grupo A) se analizó y perfeccionó el protocolo quirúrgico, comparando posteriormente resultados y en especial tiempo quirúrgico con los siguientes 6 (grupo B). Resultados: La serie incluyó 9 hombres. La mediana para edad fue de 9.3 meses. El peso promedio fue 16. 7 kg (20.4 vs 13.1 kg respectivamente). En grupo A se realizaron 4 derechas y 2 izquierdas, y el grupo B fue inverso (4 izquierdas). Tres de doce pacientes presentaban OPU secundaria a vasos aberrantes. El tiempo quirúrgico promedio por grupo fue de 171.2 (120-200 min) vs 141.7 (90-210 min) respectivamente. El seguimiento promedio fue 19.6 meses (13-24 meses), todos los pacientes tuvieron buena evolución, con MA G-3 sin obstrucción al vaciamiento y disminución de la hidronefrosis. Conclusiones: Consideramos que la disminución del tiempo quirúrgico en el segundo grupo se debió tanto a la integración del equipo como al perfeccionamiento del protocolo quirúrgico: en la técnica, colocación de un cuarto trocar, forma de colocar pig-tail, tipo y tamaño de suturas, preparación...

Laparoscopic surgical resolution for an ureteropelvic junction obstruction (UPJO) is being widely used around the world. lt is considered as a hard and difficult procedure per-se, we considered for time, materials and effort Optimization; to involve every single member of the surgical team. A surgical protocol was developed and revised, with some adjustments in the middle looking forward to reduce surgical time. Method: Prospective study including 12 patients <5kg weight with UPJO and difficult emptying MA G-3; to whom a surgical protocol for laparoscopic pyeloplasty was applied (surgical steps, suture characteristics, stent and surgical material). All cases were operated by 2 advanced skilled laparoscopic surgeons (>5 year experience); same assistant surgeon and two different surgical assistants. After the first 6 cases (group A) the protocol was revised and improved, comparing results especially surgical time with group B (n=6). Results: The series included 9 male, median ages was 9.3 months. Average weight was 16. 7 kg (20.4 vs 13.1 kg for each group). Four right-sided pyeloplasties and 2 left-sided were performed in group A, and opposite in group B (4 left-side). Three of twelve patients had UPJO secondary to polar vessels. The mean surgical time was 171.2 ( 120-200 min) vs 141. 7 (90-210 min) respective/y. Mean follow-up was 19.6 months (13-24 mo), all patients had good outcome, without obstruction in the MA G-3 study and regression of the hydronephrosis...

Histopathologic Changes of Kidney in Pediatric UPJ Obstruction / 대한비뇨기과학회지

INTRODUCTION AND OBJECTIVES: A kidney in the growing state and the possibility of spontaneous improvement are characteristics of the pediatric ureteropelvic junction obstruction (UPJO) that make the treatment of this disease difficult. We have tried to determine the histopathologic changes of the kidneys with UPJO relating to age, differential renal function and urinary tract infection (UTI). METHODS: The total number of patients was 38 (40 kidneys). The age at the operation time was under 3 months in 9 cases (9 kidneys), 3 to 12 months in 10 cases (10 kidneys), and 1 to 18 years in 20 cases (21 kidneys). Needle biopsies from 3 different sites at the lower pole of the kidney were taken. The tissue was blindly observed for the presence of irreversible change (arteriolar thickening, glomerulosclerosis, interstitial fibrosis and periglomerular fibrosis) and reversible change (inflammatory cell infiltration) by light microscopy. Each pathological finding was graded as I, II or III, and each grade was given a numerical value. Statistical analysis was done with ANOVA. RESULTS: Although the kidneys from patients under 3 months tended to show better histopathologic findings, there was no statistically significant difference in all 5 pathologic findings regardless of patient age. 5 cases (5 kidneys) with previous percutaneous nephrostomy (PCN) were not included in any group for analysis due to possible histologic changes of the renal parenchyma. Inflammatory cell infiltration, arteriolar thickening, glomerulosclerosis and periglomerular fibrosis were statistically significant in patients with previous or present UTI (14 kidneys) compared to the patients without UTI (26 kidneys). The patients with a mean differential renal function less than 30% (7 kidneys) as measured by DTPA or DMSA renal scan showed statistically significant changes in all of the 5 histopathologic findings compared to the patients with differential renal function greater than 30% (27 kidneys). 4 cases with bilateral UPJO (6 kidneys) were excluded from comparing the differential renal function. 5 kidneys with previous PCN had statistically significant degree of glomerulosclerosis compared to others. CONCLUSIONS: Although we did not determine whether pediatric UPJO affects renal growth, it is probable that statistically significant irreversible histopathologic changes do not occur according to age. Considering histopathologic findings only, differential renal function and UTI Should be key factors in deciding the management of pediatric UPJO. In addition, PCN seems to induce more severe histopathologic changes of the kidney.

Diagnostic Value of Color Doppler Ultrasonography of UPJ Obstruction / 대한비뇨기과학회지

The cause of ureteropelvic junction obstruction(UPJ) is almost due to intrinsic factor. But a small percentage of UPJ obstruction have extrinsic obstruction as a result of a crossing renal aberrant vessel. The diagnosis of UPJ obstruction by aberrant vessel is usually made at surgery because the urographic findings are nonspecific and difficult to find cause. For the purpose of detecting aberrant vessel as a cause of UPJ obstruction, authors examined 20 patients with color Doppler ultrasonographic equipment, then cause of obstruction was confirmed at the time of surgery, from July 1991 to February 1994. In seven of twenty patients aberrant vessel was detected by color Doppler ultrasonographic equipment. Among the seven patients, only three cases were caused directly by aberrant vessel, color Doppler examination disclosed a vessel or vessels at the tapering distal end of UPJ. In other two patients, aberrant vessel was detected but it was not direct cause of UPJ obstruction. Even in two of seven patients, aberrant vessel was not detected at the time of surgery. However in one of thirteen patients with no color Doppler signal at the UPJ, aberrant vessel was confirmed in surgical field. Sensitivity was 75 % and specificity was 75 % as detecting aberrant vessel by color Doppler ultrasonographic equipment. We believe that color Doppler examination is a useful method in demonstration of aberrant vessel as a cause of UPJ obstruction, although accuracy was low.

Infant pyeloplasty / 대한비뇨기과학회지

The widespread use of prenatal ultrasonography has resulted in a dramatic increase in the number of hydronephrosis. Timing. safety and benefits of performing pyeloplasty in infancy currently are being questioned. to evaluate the effect of age on the pyeloplasty. the results of 9 pyeloplasties done during infancy ( including 4 pyeloplasties in neonate) were compared with those of 11 pyeloplasties in older age group. The surgical results in two groups were equally good, with all of cases having an improved or stable IVP or ultrasonogram taken 6 months postoperatively. Complications were few and were more common in the older age group. in which 5 cases required a secondary procedure. In conclusion, pyeloplasty during infancy was as safe and successful as that of older age group.

A Case of Congenital Ureteropelvic Junction Obstruction with more than 500 Stones / 대한비뇨기과학회지

Congenital ureteropelvic junction obstruction is not an uncommon disorder with resultant hydronephrosis. With urinary stasis and infection, stone formation sometimes occurs. We recently experienced a case of congenital ureteropelvic junction obstruction with multiple (more than 500) stones. The stones are composed of uric acid, calcium, phosphate and oxalate. Herein we report this case with brief review of the literatures.

Endoscopic Surgery for Ureteropelvic Junction Obstruction / 대한비뇨기과학회지

Percutaneous Endopyelotomy is a natural outgrowth of technique developed for percutaneous ureteral and renal stone removal. In it`s comparison to the Davis ureterotomy technique, a rationale for this procedure and explanation for it`s success is provided. Endopyelotomy, which we performed experimentally to prevent recurrent stone formation, has now matured into a viable procedure under the certain guideline. This procedure has become our first choice for secondary ureteropelvic junction obstruction but primary cases were not experienced. Although classical pyeloplasty must be main surgical means to UPJ obstruction, technical and equipmental advanced could be enabled us to perform 8 endopyelotomy. We incised UPJ obstruction in 8 cases with direct vision nephroscope inserted through a percutaneous nephrostomy tract and ureteroscope. In 6 patients, renal calculi were removed endourologically during same and separate session. There were no immediate complication and nephrostogram showed adequate drainage in all cases.

Unilateral Hydronephrosis Caused by Fibrous Band Around The Ureteropelvic Junction / 대한비뇨기과학회지

A 24-year old man presented with intermittent left flank pain for two years. With urograms this case was diagnosed as unilateral hydronephrosis associated with ureteropelvic obstruction. The cause of the ureteropelvic obstruction was proven as fibrous band surgically and pathologically. He underwent resection of the fibrous band and intubated pyelo-ureterostomy, and was discharged on the 14th postoperative day.