Laparoscopic dismembered pyeloplasty

As laparoscopic nephrectomy has become a viable ablative procedure for kidney removal, additional areas of reconstructive laparoscopic urological procedures are being investigated. We describe our early experience with laparoscopic pyeloplasty for the management of ureteropelvic junction obstruction. Technical highlights include initial placement of an internal ureteral stent, lateral insufflation, placement of 5, 10 mm. trocars, pyelotomy (or reduction pyeloplasty performed with articulating laparoscopic scissors, reapproximation of the ureteropelvic junction with a running 4-zero polyglactin suture, placement of a 7 mm. suction drain in the retroperitoneal space and reapproximation of the colon to the body wall with a hernia stapler. We have performed laparoscopic dismembered pyeloplasty in 5 patients with symptomatic ureteropelvic junction obstruction. Operating time ranged from 3 to 7 hours, with the majority of time devoted to laparoscopic suturing (1 to 3 hours). Hospital stay averaged 3 days and all patients returned to normal activity within 1 week. Followup averaged 12 months (range 9 to 17 months) with complete resolution of symptoms in all patients. We believe that this innovative reconstructive laparoscopic procedure can be used for treatment of complicated ureteropelvic junction obstruction as in patients with a large, redundant renal pelvis or crossing lower pole vessels.     

Fibroepithelial polyp causing ureteropelvic obstruction in childhood

The fibroepithelial polyp is a benign tumour that occurs as a rare intraluminal mass within the urinary tract. Most commonly it is located within the ureter or ureteropelvic junction. The authors present 3 cases of fibroepithelial polyp causing obstruction of the ureteropelvic junction. Dismembering pyelonplasty resulted in disappearance of the hydronephrosis, and the postoperative course was uneventful.     

Late diagnosis of the avulsion of the pyelo-ureteral junction treated by ureterocalicostomy

The authors report an exceptional case of delayed diagnosis of avulsion of the ureteropelvic junction in a 27-year-old man. Organization of the urohaematoma prevented ureteropelvic anastomosis and the kidney could only be preserved by performing ureterocalicostomy. This technique, generally used for tuberculous retracted renal pelvis, or failure of pyelotomy or ureteropelvic junction repair in horseshoe kidneys or kidneys with retracted renal pelvis, allowed renal preservation in this case.     

Lower pole calicostomy for the management of iatrogenic ureteropelvic junction obstruction

It is often possible to use endoscopic techniques for the management of iatrogenic upper ureteral or ureteropelvic junction obstruction. However, in some cases with severe stricture disease or significant ischemic injury open surgical reconstruction is necessary. We report our experience with ileal ureter-lower pole calicostomy for the management of these complex urological injuries. During the last 3 years we treated 3 patients with severe ureteral/ureteropelvic junction obstruction secondary to iatrogenic injuries, including ureteral avulsion during ureteroscopic stone extraction, ureteral laceration during dilation for diagnostic ureteropyeloscopy, and ureteral ligation with ureteropelvic junction disruption and large peri-pelvic urinoma. In all cases unsuccessful attempts at endoscopic management necessitated open repair. Lower pole heminephrectomy was performed in all patients to expose the lower pole calix and ileal ureter-lower pole calicostomy was created due to the injury of large segments of the ureter. Satisfactory results were demonstrated on postoperative excretory urography and by a lack of symptoms. Followup averaged 23 months (range 20 to 26) with stable renal function in all patients. We believe that ileal ureter-lower pole calicostomy represents an attractive alternative for the management of severe ischemic, iatrogenic upper ureteral or ureteropelvic junction obstruction when endoscopic maneuvers are not possible or ineffective.     

Ureteroscopic treatment of ureteropelvic junction obstruction

PURPOSE: Endopyelotomy has increasingly become well accepted as the optimal management for primary and secondary ureteropelvic junction obstruction. We report our experience with ureteroscopic endopyelotomy guided by endoluminal ultrasound. MATERIALS AND METHODS: Ureteroscopic endopyelotomy was attempted in 27 patients with primary and 10 with secondary ureteropelvic junction obstruction. Retrograde pyelogram and endoluminal ultrasound were performed at the start of the procedure in all patients. Based on sonographic findings 5 patients were not considered candidates for the procedure. The remaining 13 men and 19 women were treated ureteroscopically with a rigid ureteroscope in 5 (15.6%), flexible in 20 (62.5%), and rigid and flexible in 7 (21.9%) patients. Stents were placed postoperatively for 6 to 10 weeks. The patients were followed for a mean duration of 10 months. RESULTS: The procedure was completed in all patients. Average operating time was 95 minutes including the time for imaging. Sonographic localization guided the site of incision in all patients and changed therapy in 5. It identified crossing vessels in 10 patients (31%), septum denoting high insertion in 5 (15.5%) and both in 7 (22%). Preoperative stenting was not required in any patient. Morbidity was low with no patients requiring transfusion and no evidence of ureteral strictures. Success, defined as pain-free with resolution of obstruction on diuretic renal scan, was achieved in 28 of the 32 patients (87.5%). CONCLUSIONS: Ureteroscopic endopyelotomy is a safe and effective treatment for most cases of ureteropelvic junction obstruction. Endoluminal ultrasonography of the obstructed ureteropelvic junction has gained a major role in defining which patient to treat and in directing endoluminal incisions to minimize the risk of injury to adjacent vessels. There is a higher failure rate when vessels are present.     

Anxiogenic-like effects of spontaneous and naloxone-precipitated opiate withdrawal in the elevated plus-maze

PURPOSE: Endopyelotomy has become the initial treatment of choice for ureteropelvic junction obstruction. Debate persists regarding the preferred approach (percutaneous or ureteroscopic) and the need for preoperative stenting. We review our experience with ureteroscopic endopyelotomy without preoperative stenting. MATERIALS AND METHODS: We treated 21 patients a mean of 37 years old who had ureteropelvic junction obstruction with ureteroscopy and without preoperative stenting. Endoluminal ultrasound was performed in all cases for imaging the periureteral anatomy. A minimum of 1 year of followup is available in all cases. Success was defined as pain-free status with resolution of obstruction on diuretic renal scintigraphy. RESULTS: Success was achieved in 17 of 21 patients (81%). Complications included stent irritation, postoperative urinary tract infection and stent displacement requiring repositioning in 1 case each. Crossing vessels in 57% of the patients affected success (67 versus 100% in those with and without crossing vessels, respectively). No patient had significant hemorrhage. CONCLUSIONS: Ureteroscopic endopyelotomy without preoperative stenting is effective and safe for ureteropelvic junction obstruction.     

The efficacy of endopyeloureterotomy via a transpelvic extraureteral approach

To evaluate the efficacy of endopyeloureterotomy via a transpelvic extraureteral approach for the treatment of ureteropelvic junction obstruction or upper ureteric stenosis, we analysed the results of 85 patients treated with this procedure between Aug. 1988 and June 1993. Eighty-five patients underwent 87 procedures. Each patient has been followed-up more than 6 months postoperatively. Of 87 procedures, 71 were performed in patients with ureteropelvic junction obstruction and 16 were in patients with stenosis of the upper third ureter. Primary disease was 59 and secondary disease was 28. Twenty-one procedures were performed in patients with the stenotic segment over 2 cm. The operative procedure was performed by first incising with a 22 Fr. urethrotome (ACMI Co.); the dilated renal pelvic or ureteral wall posterolaterally as long as 1-1.5 cm junction from the stenotic segment toward ureteropelvic junction, then bringing the urethrotome out retroperitoneally through the incision and finally incising the stenotic segment with the cold knife under direct vision. A 12-16 Fr. PTCS tube (Sumitomo Behkuraito Co.) was left in place for 3 weeks as a stent. Mean operative time was 101 min and average length of incised segment was 3.7 cm. Complication included pneumothorax (1 case), pseudo ureter (1 case) and renal arterial anexryma (1 case). Followed-up period ranged from 6 to 64 months with the average being 26 months. Of 87 procedures, 80 (92%) achieved a disappearance or improvement of the obstructive change and 7 failed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Determination and analysis of antigenic epitopes of prostate specific antigen (PSA) and human glandular kallikrein 2 (hK2) using synthetic peptides and computer modeling

In comparison with pyeloplasty, endourologic procedures for the treatment of ureteropelvic junction obstruction offer good success rates with less morbidity and a shorter hospitalization; however, studies have found lower success rates and increased complications in patients with crossing vessels. Conventional diagnostic angiography and intravenous urography have both been used to identify crossing vessels at the UPJ; but, a reliable, less invasive, less costly, and simpler preoperative procedure to identify crossing vessels is needed. Helical CT with CT angiography is a promising noninvasive technique for the identification of crossing vessels at the ureteropelvic junction, which can be used for surgical planning of endourologic treatment of UPJ obstruction.     

Vesicoureteral reflux and ureteropelvic junction obstruction: association, treatment options and outcome

PURPOSE: We investigated the association, treatment options and outcomes of patients with ureteropelvic junction obstruction and concomitant vesicoureteral reflux. MATERIALS AND METHODS: We analyzed 6,790 consecutive pediatric urology records at our university. Treatment options included observation, and primary pyeloplasty, ureteroneocystostomy and nephroureterectomy. Hydronephrosis, reflux and obstruction were judged as resolved, improved, unchanged or worse. RESULTS: A total of 1,140 patients had vesicoureteral reflux, 224 had ureteropelvic junction obstruction and 41 had both conditions (39 ipsilateral and 6 contralateral kidneys). There was no increased risk of obstruction in patients with reflux when all grades of reflux were grouped (odds ratio 1.26, confidence interval 0.91 to 1.71). In contrast, subgroup analysis of patients with high grade reflux demonstrated a 5-fold increased risk of obstruction (odds ratio 5.0, confidence interval 2.4 to 10.8). One patient was lost to followup. Observation of 6 kidneys led to resolution of reflux in 3 (50%), resolution of obstruction in 3 (50%) and resolution or improvement of hydronephrosis in 4 (67%). Primary pyeloplasty was done on 29 kidneys with 10 (35%) requiring subsequent ureteroneocystostomy. At latest followup hydronephrosis resolved or improved in 24 patients (83%), vesicoureteral reflux resolved or improved in 19 (66%) and ureteropelvic junction obstruction resolved in all. Primary ureteroneocystostomy was performed on 5 kidneys, all of which required subsequent pyeloplasty. Hydronephrosis resolved in 3 patients (60%), and reflux and obstruction resolved in all. Two patients treated with primary nephroureterectomy, and 1 who underwent concomitant pyeloplasty and ureteroneocystostomy have had no subsequent urological problems. One patient awaits primary pyeloplasty. CONCLUSIONS: High grade vesicoureteral reflux is associated with ureteropelvic junction obstruction. No association with low or intermediate grade reflux was demonstrated. While some patients may be monitored expectantly, in our series pyeloplasty or nephrectomy was required in 81% and ureteroneocystostomy was required in 36%. In no case did primary ureteroneocystostomy protect against the subsequent need for pyeloplasty.     

Changes in infants'' cries as a function of time in a cry bout

Endoluminal ultrasound of the obstructed ureteropelvic junction (UPJ) provides accurate anatomic information not available through other studies. Endoluminal ultrasonography in the evaluation of the obstructed UPJ can be extremely valuable and its use can be expected to expand with increasing experience with the techniques. The anatomy demonstrated through the fine resolution of this technique may ultimately provide the key to the selection of optimal therapy for the obstructed UPJ.     

Urine extravasation secondary to upper urinary tract obstruction

To the best of our knowledge, this is the first reported case of renal salvage in a neonate with presumed spontaneous perirenal leakage of urine associated with ureteropelvic junction obstruction. Many instances of such extravasation in this age group have been described with lower urinary tract obstructions. As in the latter cases, the occurrence of extravasation secondary to upper tract obstruction need not preclude primary reconstruction.     

Colocalization of iron and ceroid in human atherosclerotic lesions

Although clearly a valid alternative to dismembered pyeloplasty for ureteropelvic junction obstruction in adults, endo(uretero)pyelotomy has not been universally accepted in the general urologic community because of the 10% to 30% inferior success rate and the concern regarding hemorrhagic complications. Identification of prognostic factors for success and complications are therefore of primary importance. The length of stricture, the grade of hydronephrosis, and the level of renal function are well recognized prognostic factors. Crossing vessels also play a role, and in association with the grade of hydronephrosis, they seem to be a major prognosticator of outcome. With attention to such prognostic factors, and appropriate patient selection, results can now approach the gold standard of dismembered pyeloplasty.     

Endopyelotomy with Acucise for secondary ureteropelvic junction obstruction: report of a case

We report a case of successful endopyelotomy using the Acucise cutting balloon device for secondary ureteropelvic junction obstruction (UPJO). A 23-year-old man was hospitalized with the chief complaint of left lumbago and left hydronephrosis due to left UPJO. He underwent antegrade endopyelotomy with a nephroscope and open pyeloplasty. However, left lumbago and hydronephrosis did not show improvement. Acucise endopyelotomy was performed under epidural anesthesia. The operative time was 55 minutes and the hospital stay after the operation was 4 days. There were no operative complications and 3 months later, the operative results were satisfactory as determined by drip infusion pyelography and the disappearance of the lumbago.     

Cryotherapy of the resection edge after liver resection for colorectal cancer metastases

A 35-year-old female was referred to our clinic with a complaint of left flank pain in 1993. Drip infusion pyelography showed a filling defect of 25 x 24 mm in size in the left ureteropelvic junction. Computed tomography and ultrasonography revealed it as the renal stone. Percutaneous nephroureterolithotomy and extracorporeal shock-were lithotomy were performed. The stone was composed of 2,8-dihydroxyadenine (DHA). The patient was diagnosed as having a partial deficiency of adenine phosphoribosyltransferase (APRT) from the low APRT activity and a genotype of a compound heterozygote APRT*J/APRT*Q0 by T-cell analysis. The urinary excretion of 2,8-DHA crystals disappeared by the postoperative treatment with allopurinol. Cases of 2,8-DHA urolithiasis reported in the Japanese literature are discussed.     

Eight cases of pyelo-ureteral junction syndrome treated by laparoscopic surgery

From may 1994 to may 1995, eight consecutive patients with symptomatic congenital ureteropelvic junction syndrome (UPJS) were treated by pyeloplasty as described by Anderson, Hynes and Küss by laparoscopic surgery. Three patients had a lower pole artery crossing the anterior surface of the junction and two had a giant renal pelvis. The mean operating time was 120 minutes (min: 90 min; max: 147 min) and the mean hospital stay in the absence of complications (one case) was 3.5 days (min: 1.5 day; max: 8 days). This one complication was due to a postoperative fistula resulting from a technical error requiring an additional fortnight in hospital. All the patients are evaluable at three months. All are asymptomatic and the radiological results showed frank improvement in seven out of eight cases, while the dynamic appearance was improved in the other case. UPJS can be treated by laparoscopic surgery according to proven surgical principles, provided it is performed in a perfectly equipped operating room, by a surgeon and operating team experienced in this type of surgery.     

Ureteropelvic junction obstruction with renal pelvic calcification: a case report

Calcification in the wall of the renal pelvis is rare. We report on a 65-year-old man with hydronephrosis secondary to ureteropelvic junction obstruction with renal pelvic calcification. Calcium deposit was found in the wall of the severely dilated renal pelvis. Pathological examination revealed a damaged and hyalinized fibrous renal pelvic wall and serum calcium level was normal. Thus, we speculated that this calcification was dystrophic. Chronic extensive dilatation with intermittent hemorrhage of the renal pelvic wall may have caused this dystrophic renal pelvic calcification.     

Membrano-bulbo-urethral junction stenosis. Posterior urethra obstruction due to extreme caliber disproportion in the male urethra

OBJECTIVE: Based on 4 cases of infravesical obstruction due to extreme caliber disproportion between the posterior urethra and the penile urethra, a pathophysiological mechanism for this dynamic obstruction is given and endoscopic treatment is described. SUBJECTS: Four cases of membrano-bulbo-urethral junction (MBUJ) stenosis, seen between September 1995 and April 1996, are described. Two boys had previous successful valve resection but still showed extreme ballooning of the posterior urethra. The other 2 boys showed bladder instability on urodynamics and the male variant of the spinning top urethra on voiding cystourethrography (VCUG). RESULTS: All cases were successfully treated by endoscopic incision at the 12 o'clock position of the kink between the posterior and the penile urethra which is seen when the full bladder is expressed. Disproportion in the posterior urethra, seen on VCUG, together with bad urinary flow measured on uroflowmetry raise the suspicion of MBUJ stenosis. CONCLUSION: Although rarely seen, extreme caliber disproportion in the male urethra can cause obstruction. Ballooning of the posterior urethra, caused by urethral valves, bladder instability resisted by voluntary sphincter contraction or congenital posterior urethral dilatation, creates an obstructive kink in the urethra comparable to some obstructions in ureteropelvic junction stenosis. If suspicion of such a form of obstruction arises, cystoscopy during pressure on the full bladder is mandatory in order to see the obstruction, descending as a membrane from the vault of the urethra.     

Endoscopic nasoenteral feeding tube placement following cardiothoracic surgery

Intraluminal incision is often used for the treatment of strictures of both the upper and the lower urinary tracts. The depth of the stricture and the location of surrounding structures such as blood vessels are important factors in guiding the incision. Endoluminal ultrasonography has been shown to be effective in defining periureteral anatomy accurately. A new device is described that combines an endoluminal ultrasound transducer and cutting device (electrocautery or laser fiber) in 9F catheter. This catheter was evaluated in two live anesthetized pigs (four kidneys) and four ex-vivo kidneys. Incisions were made at the ureteropelvic junction and middle and distal ureter. The ability to image the periureteral structures and to direct the location and the adequacy of the incision were assessed. Endoluminal ultrasound imaging was excellent, and the electrocautery wire was well seen. Well-defined, limited, full-thickness incisions were made using this device and could be directed accurately toward or away from periureteral vessels. This study demonstrates the potential for endoluminal ultrasound guidance of intraluminal incisions.     

Renal pyelectasis in fetuses and neonates: diagnostic value of renal pelvis diameter in pre- and postnatal sonographic screening

OBJECTIVE: Pre- and postnatal pyelectasis detected by sonographic screening is of questionable pathologic importance. Therefore, we defined the natural course and diagnostic value of renal pelvis diameter (RPD) during fetal life and the neonatal period as such dilatation was revealed on routine sonography. MATERIALS AND METHODS: Routine sonography in pregnant women was obtained between gestational weeks 22 and 30. Sonograms were obtained for 1021 fetuses, of which 15 could not be followed up as neonates. The remaining 1006 fetuses also underwent neonatal sonography. All neonates with an RPD larger than 5 mm were followed up sonographically. Neonates with an RPD larger than 9 mm or persistent widening (> 5-9 mm) were examined by voiding cystourethrogram, radionuclide renogram, or both. RESULTS: Thirty fetuses (3%) had an RPD larger than 5 mm. Nine of these fetuses also had an RPD larger than 5 mm as neonates. Of these nine neonates, one had bilateral grade II vesicoureteric reflux (VUR) and two had urinary tract obstructions (one posterior urethral valve and one ureteropelvic junction obstruction). Forty-nine neonates whose results on fetal sonograms had been normal showed an RPD larger than 5 mm on neonatal sonograms. Grade III VUR was found in one boy, and ureteropelvic junction obstruction was found in two boys. The kidneys of 54 neonates who showed an RPD larger than 5 mm without urinary tract obstruction were followed up until an RPD of 0-5 mm was evident. RPD normalized within 1 year of birth, whether VUR was present or not. Symptomatic urinary tract infection was diagnosed in 17 infants who had no renal pelvis dilatation seen on pre-or postnatal screening during the observation period. Seven of the 17 neonates had VUR. Conversely, none of the infants with pre- postnatal dilatation presented with symptomatic urinary tract infection. However, in one neonate an asymptomatic urinary tract infection without VUR was diagnosed by routine urinalysis. CONCLUSION: In our study, we linked renal pelvis dilatation on pre- and postnatal sonograms to obstructive uropathies rather than to vesicoureteric reflux. Prenatal sonography proved less sensitive than postnatal sonography in revealing obstructive uropathies. An RPD smaller than 10 mm on neonatal sonography was of no pathologic significance because renal collecting systems normalized spontaneously in all infants within 1 year of birth. These neonates and infants had no significant risk for urinary tract infection and did not need further evaluation.     

Pharmacokinetics of troglitazone, a PPAR-gamma agonist, in patients with hepatic insufficiency

The natural history of multicystic dysplastic kidney (MCDK) is not well established. We analyzed kidney growth and renal function in 33 children with prenatally diagnosed unilateral MCDK in a long-term study. The mean observation period was 4.9 years with a range of 1-11.6 years. Abnormalities of the contralateral kidney were found in 10 of 33 patients (30%): ureteropelvic junction obstruction (5), ureterovesical junction obstruction (2), and vesicoureteral reflux (3). In 6 children the dysplastic kidney had been removed. Complete involution was observed in 48% and a decrease of size in 33% of 27 dysplastic kidneys. At the time of last examination, 27 of 29 children showed a volume of the contralateral kidney above the normal range (>145%). Hypertrophy of the contralateral kidney, defined as kidney length above 2 standard deviation scores (SDS), was seen in 24% of 33 children at birth, thus showing that hypertrophy of the contralateral kidney starts in utero and continues throughout childhood. The extent of contralateral hypertrophy was independent of associated abnormalities in this study. Mean creatinine was increased in the whole group (mean +1.13 SDS). Calculated creatinine clearance in 21 patients over 2 years was within normal limits, with a median of 102 ml/min per 1.73 m2 (range 84-143). Based on the results of this and previous studies, nephrectomy cannot be recommended in typical cases, but a regular follow-up of these patients seems necessary.