nov-7-07

download nov-7-07

of 52

Transcript of nov-7-07

  • 8/12/2019 nov-7-07

    1/52

    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)

  • 8/12/2019 nov-7-07

    2/52

    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

  • 8/12/2019 nov-7-07

    3/52

    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

  • 8/12/2019 nov-7-07

    4/52

    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

  • 8/12/2019 nov-7-07

    5/52

    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)

  • 8/12/2019 nov-7-07

    6/52

    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

  • 8/12/2019 nov-7-07

    7/52

    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)

  • 8/12/2019 nov-7-07

    8/52

  • 8/12/2019 nov-7-07

    9/52

    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

  • 8/12/2019 nov-7-07

    10/52

    Pediatric UPJO W/UPediatric UPJO W/U

    PostPost--natalnatal w/uw/u of Antenatal Hydroof Antenatal Hydro

    UltrasoundUltrasoundrenal & bladderrenal & bladder

  • 8/12/2019 nov-7-07

    11/52

    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

  • 8/12/2019 nov-7-07

    12/52

    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

  • 8/12/2019 nov-7-07

    13/52

    SFU Grading SystemSFU Grading System

    103 infants

  • 8/12/2019 nov-7-07

    14/52

    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

  • 8/12/2019 nov-7-07

    15/52

    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)

  • 8/12/2019 nov-7-07

    16/52

    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

  • 8/12/2019 nov-7-07

    17/52

    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.).)

  • 8/12/2019 nov-7-07

    18/52

    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

  • 8/12/2019 nov-7-07

    19/52

    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

  • 8/12/2019 nov-7-07

    20/522

    ?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

  • 8/12/2019 nov-7-07

    21/52

  • 8/12/2019 nov-7-07

    22/522

    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

  • 8/12/2019 nov-7-07

    23/522

    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

  • 8/12/2019 nov-7-07

    24/522

    Hot Springs, Tofino

    ManagementManagement

  • 8/12/2019 nov-7-07

    25/522

    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

  • 8/12/2019 nov-7-07

    26/522

    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

  • 8/12/2019 nov-7-07

    27/522

    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

  • 8/12/2019 nov-7-07

    28/522

    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

  • 8/12/2019 nov-7-07

    29/522

    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

  • 8/12/2019 nov-7-07

    30/523

    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 (

  • 8/12/2019 nov-7-07

    31/523

    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

  • 8/12/2019 nov-7-07

    32/523

    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

  • 8/12/2019 nov-7-07

    33/523

    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

  • 8/12/2019 nov-7-07

    34/523

    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

  • 8/12/2019 nov-7-07

    35/523

    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

  • 8/12/2019 nov-7-07

    36/523

    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

  • 8/12/2019 nov-7-07

    37/523

    RetrogradeRetrograde EndopyelotomyEndopyelotomy

    LaserLaser EndopyelotomyEndopyelotomy vs.vs. AcuciseAcucise

    J Urol 2006, 175: 614-618

    RetrogradeRetrograde EndopyelotomyEndopyelotomy

    7373--85% radiographic success85% radiographic success

  • 8/12/2019 nov-7-07

    38/523

    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

  • 8/12/2019 nov-7-07

    39/523

    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

  • 8/12/2019 nov-7-07

    40/524

    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

  • 8/12/2019 nov-7-07

    41/524

    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

  • 8/12/2019 nov-7-07

    42/524

    LaparoscopicLaparoscopic PyeloplastyPyeloplasty

    Head Feet

    R side down

    LaparoscopicLaparoscopic PyeloplastyPyeloplasty

  • 8/12/2019 nov-7-07

    43/52

  • 8/12/2019 nov-7-07

    44/524

    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

  • 8/12/2019 nov-7-07

    45/524

    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%

  • 8/12/2019 nov-7-07

    46/524

    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

  • 8/12/2019 nov-7-07

    47/524

    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

  • 8/12/2019 nov-7-07

    48/524

    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

  • 8/12/2019 nov-7-07

    49/524

    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

  • 8/12/2019 nov-7-07

    50/525

    SummarySummary

    SummarySummary

    DiagnosisDiagnosis

    Kids:Kids:

    U/SU/S

    VCUGVCUG

    RenogramRenogram

    Adults:Adults:

    CTACTA RenogramRenogram

    ?retrograde?retrograde

  • 8/12/2019 nov-7-07

    51/525

    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

  • 8/12/2019 nov-7-07

    52/52

    THE END