Simplified Open Approach to Surgical Treatment of Ureteropelvic Junction Obstruction in Young Children and Infants

Transcription

1 Hydronephrosis Simplified Open Approach to Surgical Treatment of Ureteropelvic Junction Obstruction in Young Children and Infants Eduardo Ruiz, Ricardo Soria, Edurne Ormaechea, Mauricio Marcelo Urquizo Lino, Juan Manuel Moldes and Francisco Ignacio de Badiola From the Hospital Italiano de Buenos Aires, Buenos Aires, Argentina Abbreviations and Acronyms MAG3 mercaptoacetyltriglycine UPJO ureteropelvic junction obstruction Purpose: Indications for laparoscopic pyeloplasty for ureteropelvic junction obstruction are steadily growing but there is still a group of young children in whom open surgery continues to be the procedure most performed by pediatric urologists. We report our results in young children and infants with dismembered pyeloplasty done through a small flank incision on an outpatient basis or during a short hospital stay. Materials and Methods: Between April 2001 and July 2009, 45 patients with a median age of 11.2 months (range 1 to 50), of whom 72.9% were male, with confirmed ureteropelvic junction obstruction underwent classic Anderson-Hynes dismembered pyeloplasty thorough a 2.5 to 3.5 cm flank incision. Obstruction was on the left side in 51.2% of the patients. Pyeloureteral anastomosis was performed with a continuous 7-zero polydioxanone suture over a 7Fr multiperforated pyelostomy self-designed catheter in 89% of the patients. A Double-J catheter was used in only 4 patients with other associated conditions. The stent was removed in the office 7 to 12 days after surgery. Results: Mean operative time was 92 minutes (range 60 to 150). Median hospital stay was 11.5 hours (range 6 to 35) in the whole group but it decreased to 9.4 hours in the last 22 cases. There was no reoperation due to recurrent ureteropelvic junction obstruction. Mean postoperative followup was 47.5 months. Conclusions: Ureteropelvic junction obstruction surgery in small children can be done safely through a small incision with a short hospital stay without morbidity and with good cosmesis. We believe that open pyeloplasty will continue to be the best standard treatment for ureteropelvic junction obstruction surgery in small children until miniaturization and better laparoscopic instruments allow us to reproduce these results. Key Words: kidney; ureter; obstruction; infant; surgical procedures, operative URETEROPELVIC junction obstruction is the most common congenital urinary obstructive pathology in children. Today periodic ultrasound examinations during pregnancy enable us to diagnose and investigate after birth a greater number of neonates who are usually asymptomatic despite severe unilateral urinary obstructive pathology. Surgical treatment is only done in early infancy in those with moderate to severe functional renal impairment due to urinary obstruction and echographic, persistent grade 4 hydronephrosis with an obstructive pattern that shows no response to furosemide injection on 99m Tc-MAG3, and in rare symptomatic young children and infants. 1 3 Although today many surgical techniques and approaches are available for small children, 4 6 we report our /11/ /0 Vol. 185, , June 2011 THE JOURNAL OF UROLOGY Printed in U.S.A by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. DOI: /j.juro

2 SIMPLIFIED OPEN APPROACH TO URETEROPELVIC JUNCTION OBSTRUCTION 2513 Figure 1. A, pyeloplasty through 2 cm lumbar incision in 6-month-old patient. B, pyelostomy with multiperforated transanastomotic silicone catheter fixed with 5-zero polyglycolic acid purse-string suture. results of a simple, safe, inexpensive open approach through a small incision in a short hospital stay setting. MATERIALS AND METHODS Between the 91 months from January 2001 to July 2009 dismembered open pyeloplasty was done through a 2 to 3.5 cm subcostal open incision in 45 patients, of whom 72.9% were male, between ages 1 and 50 months (median 11.2) with confirmed unilateral UPJO (fig. 1, A). UPJO was on the left side in 51.2% of patients. A prenatal diagnosis was made in 39.9% of cases. The patient was hospitalized at 7:00 a.m. When possible, surgery was scheduled at 8:00 a.m. to avoid an overnight hospital stay. Patients who remained overnight after surgery did so due to parental decision. If a Double-J catheter was used, a bladder catheter was maintained in place in a double diaper for 48 hours. Epidural blocking anesthesia was used in the first 8 patients (17.7%). It was discontinued later and replaced by local and regional bupivacaine 0.25% (maximum 3 mg/kg per dose), administered by the surgeon in combination with inhalation sevoflurane, and intravenous fentanyl and prophylactic antibiotics with a single cefazoline dose (50 mg/kg). Retrograde pyelogram was performed through a 3Fr ureteral catheter before surgery in the last 36 patients (80%) to determine the size and position of the ureteral meatus in the bladder, and identify the site and length of obstruction (fig. 2). A wide Anderson-Hynes pyeloureteral anastomosis was formed with continuous 7-zero polydioxanone over a 7Fr multiperforated, transanastomotic, self-designed pyelostomy catheter. Leaving the pelvis on a stab wound 1 to 2 cm above the anastomosis, the catheter was fixed with a 5-zero polyglycolic acid purse-string suture. Care was taken to avoid leaving any knot in contact with the catheter to avoid breakage or difficulty during catheter removal (fig. 1, B). Between 6 and 8 hours postoperatively patients were discharged from the hospital on ibuprofen (10 mg/kg) or paracetamol (25 mg/kg) for analgesia. They returned home the same afternoon or remained at a local facility depending on the distance from home to hospital. The pyelostomy catheter was maintained in place between 7 and 12 days after surgery to drain urine into a double diaper (fig. 3). It was retrieved in the office after 24 to 48 hours of catheter occlusion if the patient continued asymptomatic with minimum residual urine into the pelvis. No antibacterial postoperative prophylaxis was used on a reg- Figure 2. Retrograde pyelogram reveals low UPJO obstruction with long, narrow proximal ureter.

3 2514 SIMPLIFIED OPEN APPROACH TO URETEROPELVIC JUNCTION OBSTRUCTION Figure 3. Short incision pyelostomy catheter fixed to abdominal wall with adhesive drape and urine dripping in double diaper ular basis to avoid acquired bacterial resistance, especially to hospital bacteria. Urinalysis was done the day after catheter retrieval to identify bacteriuria or urinary infection. Renal sonogram was indicated 3 months after surgery if no symptoms were present and no postoperative urinary infection was detected. It was repeated at 12 months. Renal scintigraphy with 99m Tc-MAG3 and furosemide was only repeated if there was no expected reduction in pelvic and caliceal dilatation or symptoms recurred. RESULTS Mean operative time was 92 minutes (range 60 to 150). Median hospital stay was 11.5 hours (range 6 to 35) in the whole group but it decreased to 9.4 hours in the last 22 patients. A total of 13 patients (33.3%) remained the night after the procedure, mostly due to parental decision. A multiperforated pyelostomy catheter was placed in 89% of patients. A Double-J 3.7Fr catheter was placed in 4 patients with an associated problem, including a single functional kidney in 1, a double pyelocaliceal system in 2 and a horseshoe kidney in 1. Only 1 patient was rehospitalized. That patient required a Double-J stent due to persistent urinary leakage, fever and urinary infection 12 days after surgery, which had resolved uneventfully after stent retrieval 1 month later. One patient with a single functioning kidney presented with ureterovesical stenosis secondary to a failed attempt to introduce a inch guidewire to pass a 3.7Fr Double-J catheter. The anastomosis was finally protected with a pyelostomy catheter. An intravesical transtrigonal Cohen procedure was done in this patient 30 days after the original surgery. The patient recovered uneventfully. There was no reoperation due to recurrent UPJO. Of the patients 89% had no or mild pelvic dilatation (less than grade 3 hydronephrosis) on followup ultrasound at least 6 months after surgery. Nonobstructive, asymptomatic pelvic dilatation (15 to 20 mm) and grade 3 hydronephrosis with adequate drainage after diuretic injection during MAG3 scan was still present in 5 patients (11%). Mean postoperative followup was 47.5 months (range 4 to 103). DISCUSSION More than 60 years have passed since the original description of Anderson and Hynes in 1949 of the dismembered technique for UPJO. 7 In 1993 Shuessler et al described the laparoscopic approach in adults. 8 It was not until 1995 that Peters et al presented preliminary results of transperitoneal pyeloplasties in pediatric patients. 9 Since then, laparoscopic pyeloplasty has become increasingly popular for UPJO in the pediatric population. 3 5 Today we use laparoscopic and robotic approaches to UPJO in older children and adolescents but we did not change our minimal incision approach in small children due to the safety and good results obtained historically, and in our previous experience with this approach. 10,11 Probably a criticism of our study is the few patients and the absence of a comparative group using other surgical approaches (laparoscopic surgery using a Double-J catheter 12 ). However, given our results, we believe that trying to change our approach is not ethical. To decrease morbidity, hospital stay and costs we modified our surgical approach and some technical points in recent years. Today we prefer to perform this type of procedure early in the morning as the first surgery, if possible, to prevent young patients from staying the night at the hospital and simplify the preoperative fasting period. Although in the past we performed some of these procedures on an outpatient basis, we currently prefer patients to undergo a brief postoperative hospital stay, allowing us to achieve better clinical and pain control. Thus, patients whose parents are reluctant to leave the

4 SIMPLIFIED OPEN APPROACH TO URETEROPELVIC JUNCTION OBSTRUCTION 2515 hospital in the afternoon due to parental fear, too far a distance from home, etc, can stay at the hospital during the night. Performing immediate preoperative retrograde pyelography enabled us to localize the exact site and length of the UPJO, and rule out associated malformations, such as megaureter and ureteral valves. Thus, we decreased the length of the incision and avoided the potential morbidity related to excessive handling and mobilization of the proximal ureter. Since we used retrograde pyelography and could identify the exact site of the UPJO, incisions were no longer than 3.5 cm in the first group of patients and decreased to 2 cm and to 1.5 in the last 2 patients, who were not included in this study. Although ultrasound can also be used to identify pelvic dilatation, it does not provide information on UPJO length or anatomical characteristics of the ureteral meatus when a Double-J catheter is used. Figure 2 shows retrograde pyelogram on which a low positioned UPJO with a long abnormal ureter was diagnosed, enabling a lower, shorter incision in a 6-month-old patient. Retrograde pyelogram was identified as a factor increasing the probability of successful pyeloplasty. 13 In agreement with other groups, management of the retroperitoneal space by this approach was briefer and simpler. 10 Mean operative time was considerably decreased to an average of 92 minutes compared with the experience of others. 4,5,14 Pyeloureteral anastomosis was formed with continuous 7-zero polydioxanone over a 7Fr multiperforated pyelostomy catheter using a modification of a silicone catheter normally used for nasogastric feeding. This incurs lower cost than the combined use of a Double-J catheter and a silicone Foley bladder catheter. Pyelostomy drainage through the wound is useful as a pyeloplasty protective mechanism and as operative field drainage. It also helps decrease hospital stay since no bladder catheter is needed and postoperative pain related to transient pelvic distension is avoided. The pyelostomy tube may be easily removed on an outpatient basis at the office without anesthesia with acceptable cosmesis and low cost. This pyelostomy catheter can also be used for antegrade pyelogram if urinary leakage persists or high residual urine into the pelvis is present after the 2 days of catheter occlusion before retrieval. We noted no severe infectious complications associated with the pyelostomy catheter, in contrast with reported cases using a Double-J stent. 15 Sometimes it may be difficult to advance the catheter through the ureterovesical junction in small children. 12 Our more complex complication resulted after a failed attempt to place a Double-J stent in a patient with a single functional kidney. In this patient ureterovesical stenosis developed due to damage from guidewire, requiring surgical reimplantation, as reported previously. 16 As long as preventive pain management is achieved during surgery, postoperative pain is not an important clinical problem in young patients. During the first part of our experience the anesthesiologist preferred to perform epidural analgesia with morphine and bupivacaine. However, we moved to a more simple approach of wound incision and local nerve blockage, which was achieved by the surgeon with 0.25 bupivacaine. Also, while oral ibuprofen is usually indicated for use at home, none of our patients required opioid medication after surgery, probably due to young patient age and the small incision. Our costs are lower compared with those in the published literature, 17,18 reflecting a different structure of pricing and a different currency value. Despite this limitation when comparing a different group of patients, at our institution laparoscopic pyeloplasty is twice as expensive as an open approach and a robotic assisted approach is 3 to 4 times more expensive due to the added cost of the instruments used with the da Vinci robotic system. Thus, we only use the latter due to a personal or family decision in adolescents and young adults. We currently use a transperitoneal or retroperitoneal laparoscopic approach in children older than 5 years, always adding a Double-J catheter, a bladder catheter and a second procedure under general anesthesia to retrieve the Double-J catheter. Because of these reasons, to date we have found it difficult to change our historical open approach in young children due to the simplicity of the procedure, its low morbidity and adequate scar cosmesis, and the rare need for a secondary procedure using general anesthesia. CONCLUSIONS The open approach through a small flank incision is safe and effective for UPJO in young children and infants. The procedure can be easily done with minimal morbidity in a brief operative time with excellent cosmesis and almost no postoperative pain, allowing early discharge home. Pyelostomy catheter drainage does not prolong hospitalization and can be easily removed on an outpatient basis without further anesthesia. We believe that open pyeloplasty will continue to be the best standard treatment for UPJO surgery in young children until miniaturization and better laparoscopic instruments let us reproduce these results.

5 2516 SIMPLIFIED OPEN APPROACH TO URETEROPELVIC JUNCTION OBSTRUCTION REFERENCES 1. Gonzalez R and Schimke C: Ureteropelvic junction obstruction in infants and children. Pediatr Clin North Am 2001; 48: Hanna M: Antenatal hydronephrosis and ureteropelvic junction obstruction: the case of early intervention. Urology 2000; 55: Ruiz E: Estenosis pieloureteral en la vida fetal infancia y adolescencia. En PRONACIP. Progr actualiz Cirug Pediátr 2009; 1: Piaggio L, Franc-Guimond J, Nohl P et al: Transperitoneal laparoscopic pyeloplasty for primary repair of ureteropelvic obstruction in infants and children: comparison with open surgery. J Urol 2007; 178: Yee D, Shanberg B, Rodriguez E et al: Initial comparison of robotic assisted laparoscopic versus open pyeloplasty in children. Urology 2006; 67: Palmer l, Proano J and Palmer J: Renal pelvis cuff pyeloplasty for ureteropelvic junction obstruction for the high inserting ureter. An initial experience. J Urol 2000; 174: Anderson JC and Hynes W: Retro-caval ureter: a case diagnosed preoperatively and treated successfully by a plastic operation. Br J Urol 1949; 21: Schuessler WW, Grune MT, Tecuanhuey LV et al: Laparoscopic dismembered pyeloplasty. J Urol 1993; 150: Peters CA, Schlussel RN and Retik AB: Pediatric laparoscopic dismembered pyeloplasty. J Urol 1995; 153: Chacko J, Koyle M, Mingin G et al: The minimally invasive open pyeloplasty. J Pediatr Urol 2006; 2: Chacko JK, Koyle MA, Mingin GC et al: Minimally invasive open renal surgery. J Urol 2007; 178: Braga L, Lorenzo A, Farhat W et al: Outcome analysis and cost comparison between externalized pyeloureteral and standard stents in 470 open pyeloplasties. J Urol 2008; 180: Braga L, Lorenzo A, Bagli D et al: Risk factors for recurrent ureteropelvic junction obstruction alter pyeloplasty in a large pediatric cohort. J Urol 2008; 180: Ben-Meir D, Golan S, Ehrlich Y et al: Characteristics and clinical significance of bacterial colonization of ureteral Double-J stents in children. J Pediatr Urol 2009; 5: Lee R, Retik A, Borer J et al: Pediatric robot assisted laparoscopic dismembered pyeloplasty: comparison with a cohort of open surgery. J Urol 2006; 175: Dyer R, Chen M, Zagoria R et al: Complications of ureteral stent placement. Radiographics 2002; 22: Vemulakonda VM, Cowan C, Lendvay T et al: Surgical management of congenital ureteropelvic junction obstruction: a Pediatric Health Information System database study. J Urol 2008; 180: Penn H, Gatti J, Hoestje S et al: Laparoscopic versus open pyeloplasty in children: preliminary report of a prospective randomized trial. J Urol 2010; 184: 690.