|Year : 2017 | Volume
| Issue : 6 | Page : 154-158
Five-Year experience with pyeloplasty using intubated and nonintubated techniques
Abdalla M Etabbal, Younis M El Bashari, Hussam H Bakar
Department of Surgery, Faculty of Medicine, University of Benghazi; Department of Urology, Benghazi Medical Center, Benghazi, Libya
|Date of Web Publication||8-Nov-2017|
Abdalla M Etabbal
Department of Urology, Benghazi Medical Center, Benghazi
Source of Support: None, Conflict of Interest: None
Background: Ureteropelvic junction obstruction (UPJO) is an obstruction of urine flow from the renal pelvis to the ureter. This condition can be caused by congenital and acquired due to intrinsic or extrinsic factors. UPJO due to acquired conditions such as secondary to inflammation, passage stones, or ureteric folds is less common. In case of suspected UPJO, the critical decision to be made depends on the correlation between the radiologic findings and the physiologic picture. There have been recent and serious trials to perform the surgical repair of UPJO without intubation, with reservation of double J (DJ) stents and nephrostomy tubes for complex cases. The Aim of Study: The aim of the study was a comparison of the time of drain removal, hospital stay, complications, and the end result of surgery in intubated and nonintubated UPJO repair. Patients and Methods: A retrospective case serious study performed in Urological Departments at Benghazi Medical Center and Al-Hawari Urology Center by reviewing 51 files of consecutive patients of UPJO admitted to the department of urology from May 2010 to 2015. All patients were diagnosed using different diagnostic tools. Forty-three cases underwent reconstructive surgeries as follows: 41 (95.3%) patients underwent Anderson-Hynes-dismembered (A-H-D) pyeloplasties and 2 (4.7%) patients underwent VY Foley pyeloplasties. Out of 41 cases underwent A-H-D pyeloplasties, there were six cases underwent concomitant pyelolithotomy. Results: The time of removal percutaneous perinephric tube drain was 7th to 9th postoperative days and 7.9 ± 0.5 days. The postoperative hospital stay for all cases range from 7 days to 10 days and the mean was 8.0 ± 0.8 days. Conclusions: Despite both intubated and nonintubated techniques of UPJO repair are comparable regarding the hospital stay postoperative complication, the tubeless surgical repair of UPJO is more suitable for children and superior to the intubated technique regarding the cost of DJ stent and nephrectomy tube.
Keywords: Anderson-Hynes-dismembered pyeloplasty, hydronephrosis, pyeloplasty, ureteropelvic junction obstruction
|How to cite this article:|
Etabbal AM, El Bashari YM, Bakar HH. Five-Year experience with pyeloplasty using intubated and nonintubated techniques. Ibnosina J Med Biomed Sci 2017;9:154-8
|How to cite this URL:|
Etabbal AM, El Bashari YM, Bakar HH. Five-Year experience with pyeloplasty using intubated and nonintubated techniques. Ibnosina J Med Biomed Sci [serial online] 2017 [cited 2019 Dec 6];9:154-8. Available from: http://www.ijmbs.org/text.asp?2017/9/6/154/217866
| Introduction|| |
Ureteropelvic junction obstruction (UPJO) is blockage of urine flow renal pelvis to the ureter which results in variable degrees of renal pelvis dilations. The early diagnosis and successful management of UPJO continue to challenge the urologist; however, the surgical repair of UPJO was first recorded in the years 1886, when Trendelenburg performed the first reconstructive surgery for UPJO rather than performing wonted simple nephrectomy. With 5 years of cumulative experiences, a successful repair of UPJO by ligating the renal pelvis below the obstruction and transposing the upper ureter to the renal pelvis with performing side-to-side anastomosis was accomplished by Kuster (1891). In the year 1936, Foley demonstrated a successful pyeloplasty procedure using YV-plasty repair in twenty UPJO cases. Ten years later (1946), Anderson-Hynes-dismembered-pyeloplasty has been published. This procedure performed by removal of obstructed part of the ureter, trimming of the redundant pelvis, spatulation of the upper ureter, and then the performance of meticulous anastomosis between the ureter and renal pelvis. This highly successful technique has become the standard for surgical repair used today. Regardless the technique of surgery, the procedure must satisfy the following features: formation of a funnel at the UPJ, dependent drainage of the ureter, watertight and tension-free anastomosis of the funneled shape pelvis to the dependent draining ureter. The aim of our study is to compare the surgical repair of UPJO with or without the use of intubation in terms of time of drain removal, hospital stay, complications, and the end result of surgery.
| Patients and Methods|| |
A retrospective case series study was conducted in Urological Departments at Benghazi Medical Center and Al-Hawari Urology Center, by reviewing the files of consecutive 51 patients diagnosed as UPJO and admitted from May 2010 to May 2015. The data collected from files were age and gender of patients, presenting symptoms, side of UPJO, the diagnostic tool used, and the surgical techniques performed, and whether renal tubes were left in place or not as well as the duration of hospital stay. A routine written informative consent was obtained from the patient or from the patient guardian regarding the surgical procedure to be done and possible complications. The statistical analysis was carried out using Statistical software (SPSS Statistics for Windows, Version 22.0., IBM Corp., Armonk, NY, USA).
The patients with secondary UPJO (i.e., UPJO secondary to vesicoureteral reflux) were not included in the study because the result of surgery may be compromised by factors other than which mentioned in our study. The primary genuine cases of UPJO which treated conservatively (n = 2 cases, 3.9%), underwent nephrectomy (n = 3 cases, 5.8%), and complicated UPJO (n = 3 cases, 5.88%) also excluded from the study. In 3 cases who excluded from the study were presented with flank pain, vomiting, and fever, perioperative percutaneous nephrostomy tube was inserted to drain the affected unit. Out of these three cases, there were two newly diagnosed cases of UPJO, whereas the other one has the history of failed redo Anderson-Hynes-dismembered (A-H-D) pyeloplasty. In these cases, the surgical intervention was delayed for a period till inflammation dissolved and then pyeloplasty was done by insertion of double J (DJ) stent in addition to previously inserted nephrostomy tube to overcome edema at the site of the anastomosis. However, the remaining 43 cases underwent primary reconstructive surgery of UPJO with or without the use of intubation.
The indications of surgery were the imaging finding in the case of incidentally discovered cases or neonates; however, in the symptomatic cases, recurrent flank pain and/or recurrent urinary tract infection in addition to the imaging evidences of UPJO were the indications of surgical intervention. The diagnosis confirmed by ultrasonic examination with Lasix test and the findings of excretory urography. The radioisotope scanning is not done for all cases because it is not available in the period of the study. The techniques of reconstructive surgery of UPJO in 43 cases were A-H-D pyeloplasty (n = 41) and VY Foley Pyeloplasty (n = 2). Out of 43 patients who underwent A-H-D pyeloplasty, six (13.9%) cases underwent concomitant pyelolithotomy. The study was conducted in a retrospective manner, so the indications of intubated or nonintubated pyeloplasty are a matter of individual preference which is based on the experience of surgeons, the intraoperative surgical findings as well as the availability of the tubes, especially in the situation of decreased resources in our country. Out of the 43 patients who underwent reconstructive surgery, the DJ stent was applied for twenty patients, pigtail nephrostomy tube was inserted in five patients, and nephrostomy with external pediatric feeding tube ureteric stent was placed in seven patients. However, in 11 patients, pyeloplasty was performed without using DJ stent or nephrostomy. In our department, the initial trials of performing nonintubated pyeloplasty techniques were done by establishing a watertight anastomosis along with the creation of a small separate window in the renal pelvis to drain out the urine through external perinephric drain tube to decrease intrarenal pressure to prevent disruption of anastomotic line. The created window in the pelvic wall and anastomotic line healed simultaneously without any unwanted sequels. During this period, the ureter regains its peristaltic movement allowing the passage of urine through the anastomotic site without any sudden rise in intrarenal pressure. Nowadays, surgeons in our department get more confidence to perform watertight anastomosis without creating a separate window in the pelvic wall; nevertheless, the results of both procedures were comparable.
All patients in this series who underwent surgical intervention received prophylaxis and postoperative antibiotics as well as nonsteroidal anti-inflammatory drugs because of their analgesic and anti-inflammatory effects. After discharge, all patients were scheduled for follow-up at 3 and 6 months.
| Results|| |
The total number of patients with UPJO and underwent surgical repair with or without intubation was 43 patients, the ages of the patients ranging from 10 days old to 45 years old, the mean age of cases of UPJO was 16.7 ± 11.1 years, and male to female ratio is ~2:1. The left to right side ratio was 2.3:1. The age group and gender of patients as well as the laterality of disease were illustrated in [Table 1]. Out of 43 cases recorded in the current study, there were only 2 (4.7%) cases discovered incidentally; however, the others were symptomatic (n = 41, 95.3%). The most representative age group of UPJO was between 11 and 20 years old [Table 2]. The success rate of surgical repair in 43 cases presented with genuine UPJO underwent A-H-D pyeloplasty and VY Foley pyeloplasty with or without using intubation was 100%. In all patients underwent either intubated or nonintubated surgical repair of UPJO, the time of removal percutaneous perinephric tube drain was 7th–9th postoperative days (PODs) and the mean was 7.9 ± 0.5 days [Table 3]. However the postoperative hospital stay for all cases range from 7 to 10 days and the mean was 8.02 ± 0.8 days [Table 3]. The five patients in whom only pigtail nephrostomy tube was inserted, the pigtail nephrostomy tubes were removed in 5th–7th POD providing nephrostogram showed no contrast leak at the site of anastomosis, and once the external perinephric tube drains brought nothing for 24–48 h after removal of the pigtail nephrostomy tubes. In seven cases in whom pyeloplasty was performed using external feeding tube stent (4 Fr) in addition to nephrostomy tube, the external feeding stent was removed from 2nd to 4th POD, the perinephric tube drain was removed 24–72 h after removal of nephrostomy tube providing it remains dry; however, the nephrostomy tube was removed at 5th–7th POD. In twenty cases of UPJO underwent pyeloplasty with the intraoperative insertion of DJ stent, the external perinephric tube drain removed on the POD 7th in ten cases, 8th in seven cases, and 9th in two cases; however, the drain was left up to the 10th POD in only one case. In all cases, the external perinephric tube drains were not removed till they brought nothing at least for 24 h. However, the DJ stent removed under general anesthesia 4–8 weeks later. The 11 patients in whom neither nephrostomy tube nor DJ stent left in place, the perinephric tube drain was removed in the 7th–8th POD providing that the drain brought nothing over last 24–48 h.
|Table 1: The age and sex of patients presented with UPJO and the laterality of disease|
Click here to view
|Table 3: Timing of removal connected tubes and hospital after pyeloplasty|
Click here to view
The patients of UPJO were scheduled for follow-up for 3–6 months postoperatively. The complications were minimal and easily managed. At the early postoperative period, one patient of UPJO operated with the use of DJ stent insertion developed prolonged urine leakage of urine due to reflux of urine necessitate reinsertion of the catheter and keep perinephric tube to prevent the formation of urinoma. The DJ stent slept out through the urethra in a female patient; however, some patients developed increase in frequency due to irritation of bladder by DJ stent necessitated the start of anticholinergic drugs. No case presented with wound infection.
| Discussion|| |
UPJO may be complicated by loin pain, UTI, renal impairment, stone formation, or even hypertension. In addition to the controversies regarding the surgical repair of UPJO, it remains difficult for urologist to choose optimal time for surgical intervention because the UPJO either due to intrinsic or extrinsic factors results in functional and anatomical obstruction of urine flow from the renal pelvis to ureter, which makes the natural history of the disease variable. If the UPJO is left untreated in the first 6 months of life, in this period, the glomerular filtration rate increases several times, and it may result in progressive damage to the affected unit. Early surgical repair of genuine UPJO in pediatric age group may prevent renal parenchymal infection and irreversible renal damage. However, many surgeons facing problems associated with all intubated techniques, especially in small children, these problems include difficulty of inserting the DJ stent in small-caliber ureters at pelvi-ureteric junction in infants. However, the size of pelvis in this age group is too small to accommodate nephrostomy tube as well. These problems make surgeons searching for new techniques or try to modify the existed techniques of UPJ reconstructive surgeries. Although A-H-D pyeloplasty is considered as the gold standard for the correction of the UPJO, and it was first described as a stentless procedure with proven efficacy and a high success rate which exceeds 95%. The era of intubated techniques was elicited to prevent perianastomotic leakage of urine and therefore infection which is considered as the cause of stenosis or stricture at anastomotic site resulting in surgical failure., There are different types of drainage methods have been described including nephrostomy tube drainage, ureteral stent, or combination of these modalities. The advantage of nephrostomy tube is the ability of performing the contrast study to ensure efficacy of anastomotic site; however, the supposed advantages of stenting are maintaining alignment of the anastomosis, decreasing urinary extravasation, bypassing the transient obstruction due to edema at the anastomotic site, and preventing subsequent stenosis. The disadvantages of external and internal intubations are an increase in the incidence of UTI, ureteric stricture at the site of anastomosis (due to the pressure of a stent over the anastomotic line) as well as dislodgment, fragmentation, or migration of stents. All complications may prolong the duration of hospital stay; however, the internal stents may require a second hospital admission for removal under general anesthesia. Many studies observed a higher incidence of UTI in intubated pyeloplasties in comparison to nonintubated techniques ,. Nowadays, many surgeons tend to prefer internal renal drainage rather than external renal drainage; however, some surgeons believe that the patency of the ureteropelvic anastomoses is guaranteed by allowing passage of urine through the anastomotic site as early as possible which can be ensured by nonintubated technique., Because the duration of hospital stay becomes an important issue in some hospitals with limited resources and a lot of patients' load. There were a lot of controversies between authors regarding the benefits of both intubated and nonintubated techniques considering hospital stay, and despite that, some authors reported a shorter hospital stay in group underwent intubated pyeloplasty., Other authors mentioned that the group underwent nonintubated technique had a shorter hospital stay than the group underwent intubated technique. Most of these series explained the longer hospital stay of the group underwent intubated pyeloplasty on the basis of an increase in the incidence of UTI during the early postoperative period. However, there are few studies reported that children with stents and nephrostomy can be discharged after 3–4 days and the tubes managed at home or on OPD basis. Although the duration of hospital stay is not considered as an important issue in our department in a governmental hospital, all patients were discharged in reasonable period providing they were disconnected from any external tubes and the efficacy of anastomotic site secured. The success rate in both intubated and nonintubated techniques of open A-H-D pyeloplasty was 100% in different series., Some authors mentioned that the intubated technique is preferable in the high-risk group such as single kidney patients, redo pyeloplasty, poor overall renal function, and in the case of associated renal stones. In our study, the nephrostomy tube was inserted intraoperatively in 6 patients UPJO and concomitant renal pelvic stone; however, in other 6 cases there were no clear indications of insertion nephrostomy tubes. The current study was done in a retrospective manner. In other words, the surgeon's decision of performing intubated or nonintubated pyeloplasty as well as the time required for hospital stay were not intentionally influenced by prior plan to prove the superiority of one technique over the other. However, the average hospital stay in nonintubated technique and DJ stent using pyeloplasty were less than other intubated techniques, and the complications in both groups were minimal and easily managed.
The study was conducted retrospectively so that some information such as the time of surgery which taken from the anesthesia report was unreliable because it gives the total time of the surgery from induction to recovery, during this period there were many variables that may affect the duration of surgery such as time of induction and recovery, the individual differences between the surgeons, and the operative findings such as stones, adhesions, and associated anomalies that may affect the total time of surgery. In our country, in the last years, the radioisotope scanning is not available, so we depend on clinical findings and on the result of conventional imaging studies in the diagnosis and follow-up of the cases. As the study conducted in the governmental hospital, the files of the patients did not include the details about the cost of procedures.
| Conclusions|| |
Although the end results and the hospital stay of surgical repair of UPJO with or without the use of intubations are comparable, the nonintubated surgical repair of UPJO is suitable for children and superior to the intubated technique regarding the cost of DJ stent and nephrostomy tubes. The DJ stent insertion may be complicated with irritation of the bladder and its removal requires readmission. The intubated surgical repair of UPJO should be reserved only for complicated cases.
All authors participated equally and substantially to this work to qualify for authorship and they all reviewed and approved the final version.
Financial support and sponsorship
The study was carried out on governmental institutions; therefore, the funding was internal.
Conflicts of interest
There are no conflicts of interest.
Compliance with ethical principles
The study was approved by the hospital IRB and was conducted in accordance with ethical principles.
| References|| |
Rogers A, Hasan T. Management of secondary pelviureteric junction obstruction. Indian J Urol 2013;29:294-302.
] [Full text]
Boylu U, Basatac C, Turan T, Onol FF, Gumus E. Comparison of surgical and functional outcomes of minimally invasive and open pyeloplasty. J Laparoendosc Adv Surg Tech A 2012;22:968-71.
Foley FB. A new plastic operation for stricture at the ureteropelvic junction. J Urol 1937;38:643.
Elbatarny AM, Elafifi MA, Hashish AA, Elsharaby AM. Stented versus non-stented open pyeloplasty for primary ureteropelvic junction obstruction in children. Tanta Med J 2014;42:92-9. [Full text]
Nam JK, Lee SD, Chung MK. Modified differential renal function measurement revised by renal cross sectional area in children with ureteropelvic junction obstruction. Korean J Urol 2010;51:271-5.
Matsumoto F, Shimada K, Harada Y, Naitoh Y. Split renal function does not change after successful treatment in children with primary vesico-ureteric reflux. BJU Int 2003;92:1006-8.
Park S, Ji YH, Park YS, Kim KS. Change of hydronephrosis after pyeloplasty in children with unilateral ureteropelvic junction obstruction. Korean J Urol 2005;46:586-92.
Braga LH, Lorenzo AJ, Farhat WA, Bägli DJ, Khoury AE, Pippi Salle JL, et al.
Outcome analysis and cost comparison between externalized pyeloureteral and standard stents in 470 consecutive open pyeloplasties. J Urol 2008;180:1693-8.
Garg RK, Menon P, Narasimha Rao KL, Arora S, Batra YK. Pyeloplasty for hydronephrosis: Issues of double J stent versus nephrostomy tube as drainage technique. J Indian Assoc Pediatr Surg 2015;20:32-6.
] [Full text]
Liss ZJ, Olsen TM, Roelof BA, Steinhardt GF. Duration of urinary leakage after open non-stented dismembered pyeloplasty in pediatric patients. J Pediatr Urol 2013;9:613-6.
Mollaeian M, Ghavami-Adel M, Eskandari F, Mollaeian A. A 5-fr externalized nephroureteral catheter as the sole protective device for pediatric pyeloplasty: The experiences of 142 patients. Iran J Pediatr 2016;26:e5633.
Austin PF, Cain MP, Rink RC. Nephrostomy tube drainage with pyeloplasty: Is it necessarily a bad choice? J Urol 2000;163:1528-30.
Le TS, Le CT, Le TH, Nguyen TD, Huynh CN, Nguyen TT, et al.
Transpelvic anastomotic stenting: A good option for diversion after pyeloplasty in children. J Pediatr Urol 2011;7:363-6.
Smith KE, Holmes N, Lieb JI, Mandell J, Baskin LS, Kogan BA, et al.
Stented versus nonstented pediatric pyeloplasty: A modern series and review of the literature. J Urol 2002;168:1127-30.
YK Sarin, R Gupta, Nagdeve N. Pediatric pyeloplasty: Intubated vs. nonintubated. Indian J Urol 2006;22:35-8.
Ninan GK, Sinha C, Patel R, Marri R. Dismembered pyeloplasty using double 'J' stent in infants and children. Pediatr Surg Int 2009;25:191-4.
Bayne AP, Lee KA, Nelson ED, Cisek LJ, Gonzales ET Jr., Roth DR, et al.
The impact of surgical approach and urinary diversion on patient outcomes in pediatric pyeloplasty. J Urol 2011;186:1693-8.
Ozdemir T, Arikan A. One day hospitalization after open, double-J stented pyeloplasty. World J Pediatr 2010;6:271-3.
Babu R, Sai V. Pelvis/cortex ratio: An early marker of success following pyeloplasty in children. J Pediatr Urol 2010;6:473-6.
[Table 1], [Table 2], [Table 3]