Long-Term Results and Late Recurrence After Endoureteropyelotomy: A Critical Analysis of Prognostic Factors

Cangh, Paul J. Van; Wilmart, Jean F.; Opsomer, Reinier-Jacques; Abi-Aad, A.; Wese, François-Xavier; Lorge, Francis

doi:10.1016/s0022-5347(17)35126-1

Cited by 313 publications

(130 citation statements)

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“…These interesting observations of the natural history might reflect a time-dependent relation between the development of adult PUJO and the frequently adjacent crossing vessel. Third, the negative association between the presence of a crossing vessel and the success rate of endopyelotomy was described by Van Cangh et al [16] . In that study the long-term results of endopyelotomy were reviewed in a series of 102 consecutive patients.…”

Section: Crossing Vesselsmentioning

confidence: 86%

Laparoscopic pyeloplasty: the first decade

2004

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ports introduced to enable dissection and identification of the PUJ. The technical principles and goals are similar to those of open surgery. Depending on the type of procedure the PUJ is either incised or dismembered, and reductive pyeloplasty performed if indicated. The ureteric JJ stent is typically inserted retrogradely before (the authors' preference being 4.7 F, 26 cm) or during surgery. A drain is inserted to lie adjacent to the completed repair and a Foley catheter is left in the bladder.Patients typically commence free oral intake of fluids 8-12 h after surgery; the urethral catheter is removed after 1-2 days and the wound drain subsequently. The ureteric stent is typically removed by outpatient flexible cystoscopy at 4 weeks, after IVU. RESULTSThe results of LP are shown in Table 1 [4][5][6][7][8][9][10]; several early reports were excluded where updated results from the same institution were published more recently. Several points are worth specific comment. The success rates of LP are consistently high, at 87-98%; the rates are > 95% in series with a predominance of primary procedures, with only one exception. The 'success rate' is defined as the objective radiological success, i.e. with a patent and unobstructed PUJ (or an improvement in drainage) by either IVU or diuretic renography. Subjective improvement rates, e.g. from patient questionnaires, are invariably less than the radiological success rates by 10-30% for both open and endourological pyeloplasty. There are several possible reasons for this discrepancy, but the present discussion focuses on the objective radiological success rate, which is reported rather more consistently. The prolonged operative duration of reconstructive laparoscopy is significant, but there has been a trend towards a reduction, from a mean of 330 min in the original series to 164-252 min in contemporary series reported in the last 3 years [6][7][8][9]11]. This reflects increased confidence and ability in intracorporeal suturing and knot-tying. Laparoscopic suturing and knot-tying can be learned effectively and reinforced by regular repetition in a 'dry lab' environment. The effect of increasing experience is notable, with an experienced laparoscopist consistently performing the entire procedure (transperitoneal) in < 3.5 h [9]. The retroperitoneal approach (mean operative duration 175 min) is seemingly quicker than the transperitoneal approach (mean 246 min) in contemporary series reported since 2001. This is probably because it takes less time to dissect and identify the PUJ with the retroperitoneal technique. The low morbidity of LP is well reflected in the low incidence of complications during and after surgery even in the initial series. The risks of blood transfusion are remarkably low, being limited to anecdotal reports, in sharp contradistinction to endopyelotomy, where the transfusion rates are 3-11%. The hospital stay is short, averaging 3.8 days in the series reported since 2000.To our knowledge there has been at least one abortive attempt to compare laparosc...

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Section: Crossing Vesselsmentioning

confidence: 86%

Laparoscopic pyeloplasty: the first decade

2004

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“…Van Cangh et al [11] reported a reduction in the success rate from 95% with no marked hydronephrosis and crossing vessels, to 39% with both. Colin and Bagley [4] reported complete success with ureteroscopic endopyelotomy in cases with no crossing vessels, which decreased to 67% in presence of the vessels.…”

Section: Discussionmentioning

confidence: 99%

“…Crossing vessels are detected at the PUJ in 32-79% of adults [6,7], while they are detected in 0-11% of prenatally and 12-40% of postnatally diagnosed cases of PUJ obstruction (PUJO) [8,9]. The clinical significance of crossing vessels is attributed to the lower success rate of endopyelotomy when they are present and associated with high-grade hydronephrosis [10,11]. Furthermore, it is important to exclude the existence of such vessels before endopyelotomy, to avoid vascular complications [11,12] Methods for detecting crossing vessels include IVU, intravenous digital subtraction angiography (DSA), endoluminal ultrasonography, colour Doppler ultrasonography, CT and MR angiography [10,11,[13][14][15].…”

Section: Introductionmentioning

confidence: 99%

“…The clinical significance of crossing vessels is attributed to the lower success rate of endopyelotomy when they are present and associated with high-grade hydronephrosis [10,11]. Furthermore, it is important to exclude the existence of such vessels before endopyelotomy, to avoid vascular complications [11,12] Methods for detecting crossing vessels include IVU, intravenous digital subtraction angiography (DSA), endoluminal ultrasonography, colour Doppler ultrasonography, CT and MR angiography [10,11,[13][14][15]. Multiphasic helical CT is not invasive and provides better images for evaluating the direct relationship between crossing vessels and PUJO [14].…”

Section: Introductionmentioning

confidence: 99%

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Role of multiphasic helical computed tomography in planning surgical treatment for pelvi‐ureteric junction obstruction

et al. 2004

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OBJECTIVETo evaluate the role of multiphasic helical computed tomography (CT) in planning surgical treatment for pelvi‐ureteric junction obstruction (PUJO).PATIENTS AND METHODSMultiphasic helical CT was used in 60 consecutive patients (mean age 32 years, sd 13.72) with primary PUJO. The different images were interpreted before surgery by a urologist and radiologist. The number, type and relation of the crossing vessels to the PUJ were detected. Pyeloplasty (open or laparoscopic) was used in patients where there was a significant crossing vessel (i.e. > 2 mm in diameter and passing at the PUJ) or with ballooning of the renal pelvis. Endopyelotomy (antegrade or retrograde) was used in the other patients. Subjective and objective success rates were determined 3–6 months after treatment and then every 6 months.RESULTSHyperdense renal stones were detected in precontrast images in 15 patients, significant crossing vessels in 33 (55%), and anterior malrotation of the renal pelvis in 23 (38%; 19 associated with significant crossing vessels, i.e. ureterovascular hydronephrosis). A large para‐pelvic cyst compressing the PUJ and upper ureter was detected in one patient. Pyeloplasty was used in 45 patients, among whom the sensitivity of multiphasic helical CT in detecting crossing vessels was 97%, the specificity 92% and accuracy 96%. Uncomplicated endopyelotomy was used in 14 patients and percutaneous aspiration of the para‐pelvic cyst in one.CONCLUSIONMultiphasic helical CT can accurately delineate the spatial anatomy of the renal and peri‐renal area; it may be important in planning surgical treatment for PUJO, especially when endopyelotomy is considered.

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“…We contend that this mobilization distorts the relationship of the PUJ to an adjacent lower pole vessel, present in up to 65% of individuals [41], reducing the chances of a vessel being identi®ed as the cause of the obstruction. Precisely what proportion of vessels adjacent to the PUJ truly cause obstruction remains enigmatic [41], but a success rate as low as 39% for endopyelotomy in the presence of a lower pole vessel [22] suggests that these vessels are causative in a signi®cant proportion of patients. It is tempting to conclude that the high rate of ureteric transposition in this series contributed toward its higher success rate compared with open pyeloplasty, although the few patients included do not allow an unequivocal statement about this.…”

Section: Discussionmentioning

confidence: 99%