Nov 7 07

1
Review of UPJ
Review of UPJ
Obstruction
Obstruction
November 7, 2007 November 7, 2007
Chris Hoag, PGY5 UBC Urology Chris Hoag, PGY5 UBC Urology
References References
CWU9 CWU9 Ch115 Ch115
AUAUS 2007 AUAUS 2007 Lessons 5 & 6 Lessons 5 & 6
Literature review Literature review
The Centre of the Universe The Centre of the Universe
(video from Toronto Sick Kids Hospital) (video from Toronto Sick Kids Hospital)
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Cape Spear, NFLD
(Easternmost point in Canada)
UPJO Facts UPJO Facts
1/1500 live births 1/1500 live births
Clustering of presentation time: Clustering of presentation time:
Neonatal/antenatal (now the majority) Neonatal/antenatal (now the majority)
Adolescence/adulthood (symptoms) Adolescence/adulthood (symptoms)
#1 cause of antenatal hydro (48%) #1 cause of antenatal hydro (48%)
Boys > girls (>2:1) Boys > girls (>2:1)
L > R (2:1) L > R (2:1)
Bilateral in 10 Bilateral in 10- -40% 40%
Runs in families Runs in families
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Etiology Etiology
Primary Primary
Intrinsic Intrinsic
Extrinsic Extrinsic
Secondary Secondary
Primary UPJO Primary UPJO
Intrinsic Intrinsic
Adynamic Adynamic segment/intrinsic narrowing segment/intrinsic narrowing
Delayed/failed Delayed/failed recanalization recanalization after period after period
of obstruction of obstruction
Neuronal depletion in proximal Neuronal depletion in proximal ureter ureter
Incomplete development of circular sm. m. Incomplete development of circular sm. m.
Alteration of collagen Alteration of collagen fiber fiber composition composition
b/w sm. m. cells b/w sm. m. cells
Valvular Valvular ( (Ostling Ostling s s) mucosal folds ) mucosal folds
Persistent Persistent fetal fetal convolutions convolutions
Ureteral Ureteral polyps polyps
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Primary UPJO Primary UPJO
Extrinsic Extrinsic
Crossing vessel (anterior) Crossing vessel (anterior)
Renal Renal malrotation malrotation (over/under) (over/under)
Pathophysiology Pathophysiology of Extrinsic UPJO of Extrinsic UPJO
Crossing vessel Crossing vessel two point of kinking two point of kinking
Where Where ureter ureter drapes over drapes over
Angulated at UPJ Angulated at UPJ
Ensuing pelvic distension & Ensuing pelvic distension &
inflammation inflammation
Further adhesion kinking & Further adhesion kinking &
2 2- -point obstruction point obstruction
Ischemia, fibrosis, Ischemia, fibrosis, stenosis stenosis
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Secondary UPJO Secondary UPJO
Severe VUR (Grade IV/V) (10%) Severe VUR (Grade IV/V) (10%)
Kinking of tortuous system at relatively fixed UPJ Kinking of tortuous system at relatively fixed UPJ
Lower pole moiety of incomplete duplication Lower pole moiety of incomplete duplication
Severe VUR (Grade IV/V) (10%) Severe VUR (Grade IV/V) (10%)
Kinking of tortuous system at relatively fixed UPJ Kinking of tortuous system at relatively fixed UPJ
Lower pole moiety of incomplete duplication Lower pole moiety of incomplete duplication
Stone Stone- -related scar related scar
Iatrogenic (instrumentation) Iatrogenic (instrumentation)
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Associated Congenital Anomalies Associated Congenital Anomalies
GU Anomalies: GU Anomalies:
Contralateral Contralateral UPJO = #1 (10 UPJO = #1 (10- -40%) 40%)
VUR (up to 40%) VUR (up to 40%) usually low grade usually low grade
Renal dysplasia Renal dysplasia
MCDK MCDK
Renal agenesis (5%) Renal agenesis (5%)
Duplicated system (usually lower moiety UPJO) Duplicated system (usually lower moiety UPJO)
Horseshoe kidney Horseshoe kidney
Ectopic kidney Ectopic kidney
Non Non- -GU Anomalies: VATERR (10 GU Anomalies: VATERR (10- -20%) 20%)
Zion Canyon, Utah
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Diagnosis
Diagnosis
Presenting Presenting S&Sx S&Sx
Infants Infants
Hydronephrosis Hydronephrosis on antenatal U/S = majority on antenatal U/S = majority
Palpable abdominal mass Palpable abdominal mass
FTT FTT
Feeding problems Feeding problems
Sepsis (UTI) = presenting Sepsis (UTI) = presenting Sx Sx 30% beyond 30% beyond
neonatal period neonatal period
Pain/ Pain/hematuria hematuria (stones) (stones)
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Presenting Presenting S&Sx S&Sx
Children Children
Episodic flank/abdominal pain +/ Episodic flank/abdominal pain +/- - N/V N/V
Episodic vomiting alone Episodic vomiting alone
Hematuria Hematuria after apparently minor trauma (25%) after apparently minor trauma (25%)
Adults Adults
Episodic flank/abdominal pain (esp. with Episodic flank/abdominal pain (esp. with diuresis diuresis) )
HTN HTN
Diagnostic Dilemmas
Diagnostic Dilemmas
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Diagnostic Dilemmas Diagnostic Dilemmas
Antenatal hydro doesn Antenatal hydro doesn t necessarily = t necessarily =
obstruction obstruction
Hydro from active Hydro from active diuresis diuresis (e.g. late gestation fetal (e.g. late gestation fetal
kidney kidney high output, high compliance) high output, high compliance)
Temporary fetal kidney obstruction with Temporary fetal kidney obstruction with
spontaneous resolution (mucosal spontaneous resolution (mucosal
folds/convolutions) folds/convolutions)
Minimal hydro doesn Minimal hydro doesn t necessarily = no risk t necessarily = no risk
Intrarenal Intrarenal vs. vs. extrarenal extrarenal pelvis with UPJO pelvis with UPJO
Olympic National Park, WA
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Pediatric UPJO W/U
Pediatric UPJO W/U
Post Post- -natal natal w/u w/u of Antenatal Hydro of Antenatal Hydro
Ultrasound Ultrasound renal & bladder renal & bladder
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Ultrasound Ultrasound
Delay post Delay post- -natal U/S at least 48 hours (? 2 natal U/S at least 48 hours (? 2
weeks) weeks) d/t d/t relative relative oliguria oliguria in early postnatal in early postnatal
period period
Neonate GFR doubles in first week Neonate GFR doubles in first week
Risk of underestimating degree of hydro Risk of underestimating degree of hydro
Day 1 2 Weeks
Ultrasound Ultrasound
Key factors to note: Key factors to note:
Degree of Degree of hydronephrosis hydronephrosis
Thickness of parenchyma Thickness of parenchyma
Echotexture Echotexture of parenchyma of parenchyma
Contralateral Contralateral hypertrophy hypertrophy
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SFU Grading System SFU Grading System
Grade 1 = renal pelvis splitting only Grade 1 = renal pelvis splitting only
Grade 2 = Grade 2 = pelvicalyceal pelvicalyceal dilation (some calyces dilation (some calyces
only) only)
Grade 3 = significant Grade 3 = significant pelvicalyceal pelvicalyceal dilation (all dilation (all
calyces) calyces)
Grade 4 = Grade 3 + Grade 4 = Grade 3 + parenchymal parenchymal thinning thinning
1
4 3
2
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103 infants <1yo (71% male) with 103 infants <1yo (71% male) with hydronephrosis hydronephrosis or or
hydroureteronephrosis hydroureteronephrosis
61 of 97 61 of 97 hydronephrotic hydronephrotic kidneys = obstructed ( kidneys = obstructed (lasix lasix
renogram renogram) )
Using cutoff of Grade 3 or higher for obstruction Using cutoff of Grade 3 or higher for obstruction
88% sensitive, 95% specific 88% sensitive, 95% specific
Conclusion: Conclusion: the radiological diagnosis of obstruction the radiological diagnosis of obstruction
is linked with the grade of is linked with the grade of hydronephrosis hydronephrosis
Randomly selected ultrasounds shown to group of trainees & Randomly selected ultrasounds shown to group of trainees &
staff pediatric urologists twice (7 staff pediatric urologists twice (7- -14 days apart) & SFU 14 days apart) & SFU
grading judged grading judged
Intra Intra- -rater agreement rater agreement good good
Staff: 69 Staff: 69- -94% 94%
Trainees: 63 Trainees: 63- -90% 90%
Inter Inter- -rater agreement rater agreement modest modest
SFU0 = high SFU0 = high
SFU1,2,4 = fair SFU1,2,4 = fair
SFU3 = poor SFU3 = poor
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Ultrasound Ultrasound ?Other Markers of ?Other Markers of
Obstruction Obstruction
Pelvicaliceal Pelvicaliceal diameter > 2.0cm = high risk of diameter > 2.0cm = high risk of
requiring surgery requiring surgery
Renal Renal parenchymal parenchymal : : pelvicaliceal pelvicaliceal area area
<1.6 = correlates with obstructive pattern on diuretic <1.6 = correlates with obstructive pattern on diuretic
renography renography & need for & need for pyeloplasty pyeloplasty
>1.6 = can be safely observed >1.6 = can be safely observed
Serial ultrasounds Serial ultrasounds
Worsening Worsening hydronephrosis hydronephrosis = likely obstruction = likely obstruction
Compensatory Compensatory contralateral contralateral growth growth
Doppler U/S Doppler U/S
RI > 0.75 = more likely obstructed RI > 0.75 = more likely obstructed
RI findings further provoked with RI findings further provoked with lasix lasix dose dose
Only useful in acute obstruction, not chronic Only useful in acute obstruction, not chronic (AUAUS (AUAUS 07 07- -L5) L5)
Rule out VUR Rule out VUR
VCUG VCUG
Nuclear VCUG Nuclear VCUG
Low grade VUR common Low grade VUR common
High grade VUR may cause secondary UPJO High grade VUR may cause secondary UPJO
If equivocal obstruction If equivocal obstruction fix VUR & monitor UPJO fix VUR & monitor UPJO
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VCUG VCUG
Nuclear Nuclear Renography Renography
Has supplanted IVP as primary functional Has supplanted IVP as primary functional
diagnostic test diagnostic test
Considerable controversy in protocols for Considerable controversy in protocols for
performing and interpretation b/w centres performing and interpretation b/w centres
Well Well- -tempered tempered renogram renogram (SFU (SFU- -PNMC) PNMC)
Prehydration Prehydration with 10 with 10- -15 cc/kg NS 15 cc/kg NS
Foley catheter Foley catheter
DTPA or MAG3 (usually the latter now) DTPA or MAG3 (usually the latter now)
Diuresis Diuresis ( (lasix lasix) ) - - ???timing (F ???timing (F- -15, F0, F+20) 15, F0, F+20)
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Nuclear Nuclear Renography Renography Interpretation Interpretation
Obstruction: Obstruction:
Static measures (single test): Static measures (single test):
Rising drainage curve Rising drainage curve
T T > 20min > 20min
Differential Differential f f n n <40% <40%
Dynamic measures (serial tests): Dynamic measures (serial tests):
Declining differential renal Declining differential renal f`n f`n over time over time
Increasing hydro over time Increasing hydro over time
No Obstruction No Obstruction
Normal drainage curves Normal drainage curves
T T < 10min < 10min
Nuclear Nuclear Renography Renography Interpretation Interpretation
Causes of false positive (T Causes of false positive (T >20min) >20min): :
Dehydration Dehydration
Suboptimal dose/timing of diuretic Suboptimal dose/timing of diuretic
Poor renal function/immature kidneys Poor renal function/immature kidneys
Full bladder (no catheter) Full bladder (no catheter)
ROI poorly drawn ROI poorly drawn
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VCUG VCUG
MRI MRI
MRI MRI
Not widely used Not widely used thusfar thusfar
Gadolinium Gadolinium- -DTPA enhanced DTPA enhanced
Provide anatomical & functional information Provide anatomical & functional information
Differential renal Differential renal f f n n
Volume of enhancing renal parenchyma Volume of enhancing renal parenchyma
Renal transit time (akin to T Renal transit time (akin to T of nuclear of nuclear renogram renogram) )
Time from first cortical enhancement to contrast in Time from first cortical enhancement to contrast in ureter ureter at at
or below lower pole of kidney after or below lower pole of kidney after lasix lasix dose (>490sec = dose (>490sec =
obstr obstr.) .)
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VCUG VCUG
MRI MRI
Whitaker Test Whitaker Test
NT & Foley catheter NT & Foley catheter
Pressure readings from renal pelvis & bladder Pressure readings from renal pelvis & bladder
Flow rate @ 5 Flow rate @ 5- -10cc/sec 10cc/sec
Obstruction = Obstruction = P > 20cmH P > 20cmH
2 2
O O
Unobstructed = Unobstructed = P < 12cmH P < 12cmH
2 2
O O
Criticisms: Criticisms:
Cumbersome Cumbersome
No one knows how to do it anymore No one knows how to do it anymore
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VCUG VCUG
MRI MRI
Biomarkers Biomarkers
?Biomarkers ?Biomarkers
NAG = N NAG = N- -Aceytl Aceytl- - - -D D- -glucosaminidase glucosaminidase
TGF TGF- - 1 1
Both found at increased levels in urine of Both found at increased levels in urine of
obstructed kidneys obstructed kidneys
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15 children underwent UPJO repair vs. 11 15 children underwent UPJO repair vs. 11
controls with dilated non controls with dilated non- -obstructed kidneys obstructed kidneys
TGF TGF- - 1 measured in renal pelvis, bladder of 1 measured in renal pelvis, bladder of
UPJO kids UPJO kids preop preop & 3 & 3 mos mos postop postop
Bladder TGF Bladder TGF- - 1 measured in controls 1 measured in controls
Obstruction = TGF Obstruction = TGF- - 1 > 29pg/mg 1 > 29pg/mg creatinine creatinine
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Pediatric W/U Summary Pediatric W/U Summary
Antenatal U/S followed by post Antenatal U/S followed by post- -natal U/S at 2 natal U/S at 2
weeks weeks
VCUG to VCUG to r/o r/o VUR VUR
Nuclear Nuclear renogram renogram to define differential to define differential
function and drainage function and drainage
If acceptable differential function & drainage If acceptable differential function & drainage
curves, follow with serial U/S +/ curves, follow with serial U/S +/- - nuclear nuclear
renograms renograms (esp. if U/S changes) (esp. if U/S changes)
Kids Kids - - Who to treat? Who to treat?
Symptomatic (pain, Symptomatic (pain, hematuria hematuria, HTN, etc) , HTN, etc)
Ultrasound: Ultrasound:
Evolving Evolving parenchymal parenchymal thinning thinning
Contralateral Contralateral compensatory hypertrophy compensatory hypertrophy
Nuclear Nuclear renogram renogram: :
Declining renal Declining renal f f n n (?<40%) (?<40%)
Worsening obstruction (?T Worsening obstruction (?T <20min) <20min)
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Who to treat? Who to treat? Special case Special case
B/L UPJO (10% cases) & Solitary kidney B/L UPJO (10% cases) & Solitary kidney
Nuclear Nuclear renogram renogram & U/S interpretation more & U/S interpretation more
difficult as no difficult as no normal normal kidney for comparison kidney for comparison
Treatment decision making Treatment decision making
Relies on clinician Relies on clinician judgement judgement based on: based on:
Drainage curves Drainage curves
Degree of Degree of hydronephrosis hydronephrosis
Adult UPJO W/U Summary Adult UPJO W/U Summary
Goals: Goals:
Confirm functionally significant obstruction Confirm functionally significant obstruction
Assessment of differential renal function Assessment of differential renal function
Delineation of UPJ anatomy Delineation of UPJ anatomy
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Adult UPJO W/U Summary Adult UPJO W/U Summary
Nuclear Nuclear renogram renogram
Differential function Differential function
Drainage curves Drainage curves
CT CT- -angiogram angiogram
Vascular anatomy (?crossing vessel) Vascular anatomy (?crossing vessel)
Degree of hydro Degree of hydro
?Retrograde ?Retrograde pyelogram pyelogram
Usually at time of definitive Usually at time of definitive Tx Tx to assess stricture to assess stricture
length length
Adults Adults Who to Treat? Who to Treat?
Symptomatic Symptomatic
Complications Complications
Infection Infection
Stones Stones
Renal function compromise Renal function compromise
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Hot Springs, Tofino
Management
Management
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Management Options Management Options
Open repair Open repair
Minimally Invasive repair Minimally Invasive repair
Endoscopic Endoscopic
Laparoscopic Laparoscopic
Management Management
Open surgical repair Open surgical repair
techniques: techniques:
Foley Y Foley Y- -V V plasty plasty
No pelvic reduction No pelvic reduction
Can Can t transpose crossing t transpose crossing
vessel vessel
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Open surgical repair techniques: Open surgical repair techniques:
Culp Culp DeWeerd DeWeerd s s spiral flap spiral flap
Can get significant length with large renal pelvis Can get significant length with large renal pelvis
Davis Davis intubated intubated ureterostomy ureterostomy
Stent & NT Stent & NT
6 weeks for 6 weeks for ureteric ureteric wall regeneration wall regeneration
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Anderson Anderson- -Hynes dismembered Hynes dismembered pyeloplasty pyeloplasty
Allows transposition anterior to crossing vessels Allows transposition anterior to crossing vessels
Excision of diseased segment Excision of diseased segment
Reduction Reduction pyeloplasty pyeloplasty
Spiral flap can be used for extra length Spiral flap can be used for extra length
Open Approaches Open Approaches
Anterior Anterior subcostal subcostal muscle muscle- -splitting splitting
Flank Flank off tip of 12 or supra off tip of 12 or supra- -12 12
Dorsal Dorsal lumbotomy lumbotomy
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Outcomes of Open Repairs Outcomes of Open Repairs
No review papers/meta No review papers/meta- -analysis analysis
My review of dozens of papers: My review of dozens of papers:
Consistently >90% (92 Consistently >90% (92- -100%) 100%)
Salvage Salvage pyeloplasty pyeloplasty = 80%+ = 80%+
Fog House, Saturna Island
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Managment Managment
Minimally invasive approaches Minimally invasive approaches
Endoscopic Endoscopic
Endopyelotomy Endopyelotomy
Access: Access:
Antegrade Antegrade or retrograde or retrograde
Technique: Technique:
Balloon dilatation Balloon dilatation
Acucise Acucise
Cold Cold- -knife knife
Hot Hot- -knife knife
Laser Laser
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Endopyelotomy Endopyelotomy
Indications Indications
Mild Mild- -moderate hydro moderate hydro
Good renal function (>30%) Good renal function (>30%)
Short Short stenosis stenosis (<1.5cm) (<1.5cm)
Absence of crossing vessel Absence of crossing vessel
Previous Previous pyeloplasty pyeloplasty (open/lap) failure (open/lap) failure
Predictors of poor outcome: Predictors of poor outcome:
Crossing vessel Crossing vessel
Severe Severe hydronephrosis hydronephrosis (esp. >100cc) (esp. >100cc)
Long stricture length Long stricture length
Poor renal function (<20%) Poor renal function (<20%)
Prior failed Prior failed endopyelotomy endopyelotomy
Retrograde Retrograde Endopyelotomy Endopyelotomy
Balloon dilatation Balloon dilatation
Late 1980 Late 1980 s s
Concept = retrograde Concept = retrograde pyeloloysis pyeloloysis & & stenting stenting
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43 43 UPJ UPJ s s in 42 pts. in 42 pts.
79% primary UPJ 79% primary UPJ
30 Fr. Balloon diam. 30 Fr. Balloon diam.
10 Fr. JJ x 6wks 10 Fr. JJ x 6wks
Improvement Improvement = >5% increase split = >5% increase split f f n n OR OR
T T <20min <20min
80% improved symptoms (85% 1 80% improved symptoms (85% 1
o o
; 56% 2 ; 56% 2
o o
) )
79% 79% renographic renographic improvement (82% 1 improvement (82% 1
o o
; 56% 2 ; 56% 2
o o
) )
Balloon dilatation in kids Balloon dilatation in kids
First described in mid First described in mid- -1990`s 1990`s
10 Children with obstruction on 10 Children with obstruction on lasix lasix renogram renogram (3mos (3mos 9 yrs) 9 yrs)
C&P C&P
UVJ dilation to 5 Fr UVJ dilation to 5 Fr
3.8 F, 8Atm 3.8 F, 8Atm Meditech Meditech radial balloon dilator radial balloon dilator
3 minute dilation (hourglass deformity removed) 3 minute dilation (hourglass deformity removed)
4.8 F JJ stent x 6 weeks 4.8 F JJ stent x 6 weeks
Urology 1995 46(1): 89-91
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Outcomes: Outcomes:
Median Median f/u f/u 22mos (4 22mos (4- -25) 25)
Lasix Lasix renogram renogram @ 3 @ 3- -6 6 mos mos postop postop = 70% success = 70% success
No obstruction = 6 No obstruction = 6
Improved drainage = 1 (T Improved drainage = 1 (T 90min 90min 28min) 28min)
3 failed 3 failed
Urology 1995 46(1): 89-91
Acucise Acucise
First publication 1994 First publication 1994
2 kids 2 kids
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Acucise Acucise
77 patient series, 1991 77 patient series, 1991- -1998 1998
No preoperative vascular imaging No preoperative vascular imaging
Posterolateral Posterolateral incision of UPJ & JJ incision of UPJ & JJ stenting stenting
78% success 78% success
4% post 4% post- -operative hemorrhage (3 pts) operative hemorrhage (3 pts)
2 required 2 required embolization embolization
Acucise Acucise Endopyelotomy Endopyelotomy
52 52- -81% radiographic success 81% radiographic success
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Laser Laser ureteroscopic ureteroscopic endopyelotomy endopyelotomy
20 20 ureters ureters in 18 adult patients in 18 adult patients
11 stone 11 stone- -scar, 3 scar, 3 ureteroenteric ureteroenteric ( (neobladders neobladders), ),
5 UPJO, 1 primary 5 UPJO, 1 primary ureteric ureteric
8 Fr 8 Fr semirigid semirigid ureteroscope ureteroscope, Holmium @ 10W , Holmium @ 10W
(1J x 10Hz), incised to fat, 12F JJ stent x6wks (1J x 10Hz), incised to fat, 12F JJ stent x6wks
Laser Laser ureteroscopic ureteroscopic endopyelotomy endopyelotomy
F/U = nuclear F/U = nuclear renogram renogram or U/S & IVP or U/S & IVP
Mean stricture length = 2.25cm Mean stricture length = 2.25cm
Mean Mean f/u f/u = 60 = 60 mos mos (46 (46- -74) 74)
80% success 80% success both both ureteric ureteric & UPJ & UPJ
1 UPJO failure = high insertion 1 UPJO failure = high insertion
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Laser Laser Endopyelotomy Endopyelotomy vs. vs. Acucise Acucise
RCT, 2001 RCT, 2001- -2003 2003
40 adult patients (mean age 39); 20/group 40 adult patients (mean age 39); 20/group
14 primary UPJO; 26 secondary 14 primary UPJO; 26 secondary
Preop Preop w/u w/u = IVP, CT for vasculature, = IVP, CT for vasculature, lasix lasix renogram renogram
J Urol 2006, 175: 614-618
Techniques: Techniques:
14/7 14/7 endopyelotomy endopyelotomy stent vs. 7 Fr JJ stent vs. 7 Fr JJ
J Urol 2006, 175: 614-618
-0.5 cc contrast in balloon to ensure
position
- 75-100W x 5 sec as 2cc injected in
balloon
- re-fire x1 if still waisted
- Keep inflated x10min for hemostasis
- Retrograde pyelogram to confirm
extravasation
- 1.2 J, 10Hz = 12 W
- Lateral incision to fat
- 8 Fr. Semirigid ureteroscope
- Balloon diln prn for hemostasis (1 pt)
Acucise Acucise Laser Laser Endopyelotomy Endopyelotomy
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Success Success = subjective improvement in = subjective improvement in Sx Sx
with objective improvement in obstruction with objective improvement in obstruction
(T (T <20min, improved/stable GFR) <20min, improved/stable GFR)
J Urol 2006, 175: 614-618
Complications: Complications:
Laser = 1 patient (nausea & vomiting) Laser = 1 patient (nausea & vomiting)
Acucise Acucise = 4 patients (20%) = 4 patients (20%)
1 sepsis 1 sepsis
3 post 3 post- -op bleeds op bleeds 1u 1u pRBC pRBC s s each, no each, no embolisation embolisation
J Urol 2006, 175: 614-618
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J Urol 2006, 175: 614-618
38
Tofino Sunset
Antegrade Antegrade Endopyelotomy Endopyelotomy
Adults & older children/adolescents Adults & older children/adolescents
Via Via nephrostomy nephrostomy tract (posterior middle calyx) tract (posterior middle calyx)
Dilation, cold Dilation, cold- -knife, knife, electrocautery electrocautery, or laser , or laser
Endopyelotomy Endopyelotomy stent x6wks stent x6wks
Advantages: Advantages:
Concomitant PCNL Concomitant PCNL
Anatomic factors that Anatomic factors that
preclude preclude ureteroscopy ureteroscopy
Direct vision Direct vision
Disadvantages: Disadvantages:
Multiple anesthetics Multiple anesthetics
Increased morbidity Increased morbidity
Longer hospital stay Longer hospital stay
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1990 1990- -2002 2002
37 children with primary UPJO 37 children with primary UPJO
Mean age 11.5 yrs (4.5 Mean age 11.5 yrs (4.5- -17) 17)
Preop Preop Dx Dx = U/S & IVP (no = U/S & IVP (no renograms renograms) )
All All percutaneous percutaneous antegrade antegrade endopyelotomy endopyelotomy
F/U = IVP at 1 year F/U = IVP at 1 year postop postop
Ureteral Ureteral catheter catheter methylene methylene blue in pelvis blue in pelvis
Middle Middle calyceal calyceal puncture puncture
Dilated to 26 Fr. Dilated to 26 Fr.
Wire placed Wire placed antegrade antegrade across UPJ (catheter removed) across UPJ (catheter removed)
Cold Cold endopyelotomy endopyelotomy knife knife dorsolateral dorsolateral incision to fat incision to fat
6 6- -12 Fr. JJ stent or 12 Fr. JJ stent or trans trans- -renal drain renal drain x 6 weeks x 6 weeks
Antegrade Antegrade nephrostogram nephrostogram extravasation extravasation confirmed full confirmed full- -
thickness incision thickness incision
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Outcomes: Outcomes:
Complications: Complications:
2 children required exploration 2 children required exploration d/t d/t bleeding from bleeding from
crossing vessel crossing vessel ligation & open ligation & open pyeloplasty pyeloplasty
4 children with fever 4 children with fever ampicillin ampicillin & & acetominophen acetominophen
Hospital stay = 2 Hospital stay = 2- -10 days (mean = 6) 10 days (mean = 6)
81% 81% good good , 8% , 8% satisfactory satisfactory , 11% failures , 11% failures
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So long ago, I cant remember
Laparoscopic Laparoscopic Pyeloplasty Pyeloplasty
First described in adults in 1993 ( First described in adults in 1993 (Kavoussi Kavoussi) )
First described in kids in 1999 (Tan) First described in kids in 1999 (Tan)
First pediatric robot First pediatric robot- -assisted described in 2002 assisted described in 2002
(Peters) (Peters)
Transperitoneal Transperitoneal vs. retroperitoneal vs. retroperitoneal
Probably little advantage in child < 2yrs (DL Probably little advantage in child < 2yrs (DL
equally non equally non- -morbid) morbid)
Increasingly the preferred first Increasingly the preferred first- -line line
approach approach
42
Head
Feet
R side down
43
Outcomes are equivalent to open (symptomatic Outcomes are equivalent to open (symptomatic
& objective) & objective)
Radiographic success rates: 88 Radiographic success rates: 88- -100% 100%
Open vs. Lap Open vs. Lap Pyeloplasty Pyeloplasty Trials (Adults): Trials (Adults):
Succes Succes = radiographic ( = radiographic (renogram renogram) )
Currently, the role of open surgery in the surgical algorithm of Currently, the role of open surgery in the surgical algorithm of UPJO is UPJO is
reserved for patients who require reserved for patients who require pyeloplasty pyeloplasty when laparoscopic surgery is when laparoscopic surgery is
unavailable or technically unavailable or technically prohibitive prohibitive
AUAUS AUAUS 26(6) 26(6)
5-11 mos
23 mos
12+ mos
F/U F/U
86% 94% Baldwin, 2003
93% 96% Klingler, 2003
94% 98% Bauer, 1999
Open Success Open Success Lap Lap
Success Success
Study Study
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Expanding indications: Expanding indications:
Renal calculi (concomitant Renal calculi (concomitant pyelolithotomy pyelolithotomy) )
Solitary kidneys Solitary kidneys
Anatomically anomalous kidneys Anatomically anomalous kidneys
15 pure 15 pure retroperitoneoscopic retroperitoneoscopic pyeloplasties pyeloplasties vs. vs.
first 8 first 8 DaVinci DaVinci- -assisted assisted pyeloplasties pyeloplasties
Robot used for Robot used for anastamosis anastamosis only only
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Operative (skin Operative (skin- -skin) time significantly shorter for skin) time significantly shorter for
robot (172 vs. 210 min) robot (172 vs. 210 min)
Setup time for robot = 40 min Setup time for robot = 40 min
Conclusion: for first 8 cases, robot was time neutral, Conclusion: for first 8 cases, robot was time neutral,
complication neutral, hospital complication neutral, hospital- -stay neutral stay neutral
Robotic Robotic- -assisted Success Rates: 94 assisted Success Rates: 94- -100% 100%
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Treatment Algorithm (Adult) Treatment Algorithm (Adult)
Outcomes Summary Outcomes Summary
52-81%
2
Limited use Acucise Acucise
88-100% 87-100%
Pyeloplasty Pyeloplasty
67-88% 72-92%
3
Antegrade Antegrade
endopyelotomy endopyelotomy
73-85%
2
~67%
Laser Laser
endopyelotomy endopyelotomy
86-100% 90-100% Open repair Open repair
Adult success rates Adult success rates Pediatric success rates Pediatric success rates Technique Technique
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Outcomes Summary Outcomes Summary
References: References:
1. 1. Tan et al, Urology 1995, 46(1): 89 Tan et al, Urology 1995, 46(1): 89- -91 91
2. 2. El El- -Nahas Nahas, JU 2006, 175: 614 , JU 2006, 175: 614- -618 618
3. 3. Tallai Tallai, J , J Endourol Endourol 2004, 18(10): 952 2004, 18(10): 952- -8 8
Primary Treatment Failure Primary Treatment Failure
Salvage = try the other option Salvage = try the other option
72 adult patients 72 adult patients
Antegrade Antegrade endopyelotomy endopyelotomy
Mean Mean f/u f/u = 88.5 = 88.5 mos mos
87.5% clinical & radiographic success 87.5% clinical & radiographic success
48
Primary Treatment Failure Primary Treatment Failure
Salvage = try the other option Salvage = try the other option
43 adult patients underwent open 43 adult patients underwent open pyeloplasty pyeloplasty
after after endopyelotomy endopyelotomy failure failure
95% clinical & radiographic success 95% clinical & radiographic success
Post Post- -treatment Follow treatment Follow- -up up
Pediatric UPJO: Pediatric UPJO:
Serial U/S Serial U/S
Gradual improvement in hydro is the rule Gradual improvement in hydro is the rule
<50% improve within 6 months of repair <50% improve within 6 months of repair
80% improve at 2 years 80% improve at 2 years
Monitor renal growth Monitor renal growth
Worsening hydro should prompt nuclear Worsening hydro should prompt nuclear renogram renogram
Indications for nuclear Indications for nuclear renogram renogram
Worsening hydro on U/S Worsening hydro on U/S
Poor renal growth on U/S Poor renal growth on U/S
Persistent symptoms Persistent symptoms
49
Histologic Histologic Findings in UPJO Findings in UPJO
Biopsy findings of kidneys with UPJO Biopsy findings of kidneys with UPJO
Dilation of collecting ducts & Bowman Dilation of collecting ducts & Bowman s space s space
Decreased # Decreased # glomeruli glomeruli
Interstitial fibrosis & inflammation Interstitial fibrosis & inflammation
Global/segmental sclerosis Global/segmental sclerosis
Cortical cysts Cortical cysts
Duck Sanctuary
50
Summary
Summary
Summary Summary
Diagnosis Diagnosis
Kids: Kids:
U/S U/S
VCUG VCUG
Renogram Renogram
Adults: Adults:
CTA CTA
Renogram Renogram
?retrograde ?retrograde
51
Summary Summary
Decision to treat: Decision to treat:
Symptoms Symptoms
Complications (stones, infection) Complications (stones, infection)
Declining renal function Declining renal function
U/S criteria = U/S criteria = parenchymal parenchymal thinning, thinning, contralateral contralateral
hypertrophy hypertrophy
Renogram Renogram criteria = worsening split criteria = worsening split f f n n, ?drainage , ?drainage
curves, ?T curves, ?T
Summary Summary
Treatment modality: Treatment modality:
Kids: Kids:
Open > Endoscopic Open > Endoscopic
Lap data emerging (esp. age 2+) Lap data emerging (esp. age 2+)
Adults Adults
Lap = Open Lap = Open > > Endoscopic Endoscopic
First line choice = discretion of clinician First line choice = discretion of clinician
Salvage Salvage
Pyeloplasty Pyeloplasty Endoscopic Endoscopic
Endoscopic Endoscopic Pyeloplasty Pyeloplasty
52
THE END

Nov 7 07

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