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UPDATE MANAGEMENT IN PEDIATRIC URETERO-PELVIC

JUNCTION OBSTRUCTION: OPEN PYELOPLASTY

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU

Normah Medical Specialist Centre, Kuching, MALAYSIA.

clarencelei@gmail.com

Introduction And Objective:

There is an increasing incidence of hydronephrosis in children, mainly due to the use of antenatal ultrasound.  Indeed, hydronephrosis is the commonest antenatal ultrasound abnormality.  Less than a quarter of them eventually need surgery. The majority can be followed up with ultrasound alone, monitoring the APD, anterior posterior diameter of the hydronephrosis.  If the APD is more than 15 mm. or if there is increasing hydronephrosis, further investigations is needed before surgery.

Materials And Methods:

The first author has been doing mainly open pyeloplasty and his personal series from 1987 to 2007 included 80 cases.   In 1949, 2 English surgeons, Anderson and Hynes described dismembered pyeloplasty: this was first used for a case of retrocaval ureter.  This is the surgical technique used. Under general anaesthesia, an anterior loin incision is made, exploring the pelvi-ureteric junction in the retroperitoneal space.  A stay suture is placed on the lateral aspect of the ureter which is widely spatulated.  The redundant (especially extrarenal) pelvis is excised, taking care to preserve the vessels and not to enter the calyces. The pelvis is closed with absorbable continuous suture. The ueteropelvic junction is closed with a combination of interrupted and continuous absorbable sutures.  When there is a crossing lower pole vessel, dismemberment allows transposition of the UPJ in relation to the vessels.  In small male infant, I typically leave 2 feeding tubes: 1 as the nephrostomy and the other as a stent over the UPJ. The stent can be removed after a week and the nephrostomy clamped and removed 48 hours later.  It is also important for the patient to have a urethral catheter during the first few days.  For bigger children or in female, a pediatric ureteric stent can facilitate earlier discharge. The stent can be removed under a general anaesthetic after a month.  No case required surgical re-exploration; 1 had prolonged nephrostomy leak (1 week) and another had acute urinary retention.

The da Vinci Robot was introduced to the Sarawak General Hospital in 2008.  From 2008 to 2013, 215 cases of robotic surgeries were performed.  The da Vinci Robot programme included prostatectomy (58), cystectomy (25), partial nephrectomy (17),  pyeloplasty (17), hysterectomy (44), AP resection (23).  This author previously reported on the robot assisted laparoscopic pyeloplasty done in 2009 (9 out of 38 executive robot cases in 12 months).  Most of the RALP cases are in older children with a mean body weight of 38 kgs and a mean operative time of 245 mins (presented at the 20^th Video Urology World Congress, 24.7.2009, Abstract PP-21).

Results:

Indications for surgery are: (1) pyonephrosis, usually preceded with a nephrostomy and with  good urine output, (2) a palpable abdominal mass which may be intermittent and associated with discomfort, (3) ultrasound appearance of hydronephrosis (“Mickey Mouse”) and an increased AP diameter,  (4) radio-isotope scan, usually MAG-3 with IV Lasix.  Decreasing function, especially when the differential function is less than 35%,  is an indication for surgery.  When a radio isotope is not available, a diuretic IVU with increasing hydronephrosis at the 15 mins. post IV Lasix is acceptable evidence of obstruction.

Patients are typically followed up with postoperative serial ultrasounds, usually for a year. When post-operative ultrasound improvement is equivocal, a follow-up radio isotope scan is indicated.  Most patients are from long distances and do not come for follow-up if they are asymptomatic.

Conclusion:

Open surgery is proven to be a gold standard for the surgical treatment of UPJO. The results are good.  In male infants, open pyeloplasty is definitely the preferred option.  When there is an ongoing da Vinci Robot surgical programme, robot assisted laparoscopic pyeloplasty can be achieved.  When the surgeon has the laparoscopic skills and the surgical volume, a pure laparoscopic pyeloplasty programme (with pediatric instruments) can also be  offered.