Clinical and radiographic outcomes following salvage intervention for ureteropelvic junction obstruction

ABSTRACT Purpose: We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO). Materials and Methods: A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both. Results: Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF. Conclusions: Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.

Minimally Invasive Pyeloplasty in Horseshoe Kidneys with Ureteropelvic Junction obstruction: A case series

Background and Purpose Horseshoe kidney is an uncommon renal anomaly often associated with ureteropelvic junction (UPJ) obstruction. Advanced minimally invasive surgical (MIS) reconstructive techniques including laparoscopic and robotic surgery are now being utilized in this population. However, fewer than 30 cases of MIS UPJ reconstruction in horseshoe kidneys have been reported. We herein report our experience with these techniques in the largest series to date. Materials and Methods We performed a retrospective chart review of nine patients with UPJ obstruction in horseshoe kidneys who underwent MIS repair at our institution between March 2000 and January 2012. Four underwent laparoscopic, two robotic, and one laparoendoscopic single-site (LESS) dismembered pyeloplasty. An additional two pediatric patients underwent robotic Hellstrom repair. Perioperative outcomes and treatment success were evaluated. Results Median patient age was 18 years (range 2.5-62 years). Median operative time was 136 minutes (range 109-230 min.) and there were no perioperative complications. After a median follow-up of 11 months, clinical (symptomatic) success was 100%, while radiographic success based on MAG-3 renogram was 78%. The two failures were defined by prolonged t1/2 drainage, but neither patient has required salvage therapy as they remain asymptomatic with stable differential renal function. Conclusions MIS repair of UPJ obstruction in horseshoe kidneys is feasible and safe. Although excellent short-term clinical success is achieved, radiographic success may be lower than MIS pyeloplasty in heterotopic kidneys, possibly due to inherent differences in anatomy. Larger studies are needed to evaluate MIS pyeloplasty in this population. .

Laparoscopic partial nephrectomy: a procedure in evolution / Nefrectomia laparoscópica parcial: um procedimento em evolução

A nefrectomia laparoscópica parcial (NLP) foi inicialmente descrita nos modelos animais, e subseqüentemente realizada em 1992 num paciente com pielonefrite e litíase em 1992. Num esforço para diminuir a morbidade operatória e melhorar a hemostasia laparoscópica, vários pesquisadores têm desenvolvido inúmeras técnicas para facilitar o procedimento. Este artigo irá descrever as várias técnicas que atualmente estão sendo realizadas clinicamente, além daquelas em desenvolvimento, e também discutirá as possibilidades que vêm sendo desenvolvidas para o futuro. As principais técnicas descritas e discutidas são: nefrectomia laparoscópica pura (duplicação da cirurgia aberta), torniquete amarrado, torniquete renal com alça dupla, endosnare, nefrectomia laparoscópica parcial com auxílio manual, corte ultrassônico, coagulação por rádio-freqüência, jato de água, laser por microondas e de hólmio. Concluindo, devemos enfatizar que, para que um procedimento seja realizado laparoscopicamente deve-se demonstrar que esta abordagem tem igual ou superior eficácia, e com menor morbidade, quando comparada à cirurgia aberta. Isto é evidente no caso da nefrectomia laparoscópica radical. Se o mesmo se aplica à nefrectomia laparoscópica parcial (NLP) ainda está para ser determinado. Entretanto, até o momento, as técnicas descritas têm obtido sucesso em modelos animais e em pequenas séries clínicas. Desta forma, a NLP é certamente um procedimento eficaz aplicável a muitos casos. Entretanto, a NLP não substituirá a nefrectomia parcial aberta no caso de vários tipos de tumores.