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Review of UPJReview of UPJ
ObstructionObstruction
November 7, 2007November 7, 2007
Chris Hoag, PGY5 UBC UrologyChris Hoag, PGY5 UBC Urology
ReferencesReferences
CWU9CWU9Ch115Ch115
AUAUS 2007AUAUS 2007Lessons 5 & 6Lessons 5 & 6
Literature reviewLiterature review
The Centre of the UniverseThe 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 FactsUPJO Facts
1/1500 live births1/1500 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 10Bilateral in 10--40%40%
Runs in familiesRuns in families
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EtiologyEtiology
PrimaryPrimary
IntrinsicIntrinsic
ExtrinsicExtrinsic
SecondarySecondary
Primary UPJOPrimary UPJO
IntrinsicIntrinsic
AdynamicAdynamic segment/intrinsic narrowingsegment/intrinsic narrowing
Delayed/failedDelayed/failed recanalizationrecanalization after periodafter period
of obstructionof obstruction
Neuronal depletion in proximalNeuronal depletion in proximal ureterureter
Incomplete development of circular sm. m.Incomplete development of circular sm. m.
Alteration of collagenAlteration of collagen fiberfibercompositioncomposition
b/w sm. m. cellsb/w sm. m. cells
ValvularValvular((OstlingOstlingss) mucosal folds) mucosal folds
PersistentPersistent fetalfetal convolutionsconvolutions
UreteralUreteralpolypspolyps
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Primary UPJOPrimary UPJO
ExtrinsicExtrinsic
Crossing vessel (anterior)Crossing vessel (anterior)
RenalRenal malrotationmalrotation (over/under)(over/under)
PathophysiologyPathophysiology of Extrinsic UPJOof Extrinsic UPJO
Crossing vesselCrossing vessel two point of kinkingtwo point of kinking
WhereWhere ureterureterdrapes overdrapes over
Angulated at UPJAngulated at UPJ
Ensuing pelvic distension &Ensuing pelvic distension &
inflammationinflammation
Further adhesion kinking &Further adhesion kinking &22--point obstructionpoint obstruction
Ischemia, fibrosis,Ischemia, fibrosis, stenosisstenosis
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Secondary UPJOSecondary UPJO
Severe VUR (Grade IV/V) (10%)Severe VUR (Grade IV/V) (10%)
Kinking of tortuous system at relatively fixed UPJKinking of tortuous system at relatively fixed UPJ
Lower pole moiety of incomplete duplicationLower pole moiety of incomplete duplication
Secondary UPJOSecondary UPJO
Severe VUR (Grade IV/V) (10%)Severe VUR (Grade IV/V) (10%)
Kinking of tortuous system at relatively fixed UPJKinking of tortuous system at relatively fixed UPJ
Lower pole moiety of incomplete duplicationLower pole moiety of incomplete duplication
StoneStone--related scarrelated scar
Iatrogenic (instrumentation)Iatrogenic (instrumentation)
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Associated Congenital AnomaliesAssociated Congenital Anomalies
GU Anomalies:GU Anomalies:
ContralateralContralateral UPJO = #1 (10UPJO = #1 (10--40%)40%)
VUR (up to 40%)VUR (up to 40%)usually low gradeusually low grade
Renal dysplasiaRenal dysplasia
MCDKMCDK
Renal agenesis (5%)Renal agenesis (5%)
Duplicated system (usually lower moiety UPJO)Duplicated system (usually lower moiety UPJO)
Horseshoe kidneyHorseshoe kidney Ectopic kidneyEctopic kidney
NonNon--GU Anomalies: VATERR (10GU Anomalies: VATERR (10--20%)20%)
Zion Canyon, Utah
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DiagnosisDiagnosis
PresentingPresenting S&SxS&Sx
InfantsInfants
HydronephrosisHydronephrosis on antenatal U/S = majorityon antenatal U/S = majority
Palpable abdominal massPalpable abdominal mass
FTTFTT
Feeding problemsFeeding problems
Sepsis (UTI) = presentingSepsis (UTI) = presenting SxSx 30% beyond30% beyond
neonatal periodneonatal period
Pain/Pain/hematuriahematuria (stones)(stones)
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Diagnostic DilemmasDiagnostic Dilemmas
Antenatal hydro doesnAntenatal hydro doesnt necessarily =t necessarily =
obstructionobstruction
Hydro from activeHydro from active diuresisdiuresis (e.g. late gestation fetal(e.g. late gestation fetal
kidneykidney high output, high compliance)high output, high compliance)
Temporary fetal kidney obstruction withTemporary fetal kidney obstruction with
spontaneous resolution (mucosalspontaneous resolution (mucosal
folds/convolutions)folds/convolutions)
Minimal hydro doesnMinimal hydro doesnt necessarily = no riskt necessarily = no risk IntrarenalIntrarenal vs.vs. extrarenalextrarenalpelvis with UPJOpelvis with UPJO
Olympic National Park, WA
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Pediatric UPJO W/UPediatric UPJO W/U
PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro
UltrasoundUltrasoundrenal & bladderrenal & bladder
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UltrasoundUltrasound
Delay postDelay post--natal U/S at least 48 hours (? 2natal U/S at least 48 hours (? 2
weeks)weeks) d/td/t relativerelative oliguriaoliguria in early postnatalin early postnatal
periodperiod
Neonate GFR doubles in first weekNeonate GFR doubles in first week
Risk of underestimating degree of hydroRisk of underestimating degree of hydro
Day 1 2 Weeks
UltrasoundUltrasound
Key factors to note:Key factors to note:
Degree ofDegree of hydronephrosishydronephrosis
Thickness of parenchymaThickness of parenchyma
EchotextureEchotexture of parenchymaof parenchyma
ContralateralContralateral hypertrophyhypertrophy
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SFU Grading SystemSFU Grading System
Grade 1 = renal pelvis splitting onlyGrade 1 = renal pelvis splitting only
Grade 2 =Grade 2 =pelvicalycealpelvicalyceal dilation (some calycesdilation (some calyces
only)only)
Grade 3 = significantGrade 3 = significantpelvicalycealpelvicalyceal dilation (alldilation (all
calyces)calyces)
Grade 4 = Grade 3 +Grade 4 = Grade 3 +parenchymalparenchymal thinningthinning
SFU Grading SystemSFU Grading System
1
43
2
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SFU Grading SystemSFU Grading System
103 infants
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UltrasoundUltrasound?Other Markers of?Other Markers of
ObstructionObstruction PelvicalicealPelvicaliceal diameter > 2.0cm = high risk ofdiameter > 2.0cm = high risk of
requiring surgeryrequiring surgery
RenalRenalparenchymalparenchymal ::pelvicalicealpelvicaliceal areaarea 1.6 = can be safely observed
Serial ultrasoundsSerial ultrasounds WorseningWorsening hydronephrosishydronephrosis = likely obstruction= likely obstruction
CompensatoryCompensatory contralateralcontralateral growthgrowth
Doppler U/SDoppler U/S RI > 0.75 = more likely obstructedRI > 0.75 = more likely obstructed
RI findings further provoked withRI findings further provoked with lasixlasix dosedose
Only useful in acute obstruction, not chronicOnly useful in acute obstruction, not chronic (AUAUS(AUAUS 0707--L5)L5)
PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro
UltrasoundUltrasoundrenal & bladderrenal & bladder
Rule out VURRule out VUR
VCUGVCUG
Nuclear VCUGNuclear VCUG
Low grade VUR commonLow grade VUR common High grade VUR may cause secondary UPJOHigh grade VUR may cause secondary UPJO
If equivocal obstructionIf equivocal obstruction fix VUR & monitor UPJOfix VUR & monitor UPJO
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PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro
UltrasoundUltrasoundrenal & bladderrenal & bladder
VCUGVCUG
NuclearNuclear RenographyRenography
NuclearNuclear RenographyRenography
Has supplanted IVP as primary functionalHas supplanted IVP as primary functionaldiagnostic testdiagnostic test
Considerable controversy in protocols forConsiderable controversy in protocols forperforming and interpretation b/w centresperforming and interpretation b/w centres
WellWell--temperedtempered renogramrenogram (SFU(SFU--PNMC)PNMC)
PrehydrationPrehydration with 10with 10--15 cc/kg NS15 cc/kg NS
Foley catheterFoley catheter DTPA or MAG3 (usually the latter now)DTPA or MAG3 (usually the latter now)
DiuresisDiuresis ((lasixlasix)) -- ???timing (F???timing (F--15, F0, F+20)15, F0, F+20)
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NuclearNuclear RenographyRenography
NuclearNuclear RenographyRenography InterpretationInterpretation
Obstruction:Obstruction:
Static measures (single test):Static measures (single test):
Rising drainage curveRising drainage curve
TT > 20min> 20min
DifferentialDifferential ffnn 20min)::
DehydrationDehydration
Suboptimal dose/timing of diureticSuboptimal dose/timing of diuretic
Poor renal function/immature kidneysPoor renal function/immature kidneys
Full bladder (no catheter)Full bladder (no catheter)
ROI poorly drawnROI poorly drawn
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PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro
UltrasoundUltrasoundrenal & bladderrenal & bladder
VCUGVCUG
NuclearNuclear RenographyRenography
MRIMRI
MRIMRI
Not widely usedNot widely used thusfarthusfar
GadoliniumGadolinium--DTPA enhancedDTPA enhanced
Provide anatomical & functional informationProvide anatomical & functional information
Differential renalDifferential renal ffnn
Volume of enhancing renal parenchymaVolume of enhancing renal parenchyma
Renal transit time (akin to TRenal transit time (akin to T of nuclearof nuclear renogramrenogram))
Time from first cortical enhancement to contrast inTime from first cortical enhancement to contrast in ureterureteratat
or below lower pole of kidney afteror below lower pole of kidney after lasixlasix dose (>490sec =dose (>490sec =
obstrobstr.).)
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PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro
UltrasoundUltrasoundrenal & bladderrenal & bladder
VCUGVCUG
NuclearNuclear RenographyRenography
MRIMRI
Whitaker TestWhitaker Test
Whitaker TestWhitaker Test
NT & Foley catheterNT & Foley catheter
Pressure readings from renal pelvis & bladderPressure readings from renal pelvis & bladder
Flow rate @ 5Flow rate @ 5--10cc/sec10cc/sec
Obstruction =Obstruction = P > 20cmHP > 20cmH22OO
Unobstructed =Unobstructed = P < 12cmHP < 12cmH22OO
Criticisms:Criticisms:
CumbersomeCumbersome
No one knows how to do it anymoreNo one knows how to do it anymore
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PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro
UltrasoundUltrasoundrenal & bladderrenal & bladder
VCUGVCUG
NuclearNuclear RenographyRenography
MRIMRI
Whitaker TestWhitaker Test
BiomarkersBiomarkers
?Biomarkers?Biomarkers
NAG = NNAG = N--AceytlAceytl----DD--glucosaminidaseglucosaminidase
TGFTGF--11
Both found at increased levels in urine ofBoth found at increased levels in urine of
obstructed kidneysobstructed kidneys
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?Biomarkers?Biomarkers
15 children underwent UPJO repair vs. 1115 children underwent UPJO repair vs. 11
controls with dilated noncontrols with dilated non--obstructed kidneysobstructed kidneys
TGFTGF
--
1 measured in renal pelvis, bladder of1 measured in renal pelvis, bladder of
UPJO kidsUPJO kidspreoppreop & 3& 3 mosmospostoppostop
Bladder TGFBladder TGF--1 measured in controls1 measured in controls
?Biomarkers?Biomarkers
Obstruction = TGFObstruction = TGF--1 > 29pg/mg1 > 29pg/mg creatininecreatinine
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Who to treat?Who to treat?Special caseSpecial case
B/L UPJO (10% cases) & Solitary kidneyB/L UPJO (10% cases) & Solitary kidney
NuclearNuclear renogramrenogram & U/S interpretation more& U/S interpretation more
difficult as nodifficult as no normalnormal kidney for comparisonkidney for comparison
Treatment decision makingTreatment decision making
Relies on clinicianRelies on clinicianjudgementjudgementbased on:based on:
Drainage curvesDrainage curves
Degree ofDegree of hydronephrosishydronephrosis
Adult UPJO W/U SummaryAdult UPJO W/U Summary
Goals:Goals:
Confirm functionally significant obstructionConfirm functionally significant obstruction
Assessment of differential renal functionAssessment of differential renal function
Delineation of UPJ anatomyDelineation of UPJ anatomy
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Adult UPJO W/U SummaryAdult UPJO W/U Summary
NuclearNuclear renogramrenogram
Differential functionDifferential function
Drainage curvesDrainage curves
CTCT--angiogramangiogram
Vascular anatomy (?crossing vessel)Vascular anatomy (?crossing vessel)
Degree of hydroDegree of hydro
?Retrograde?Retrogradepyelogrampyelogram
Usually at time of definitiveUsually at time of definitive TxTx to assess strictureto assess stricturelengthlength
AdultsAdultsWho to Treat?Who to Treat?
SymptomaticSymptomatic
ComplicationsComplications
InfectionInfection
StonesStones
Renal function compromiseRenal function compromise
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Hot Springs, Tofino
ManagementManagement
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Management OptionsManagement Options
Open repairOpen repair
Minimally Invasive repairMinimally Invasive repair
EndoscopicEndoscopic
LaparoscopicLaparoscopic
ManagementManagement
Open surgical repairOpen surgical repair
techniques:techniques:
Foley YFoley Y--VVplastyplasty
No pelvic reductionNo pelvic reduction
CanCant transpose crossingt transpose crossing
vesselvessel
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ManagementManagement
Open surgical repair techniques:Open surgical repair techniques:
CulpCulp DeWeerdDeWeerdss spiral flapspiral flap
Can get significant length with large renal pelvisCan get significant length with large renal pelvis
ManagementManagement
Open surgical repair techniques:Open surgical repair techniques:
DavisDavis intubatedintubated ureterostomyureterostomy
Stent & NTStent & NT
6 weeks for6 weeks for uretericureteric wall regenerationwall regeneration
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ManagementManagement
Open surgical repair techniques:Open surgical repair techniques:
AndersonAnderson--Hynes dismemberedHynes dismemberedpyeloplastypyeloplasty
Allows transposition anterior to crossing vesselsAllows transposition anterior to crossing vessels
Excision of diseased segmentExcision of diseased segment
ReductionReductionpyeloplastypyeloplasty
Spiral flap can be used for extra lengthSpiral flap can be used for extra length
ManagementManagement
Open ApproachesOpen Approaches
AnteriorAnterior subcostalsubcostal musclemuscle--splittingsplitting
FlankFlankoff tip of 12 or supraoff tip of 12 or supra--1212
DorsalDorsal lumbotomylumbotomy
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Outcomes of Open RepairsOutcomes of Open Repairs
No review papers/metaNo review papers/meta--analysisanalysis
My review of dozens of papers:My review of dozens of papers:
Consistently >90% (92Consistently >90% (92--100%)100%)
SalvageSalvagepyeloplastypyeloplasty = 80%+= 80%+
Fog House, Saturna Island
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ManagmentManagment
Minimally invasive approachesMinimally invasive approaches
EndoscopicEndoscopic
LaparoscopicLaparoscopic
EndopyelotomyEndopyelotomy
Access:Access:
AntegradeAntegrade or retrogradeor retrograde
Technique:Technique:
Balloon dilatationBalloon dilatation
AcuciseAcucise
ColdCold--knifeknife
HotHot--knifeknife
LaserLaser
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EndopyelotomyEndopyelotomy
IndicationsIndications MildMild--moderate hydromoderate hydro
Good renal function (>30%)Good renal function (>30%)
ShortShort stenosisstenosis (100cc) Long stricture lengthLong stricture length
Poor renal function (
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RetrogradeRetrograde EndopyelotomyEndopyelotomy
4343 UPJUPJss in 42 pts.in 42 pts.
79% primary UPJ79% primary UPJ
30 Fr. Balloon diam.30 Fr. Balloon diam.
10 Fr. JJ x 6wks10 Fr. JJ x 6wks
ImprovementImprovement = >5% increase split= >5% increase split ffnn OROR
TT
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RetrogradeRetrograde EndopyelotomyEndopyelotomy
Outcomes:Outcomes:
MedianMedian f/uf/u 22mos (422mos (4--25)25)
LasixLasix renogramrenogram @ 3@ 3--66 mosmospostoppostop = 70% success= 70% success No obstruction = 6No obstruction = 6
Improved drainage = 1 (TImproved drainage = 1 (T 90min90min 28min)28min)
3 failed3 failedUrology 1995 46(1): 89-91
RetrogradeRetrograde EndopyelotomyEndopyelotomy
AcuciseAcucise
First publication 1994First publication 1994
2 kids2 kids
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RetrogradeRetrograde EndopyelotomyEndopyelotomy
AcuciseAcucise
77 patient series, 199177 patient series, 1991--19981998
No preoperative vascular imagingNo preoperative vascular imaging
PosterolateralPosterolateral incision of UPJ & JJincision of UPJ & JJ stentingstenting
78% success78% success 4% post4% post--operative hemorrhage (3 pts)operative hemorrhage (3 pts)
2 required2 required embolizationembolization
AcuciseAcucise EndopyelotomyEndopyelotomy
5252--81% radiographic success81% radiographic success
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RetrogradeRetrograde EndopyelotomyEndopyelotomy
LaserLaser ureteroscopicureteroscopic endopyelotomyendopyelotomy
2020 uretersureters in 18 adult patientsin 18 adult patients
11 stone11 stone--scar, 3scar, 3 ureteroentericureteroenteric ((neobladdersneobladders),),
5 UPJO, 1 primary5 UPJO, 1 primary uretericureteric
8 Fr8 Fr semirigidsemirigid ureteroscopeureteroscope, Holmium @ 10W, Holmium @ 10W(1J x 10Hz), incised to fat, 12F JJ stent x6wks(1J x 10Hz), incised to fat, 12F JJ stent x6wks
RetrogradeRetrograde EndopyelotomyEndopyelotomy
LaserLaser ureteroscopicureteroscopic endopyelotomyendopyelotomy
F/U = nuclearF/U = nuclear renogramrenogram or U/S & IVPor U/S & IVP
Mean stricture length = 2.25cmMean stricture length = 2.25cm
MeanMean f/uf/u = 60= 60 mosmos (46(46--74)74)
80% success80% successbothboth uretericureteric & UPJ& UPJ
1 UPJO failure = high insertion1 UPJO failure = high insertion
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RetrogradeRetrograde EndopyelotomyEndopyelotomy
LaserLaser EndopyelotomyEndopyelotomy vs.vs. AcuciseAcucise
RCT, 2001RCT, 2001--20032003
40 adult patients (mean age 39); 20/group40 adult patients (mean age 39); 20/group
14 primary UPJO; 26 secondary14 primary UPJO; 26 secondary
PreopPreop w/uw/u = IVP, CT for vasculature,= IVP, CT for vasculature, lasixlasix renogramrenogram
J Urol 2006, 175: 614-618
RetrogradeRetrograde EndopyelotomyEndopyelotomy
LaserLaser EndopyelotomyEndopyelotomy vs.vs. AcuciseAcucise
Techniques:Techniques:
14/714/7 endopyelotomyendopyelotomy stent vs. 7 Fr JJstent vs. 7 Fr JJJ 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)
AcuciseAcuciseLaserLaser EndopyelotomyEndopyelotomy
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RetrogradeRetrograde EndopyelotomyEndopyelotomy
LaserLaser EndopyelotomyEndopyelotomy vs.vs. AcuciseAcucise
SuccessSuccess = subjective improvement in= subjective improvement in SxSx
with objective improvement in obstructionwith objective improvement in obstruction
(T(T
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RetrogradeRetrograde EndopyelotomyEndopyelotomy
LaserLaser EndopyelotomyEndopyelotomy vs.vs. AcuciseAcucise
J Urol 2006, 175: 614-618
RetrogradeRetrograde EndopyelotomyEndopyelotomy
7373--85% radiographic success85% radiographic success
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Tofino Sunset
AntegradeAntegrade EndopyelotomyEndopyelotomy
Adults & older children/adolescentsAdults & older children/adolescents
ViaVia nephrostomynephrostomy tract (posterior middle calyx)tract (posterior middle calyx)
Dilation, coldDilation, cold--knife,knife, electrocauteryelectrocautery, or laser, or laser
EndopyelotomyEndopyelotomy stent x6wksstent x6wks
Advantages:Advantages:
Concomitant PCNLConcomitant PCNL Anatomic factors thatAnatomic factors that
precludepreclude ureteroscopyureteroscopy
Direct visionDirect vision
Disadvantages:Disadvantages:
Multiple anestheticsMultiple anesthetics Increased morbidityIncreased morbidity
Longer hospital stayLonger hospital stay
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AntegradeAntegrade EndopyelotomyEndopyelotomy
19901990--20022002
37 children with primary UPJO37 children with primary UPJO
Mean age 11.5 yrs (4.5Mean age 11.5 yrs (4.5--17)17)
PreopPreop DxDx = U/S & IVP (no= U/S & IVP (no renogramsrenograms)) AllAllpercutaneouspercutaneous antegradeantegrade endopyelotomyendopyelotomy
F/U = IVP at 1 yearF/U = IVP at 1 yearpostoppostop
AntegradeAntegrade EndopyelotomyEndopyelotomy
Technique:Technique:
UreteralUreteral cathetercatheter methylenemethyleneblue in pelvisblue in pelvis
MiddleMiddle calycealcalycealpuncturepuncture
Dilated to 26 Fr.Dilated to 26 Fr.
Wire placedWire placed antegradeantegrade across UPJ (catheter removed)across UPJ (catheter removed)
ColdCold endopyelotomyendopyelotomy knifeknifedorsolateraldorsolateral incision to fatincision to fat
66--12 Fr. JJ stent or12 Fr. JJ stent or transtrans--renal drainrenal drain x 6 weeksx 6 weeks
AntegradeAntegrade nephrostogramnephrostogram extravasationextravasation confirmed fullconfirmed full--
thickness incisionthickness incision
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AntegradeAntegrade EndopyelotomyEndopyelotomy
Outcomes:Outcomes:
Complications:Complications:
2 children required exploration2 children required exploration d/td/tbleeding frombleeding from
crossing vesselcrossing vessel ligation & openligation & openpyeloplastypyeloplasty
4 children with fever4 children with fever ampicillinampicillin && acetominophenacetominophen
Hospital stay = 2Hospital stay = 2--10 days (mean = 6)10 days (mean = 6) 81%81% goodgood, 8%, 8% satisfactorysatisfactory, 11% failures, 11% failures
AntegradeAntegrade EndopyelotomyEndopyelotomy
7373--88% radiographic success88% radiographic success
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So long ago, I cant remember
LaparoscopicLaparoscopic PyeloplastyPyeloplasty
First described in adults in 1993 (First described in adults in 1993 (KavoussiKavoussi))
First described in kids in 1999 (Tan)First described in kids in 1999 (Tan)
First pediatric robotFirst pediatric robot--assisted described in 2002assisted described in 2002(Peters)(Peters)
TransperitonealTransperitoneal vs. retroperitonealvs. retroperitoneal
Probably little advantage in child < 2yrs (DLProbably little advantage in child < 2yrs (DLequally nonequally non--morbid)morbid)
Increasingly the preferred firstIncreasingly the preferred first--linelineapproachapproach
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LaparoscopicLaparoscopic PyeloplastyPyeloplasty
Head Feet
R side down
LaparoscopicLaparoscopic PyeloplastyPyeloplasty
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LaparoscopicLaparoscopic PyeloplastyPyeloplasty
Expanding indications:Expanding indications:
Secondary UPJOSecondary UPJO
Renal calculi (concomitantRenal calculi (concomitantpyelolithotomypyelolithotomy))
Solitary kidneysSolitary kidneys
Anatomically anomalous kidneysAnatomically anomalous kidneys
LaparoscopicLaparoscopic PyeloplastyPyeloplasty
15 pure15 pure retroperitoneoscopicretroperitoneoscopicpyeloplastiespyeloplasties vs.vs.
first 8first 8 DaVinciDaVinci--assistedassistedpyeloplastiespyeloplasties
Robot used forRobot used for anastamosisanastamosis onlyonly
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LaparoscopicLaparoscopic PyeloplastyPyeloplasty
Operative (skinOperative (skin--skin) time significantly shorter forskin) time significantly shorter for
robot (172 vs. 210 min)robot (172 vs. 210 min)
Setup time for robot = 40 minSetup 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, hospitalcomplication neutral, hospital--stay neutralstay neutral
LaparoscopicLaparoscopic PyeloplastyPyeloplasty
RoboticRobotic--assisted Success Rates: 94assisted Success Rates: 94--100%100%
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Treatment Algorithm (Adult)Treatment Algorithm (Adult)
Outcomes SummaryOutcomes Summary
52-81%2Limited useAcuciseAcucise
88-100%87-100%LaparoscopicLaparoscopic
PyeloplastyPyeloplasty
67-88%72-92%3AntegradeAntegrade
endopyelotomyendopyelotomy
73-85%2~67%LaserLaser
endopyelotomyendopyelotomy
86-100%90-100%Open repairOpen repair
Adult success ratesAdult success ratesPediatric success ratesPediatric success ratesTechniqueTechnique
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Outcomes SummaryOutcomes Summary
References:References:
1.1. Tan et al, Urology 1995, 46(1): 89Tan et al, Urology 1995, 46(1): 89--9191
2.2. ElEl--NahasNahas, JU 2006, 175: 614, JU 2006, 175: 614--618618
3.3. TallaiTallai, J, J EndourolEndourol 2004, 18(10): 9522004, 18(10): 952--88
Primary Treatment FailurePrimary Treatment Failure
Salvage = try the other optionSalvage = try the other option
72 adult patients72 adult patients AntegradeAntegrade endopyelotomyendopyelotomy
MeanMean f/uf/u = 88.5= 88.5 mosmos
87.5% clinical & radiographic success87.5% clinical & radiographic success
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Primary Treatment FailurePrimary Treatment Failure
Salvage = try the other optionSalvage = try the other option
43 adult patients underwent open43 adult patients underwent openpyeloplastypyeloplasty
afterafter endopyelotomyendopyelotomy failurefailure 95% clinical & radiographic success95% clinical & radiographic success
PostPost--treatment Followtreatment Follow--upup
Pediatric UPJO:Pediatric UPJO:
Serial U/SSerial U/S
Gradual improvement in hydro is the ruleGradual improvement in hydro is the rule
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HistologicHistologic Findings in UPJOFindings in UPJO
Biopsy findings of kidneys with UPJOBiopsy findings of kidneys with UPJO
Dilation of collecting ducts & BowmanDilation of collecting ducts & Bowmans spaces space
Decreased #Decreased # glomeruliglomeruli
Interstitial fibrosis & inflammationInterstitial fibrosis & inflammation
Global/segmental sclerosisGlobal/segmental sclerosis
Cortical cystsCortical cysts
Duck Sanctuary
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SummarySummary
SummarySummary
DiagnosisDiagnosis
Kids:Kids:
U/SU/S
VCUGVCUG
RenogramRenogram
Adults:Adults:
CTACTA RenogramRenogram
?retrograde?retrograde
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SummarySummary
Decision to treat:Decision to treat:
SymptomsSymptoms
Complications (stones, infection)Complications (stones, infection)
Declining renal functionDeclining renal function
U/S criteria =U/S criteria =parenchymalparenchymal thinning,thinning, contralateralcontralateral
hypertrophyhypertrophy
RenogramRenogram criteria = worsening splitcriteria = worsening split ffnn, ?drainage, ?drainage
curves, ?Tcurves, ?T
SummarySummary
Treatment modality:Treatment modality:
Kids:Kids:
Open > EndoscopicOpen > Endoscopic
Lap data emerging (esp. age 2+)Lap data emerging (esp. age 2+)
AdultsAdults
Lap = OpenLap = Open >> EndoscopicEndoscopic
First line choice = discretion of clinicianFirst line choice = discretion of clinician
SalvageSalvage
PyeloplastyPyeloplasty EndoscopicEndoscopic
EndoscopicEndoscopic PyeloplastyPyeloplasty
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THE END