30th ESPU Congress - Lyon, France - 2019

S6: OBSTRUCTION & HYDRONEPHROSIS 2

Moderators: Anthony Herndon (USA), Goedele Beckers (Netherlands)

ESPU Meeting on Thursday 25, April 2019, 09:40 - 10:26


09:40 - 09:43
S6-1 (PP)

VALIDATION OF HYDRONEPHROSIS SEVERITY SCORE FOR PREDICTION OF NEED FOR SURGEY IN PATIENTS WITH UPJO IN A PROSPECTIVE DATABASE

Smruthi RAMESH 1, Melissa MCGRATH 1, Kornelia PALCZEK 1 and Luis BRAGA 2
1) McMaster University - McMaster Children's Hospital, Surgery, Hamilton, CANADA - 2) McMaster University - McMaster Children's Hospital, Department of Surgery / Urology, Hamilton, CANADA

PURPOSE

The hydronephrosis severity score (HSS), which relies on SFU HN grades, differential renal function (DRF) and drainage curve patterns was previously described to assess the severity of UPJO-like cases and the likelihood of surgical intervention. Herein, we sought to validate this scoring system in our PHN population with UPJO-like.

MATERIAL AND METHODS

A prospectively collected PHN database was reviewed to extract UPJO-like patients. Children with VUR, primary megaureter and other associated anomalies were excluded. HSS was calculated at the initial, interim and last follow-up clinic visits. Scores were analyzed regarding its usefulness to predict need for pyeloplasty. 

RESULTS

Of 168 patients, 131(78%) were male, 120 (71%) had left UPJO-like, and 113 (67%) had a pyeloplasty. The median age at baseline was 2 months (IQR1-4). According to initial (1st clinic visit) HSS, 5/36(14%) patients with a 0-4 score, 93/116 (80%) with a 5-8 score, and 15/16 (94%) with a 9-12 score underwent pyeloplasty, respectively (p<0.01). When HSS cut off values were changed to mild (0-3), moderate (4-7) and severe (8-12), modified mild group was more representative of a true low risk category with no patients requiring surgery and the new high risk group include almost 100% of patients who had pyeloplasty. 

CONCLUSIONS

The new proposed HHS system for UPJO-like patients was reproducible, however cut off values needed to be reassessed to accurately reflect true risk categories, as the purpose of this system was to differentiate those who will need surgery from those who may be managed conservatively. Changing risk groups to mild(0-3), moderate(4-7) and severe(8-12) allowed for better discrimination of patients who would undergo surgical intervention from those who no longer need monitoring.  


09:43 - 09:46
S6-2 (PP)

A MULTI-INSTITUTIONAL COMPARISON OF OPEN, LAPAROSCOPIC AND ROBOT-ASSISTED PYELOPLASTY FOR URETERO-PELVIC JUNCTION OBSTRUCTION IN INFANTS.

Ciro ANDOLFI 1, Ximena RECABAL 2, Jonhatan WALKER 3, Nimrod BARASHI 1, Francisco REED 4, Pedro-Jose LOPEZ 2, Duncan WILCOX 3 and Mohan GUNDETI 5
1) University of Chicago, Chicago, USA - 2) Hospital Exequiel Gonzalez Cortes, Surgery, Santiago, CHILE - 3) University of Colorado, Surgery, Denver, USA - 4) Hospital Exequiel Gonzalez Cortes, Santiago, CHILE - 5) University of Chicago, Surgery, Chicago, USA

PURPOSE

To compare the outcomes of open (OP), laparoscopic (LP) and robot-assisted (RAP) pyeloplasty for ureteropelvic junction obstruction (UPJO).

MATERIAL AND METHODS

We retrospectively reviewed the medical records, from a prospectively maintained database, of patients who underwent OP, LP and RAP at 3 different medical institutions, between December 2009 and December 2017.

RESULTS

Thirty-nine patients underwent OP, 26 LP and 39 RAP. No conversion to open occurred in the LP and RAP cohorts. The mean operative time (OT) of RAP was longer than OP and LP. However, LP had a statistically significant steeper learning curve (LC) as compared to RAP. There was no difference in rate of complication events between OP and LP. RAP was found to have a significantly lower rate of complication events as compared to OP. However, for Clavien-Dindo grade III, no difference in complication rates was found between groups. Post-operative rates of opioids use were similar between OP and RAP, however, RAP required on average a significantly lower dosage. In addition, 5 OP patients required opioids after hospital discharge. No difference was found between the three groups in success rates, and post-operative remaining moiety functions at MAG3 renal scan. Median follow up was 84 months. All data are presented in table 1.

Table1: Open vs Laparoscopic vs Robot-Assisted Pyeloplasty

  OP LP RP   OP vs LP OP vs RP LP vs RP
Patients 39 26 39 P*
OT (min) 106 (± 30) 121 (± 37) 151 (± 54) <0.001 0.112 <0.001 0.004
(Mean± SD)
LOS (days) 1.1 (± 0.3) 2 (± 0.8) 1.5 (± 0.7) <0.001 <0.001 0.011 0.027
Complication events 15 (38.5%) 8 (30.8%) 7 (17.9%) 0.131 0.525 0.044 0.229
Clavien-Dindo grade I 6 0 1 - - 0.047 -
II 6 5 4 0.587 0.685 0.498 0.304
III 3 3 2 0.636 0.275 0.643 0.342
Use of opioids 17 (44%) NA 13 (33%) - - 0.351 -
Total opioid dose  0.8±0.5 NA 0.5±0.5 - - 0.033 -
per patient (mg)
Average opioid dose (mg/kg) 0.1±0.05 NA 0.08±0.08 - - 0.036 -
Success rate (%) 37 (95%) 24 (92%) 38 (97%) 0.634 - - -
Post-operative kidney function at MAG3 scan  37.3 (± 20.7) 36.6 (± 14.8) 37± 14.2 0.338 - - -
LC correlation coefficient (r) - – 0.36  – 0.68  - - - 0.004

OP: Open Pyeloplasty; LP: Laparoscopic Pyeloplasty; Robot-Assisted Pyeloplasty (RAP); OT: Operative Time; LOS: Length Of Stay; LC: Learning Curve; NA: Not Available.

*Statistical analysis: c2 test, One-way ANOVA, Mann-Whitney U test, Fisher r-to-z transformation.

CONCLUSIONS

LP and RAP are safe and effective minimally invasive procedures for the treatment of UPJO with similar outcomes as compared to OP. Despite the shorter OT, LP has shown to have a steeper learning curve as compared to RAP.


09:46 - 09:49
S6-3 (PP)

★ RESULTS OF INTRAPELVIC PRESSURE MONITORING AFTER DISMEMBERED PYELOPLASTY IN CHILDREN

Vladimir SIZONOV 1, Mikhail KOGAN 2 and Vladimir ORLOV 1
1) Regional Children's Hospital, Paediatric Urology, Rostov On Don, RUSSIAN FEDERATION - 2) The Rostov State Medical University, Urology, Rostov-On-Don, RUSSIAN FEDERATION

PURPOSE

The choice of timing for pelvic drainage following pyeloplasty in children is determined by accumulated clinical experience of implementing various urinary diversion strategies. To research the dynamics in the functional patency of pyeloureteral anastomosis, we studied intrapelvic pressure (IP) for two weeks following the surgery.

MATERIAL AND METHODS

IP was monitored in 31 children through a pyelostomy tube for 20 hours during a day for initial 14 days following dismembered pyeloplasty performed without stenting of the pyeloureteral anastomosis. Average age of the patients was 73.9±18.4 months, 21 (67.7%) boy and 10 (32.3%) girls. IP was registered by a mobile device recording the pressure values with simultaneous registration of time intervals when the patient was in horizontal or vertical position, with subsequent calculation of the average IP values. Average IP for every day following surgery was calculated based on the data of all patients collected during that day. We stopped the research whenever febrile temperature or pain complaints appeared. Wilcoxon rank-sum test and Friedman test were used as statistical tools.

RESULTS

The research was discontinued in 5 cases: 4 (80%) - in connection with pain, in 1 case (20%) - because of temperature rising to febrile values. Average IP during the first 6 days remains stable within standard limits (13.4-13.9 cmH2O) without statistically significant differences. By day 7-8, we noted pressure increase (17.9[15.8-19.2] - 20.2[18.9-21.1] cmH2O) reaching maximum values by day 9 (20.7[18.5-21.2] cmH2O) (p<0.0001). Beginning with day 11, a decrease in average IP was registered (p<0.001), reaching by the day 14 the values (13.2[11.8-14.9] cmH2O) obtained during the days 2-6 after the operation (р>0.3).

CONCLUSIONS

Beginning with day 7 following pyeloplasty, an abnormality is noted in functional patency of pyeloureteral anastomosis disappearing by the day 14 after surgery, which should be viewed as the earliest time to consider stopping drainage of the upper urinary tract


09:49 - 09:52
S6-4 (PP)

★ URETEROURETEROSTOMY IN PATIENTS WITH COMPLEX DUPLEX MALFORMATIONS: DOES A LARGE DIAMETER OF THE DONOR URETER AFFECT THE OUTCOME?

Bernhard HAID 1, Eva LAUSENMEYER 2, Mirjam HARMS 3, Marco SCHNABEL 4, Judith ROESCH 3, Wolfgang RÖSCH 2 and Josef OSWALD 3
1) Hospital of the Sisters of Charity, Pediatric Urology, Linz, AUSTRIA - 2) Klinik St. Hedwig - University Medical Center of Regensburg, Department of Pediatric Urology, Regensburg, GERMANY - 3) Hospital of the Sisters of Charity, Department of Pediatric Urology, Linz, AUSTRIA - 4) Caritas Krankenhaus St. Josef, Department of Urology, Regensburg, GERMANY

PURPOSE

Ureteroureterostomy is an commonly adopted, minimally invasive approach for the management of duplex anomalies requiring diversion of e.g. ectopic upper-pole ureters. We hypothesized that large diameters of the donor-ureter could affect the outcome of this procedure.

PATIENTS AND METHODS

36 patients from two centers were retrospectively reviewed. To compare patients with small vs. large donor-ureters the group was split at the median of the preoperative, sonographically measured diameter at the level of the future anastomosis (n=17 <1.3cm, mean 0.79cm vs. n=18 ≥1.3cm, mean 1.68cm, p<0.001). Ureteroureterostomy was performed in an end-to side fashion with tapering of the donor-ureter as required. The groups were comparable in age (3.1 vs. 3.05 years, p=0.94), sex (m/f, 5/12 vs. 3/15, p=0.44), duration of follow-up (13.6 vs. 19.1 months, p=0.467) and number of preoperative fUTIs (9 vs. 9). Outcomes were compared using Fisher’s Exact Test, Student’s t-test and Wilcoxon Test. 

RESULTS

There was no significant difference in operative time (134 vs. 114mins, p=0.13), duration of hospital stay (4.17 vs. 4.0days, p=0.72) or number of perioperative complications (2 febrile UTIs in each group). Reoperations during follow-up (1 stump resection and 1 endoscopic VUR procedure) occurred rarely and exclusively in the group with small donor-ureter diameter (p=0.229). The mean preoperative hydronephrosis grade was larger in the group with large donor-ureters as compared to the group with small donor-ureters (mean 2.83 SFU vs. 1.53, p=0.007). During follow-up, the mean hydronephrosis grade in patients with large donor-ureters improved from 2.83 to 1.39 (p<0.001). In patients with small donor-ureters the mean hydronephrosis grade remained unchanged. 

CONCLUSIONS

A donor-ureter diameter ≥1.3cm in ureteroureterostomy was not associated with a higher complication rate or a worse outcome considering further UTIs or reoperations. The postoperative reduction in hydronephrosis grade was more pronounced in patients with larger donor-ureters.


09:52 - 10:04
Discussion
 

10:04 - 10:07
S6-5 (PP)

LAPAROSCOPIC VASCULAR HITCH IS WORTH TAKING INTO ACCOUNT IN CHILDREN WITH UPJO CAUSED BY POLAR VESSELS

Andrzej GOLEBIEWSKI, Leszek KOMASARA, Stefan ANZELEWICZ and Piotr CZAUDERNA
MEDICAL UNIVERSITY OF GDANSK, Surgery and Urology for Children and Adolescents, Gdansk, POLAND

PURPOSE

Vascular hitch (VH), the transposition of lower pole crossing vessels (CV), is an alternative technique for treatment of UPJO caused by extrinsic compression. We report a prospective study of laparoscopic VH in children with intermediate follow-up.

MATERIAL AND METHODS

Prospective analysis of 12 consecutive children treated by laparoscopic VH and age-matching 28 children treated by laparoscopic dismembered pyeloplasty. Criteria for VH procedure were: lower pole crossing vessels with moderate hydronephrosis and poor renal drainage confirmed in renal ultrasonography and MAG-3 renal scan. All patients presented intermittent hydronephrosis, recurrent flank pain and hematuria. Diuretic test (DT) was performed before and after laparoscopic VH confirming extrinsic UPJO and normal ureter with UPJ peristalsis. In cases of negative DT- laparoscopic dismembered pyeloplasty was performed. Follow-up included renal ultrasonography and MAG-3 renal scan. Success was defined by resolution of symptoms with improvement in hydronephrosis and drainage.

RESULTS

15 children presenting with flank pain, hydronephrosis, impaired drainage and lower-pole crossing vessels at a mean age of 8.5 years were selected for laparoscopic VH. 12 patients (positive-DT) underwent VH, 3 patients (negative-DT)- underwent dismembered pyeloplasty. The mean operative time of laparoscopic VH was 96 min. (40-130), and length of hospital stay was 3 days (1-5). No ureteral catheters were placed intraoperatively. Mean follow-up of 18 months showed success in all patients with resolution of symptoms. Two children have shown improvment of hydronephrosis and symptoms, but still present impaired drainage on MAG-3 renal scan. Laparoscopic VH and dismembered pyeloplasty showed no difference in success rate.

CONCLUSIONS

At intermediate follow-up the laparoscopic VH procedure has been successful in treating a selected group of children with UPJO caused by CV, and represents a safe and reliable alternative to standard dismembered pyeloplasty. VH is not an alternative surgery of UPJO, but a complementary way to repair hydronephrosis in very selected cases.


10:07 - 10:12
S6-6 (VP)

THE ‘VASCULAR HITCH'-PROCEDURE IS AS A VALUABLE ALTERNATIVE TO DISMEMBERED PYELOPLASTY IN PATIENTS WITH URETEROPELVIC JUNCTION OBSTRUCTION DUE TO ABERRANT LOWER POLE VESSELS - A VIDEO PRESENTATION

Katrin ZAHN 1, Nina HUCK 2 and Raimund STEIN 2
1) UMM Mannheim, Pediatric, Adolescent and Reconstructive Surgery, Mannheim, GERMANY - 2) UMM Mannheim, Pediatric, Adolescent and Reconstructice Urology, Mannheim, GERMANY

PURPOSE

Dismembered pyeloplasty is the gold-standard procedure in patients with ureteropelvic junction obstruction (UPJ) and aberrant lower pole vessels which can also be performed minimally-invasive.

MATERIAL AND METHODS

Our 'vascular-hitch' technique is presented.The transabdominal approach is used for laparoscopic exploration after preoperative intravenous hydration. If aberrant lower pole vessels are identified, careful dissection off the UPJ is performed. If the pyelon shows good peristalsis and emptying, the UPJ is brought caudal and the aberrant lower pole vessels are enveloped in a pyelon-tunnel. Care has to be taken not to make the tunnel too tight and to have a good distance to the UPJ. Under visual control and forced diuresis (Furosemid is given) the UPJ is observed to exclude any persistent obstruction. In cases of doubts a dismembered pyeloplasty is performed.

RESULTS

Out of 26 patients, one of our first patients required open re-do-surgery. In 2 patients a dismembered pyeloplasty was performed after initial vascular hitch procedure during the same surgery. In all of the 25 laparoscopic patients resolution or significant reduction of hydronephrosis was seen in follow-up of 0.5 to 8 years. No arterial hypertension was observed.

CONCLUSIONS

We think that our technique is safe and might be a valuable alternative to dismembered pyeloplasty in children presenting with aberrant lower pole vessels - not requiring stents. The majority of these patients does not present a clinically relevant concomitant intrinsic stenosis of the UPJ. Preliminary results are promising, but longterm-outcome until adulthood has yet to be awaited.


10:12 - 10:17
S6-7 (VP)

THE ROBOTIC APPROACH TO FRALEY SYNDROME

Dario Guido MINOLI, Erica Adalgisa DE MARCO, Michele GNECH, Alfredo BERRETTINI and Gianantonio MANZONI
Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Paediatric Urology, Milano, ITALY

PURPOSE

Fraley's syndrome results from a rare anatomic variant of the renal vasculature that compresses the upper pole infundibulum resulting in intermittent calyceal obstruction with symptoms of flank pain and/or hematuria. We report the case of a 15-year-old boy with typical presentation

MATERIAL AND METHODS

A 15 year-old-boy referred to our center for the presence of colicky lombar pain associated with macroscopic hematuria which was present in the last 7 years. Imaging studies with US, CT scan and MRI showed a left duplex system with dilatation of the upper moiety. A MAG3 scan showed reduced function of the upper moiety and the surgical decision was conservative with  a laparoscopic-assisted robotic pieloplasty instead of an upper hemi-nephrectomy. The anatomy found was typical for Fraley Sindrome with the renal vasculature crossing and compressing the infundibulum of the upper pole ureter in an incomplete duplex system. Section of the upper infundibulum with uncrossing of the vessels and pyelo-ureteral anastomosis was performed

RESULTS

The boy has been discharged on the 2nd post-operative day. A retrograde pielography was performed at stent removal confirming a patent anastomosis. Follow-up ultrasound showed mild residual calico-pelvic dilatation in the upper moiety and the patient is now symptom free.

CONCLUSIONS

Although the surgical management of Fraley's syndrome has historically involved complex open renal reconstruction, a  robotic-assisted laparoscopic approach to the upper pole infundibulum is feasible and offers significant advantages


10:17 - 10:26
Discussion