Long-term outcome of kidneys with initially poor drainage or no drainage following pyeloplasty

Abstract

Pyeloplasty for congenital ureteropelvic junction (UPJ) obstruction enjoys a 90-95% success rate. Although treatment of the failed pyeloplasty has been addressed in the literature, management of the poorly draining or nondraining renal unit in the immediate postoperative period has not received any attention. For this purpose the medical records of 33 consecutive children (37 renal units) treated by dismembered pyeloplasty between 1986 and 1992 were reviewed. All of our pyeloplasties were stented and urine was diverted via a nephrostomy tube. All patients underwent a nephrostogram following stent removal 1 week postoperatively. These studies showed poor drainage, or no, across the newly reconstructed anastomosis in 7 of 37 renal units (19%). The ages of these 4 boys and 3 girls at the time of pyeloplasty ranged between 7 weeks and 5 years (mean 22 months). In four patients, good drainage occurred without intervention by 2-4 weeks postoperation. In two patients, percutaneous balloon dilation of the anastomosis via the intraoperatively placed nephrostomy tube was required at 3 and 6 weeks, respectively. The remaining patient failed percutaneous dilation, necessitating a ureterocalycostomy at 9 weeks following pyeloplasty. The long-term follow-up for the entire group of 33 children averaged 30 months and consisted of radionuclide diuresis renography in 84% of cases or intravenous pyelography in the remainder. All patients had excellent long-term outcomes as assessed by comparison of the postoperative studies with the baseline studies obtained preoperatively. Our results show that kidneys with initially poor drainage, or even no drainage, across the newly reconstructed anastomosis following pyeloplasty can be salvaged with an excellent long-term outcome comparable with that of the group with initially good drainage. In addition, intervention was necessary in only 43% of renal units with initial compromise and was facilitated by the intraoperatively placed nephrostomy tube. We recommend that percutaneous dilation be done at between 4 and 6 weeks postpyeloplasty, as the waiting period was long enough to allow for spontaneous improvement without precluding a successful outcome if drainage failed to occur. Ureterocalycostomy was rarely necessary.

Robot-Assisted Laparoscopic Reoperative Repair for Failed Pyeloplasty in Children: A Safe and Highly Effective Treatment Option

“…Persistent obstruction can sometimes be successfully managed by stent placement or balloon dilation, although success is limited and little information is available in the literature on ideal candidates for this approach. [12][13][14] Endoscopic attempts to salvage recurrent/persistent UPJ obstruction have mixed results. Success was observed in only 39% of children treated with retrograde endopyelotomy by Braga et al, compared to their 100% success for reoperative pyeloplasty.…”

Factors Accountable for Unabated Obstruction Following Pyeloplasty

“…Some studies show functional improvement in SRF[ 2 3 4 5 ] and some show improvement in FWO[ 6 7 8 9 10 ] following pyeloplasty. On the other hand, some show persistent obstructive curve[ 10 11 12 ] in FWO or minimal changes in SRF[ 13 14 ] as outcome.…”

Early mercaptoacetyltriglycine(MAG‐3) diuretic renography results after pyeloplasty

“…There is a common misconception that the reconstructed ureter soon after surgery is unable to transmit radioisotopes and respond appropriately to furosemide challenge. It has been demonstrated by Schlossberg that after a period of healing of 3–6 weeks there is return of normal electrical conductivity and completion of smooth muscle bridging; the PUJ can efficiently transmit a bolus of urine as early as 1 week after repair .…”