The minimally invasive management of ureteropelvic junction obstruction in horseshoe kidneys.

PURPOSE: Data regarding the treatment of ureteropelvic junction obstruction (UPJO) in horseshoe kidneys are limited. We performed a retrospective analysis of our experience with minimally invasive treatment of UPJO in patients with this anomaly. METHODS: Between March of 1996 and March 2008, 9 patients with horseshoe kidneys were treated for UPJO at our institution. Of these patients, 6 were managed with retrograde endopyelotomy, 2 with laparoscopic pyeloplasty, and one by robotic pyeloplasty. Outcomes of these procedures were retrospectively reviewed. RESULTS: A total of nine patients were available for analysis. Four of six patients who underwent endopyelotomy had available follow-up, with a mean of 56 months. The success rate for these patients was 75%. Two of three patients (67%) in the laparoscopic/robotic cohort were successfully treated with a mean follow-up of 21 months. CONCLUSIONS: UPJO in horseshoe kidneys can pose a therapeutic dilemma. The minimally invasive treatment of these patients is feasible with good success rates for both endopyelotomy and laparoscopic/robotic pyeloplasty.

The minimally invasive treatment of ureteropelvic junction obstruction: a review of our experience during the last decade.

PURPOSE: The minimally invasive treatment of ureteropelvic junction obstruction has evolved during the last decade from endoscopic to laparoscopic and robotic. We review our 10-year experience with ureteropelvic junction obstruction, and report on our experience and followup. MATERIALS AND METHODS: We reviewed all patients treated during the last 10 years. There were 294 procedures performed with complete records on 273 patients including 128 retrograde endopyelotomies, 116 laparoscopic pyeloplasties and 29 robotic pyeloplasties. Technique for each procedure is reviewed. Statistical analysis was performed on all results. Variables evaluated were gender, age (younger than 41 vs 41 years or older), side (right or left), presence of crossing vessels, presence of a high insertion, primary or secondary procedure and whether prior endopyelotomy or pyeloplasty had been performed. RESULTS: Mean followup for endopyelotomy, laparoscopic pyeloplasty and robotic pyeloplasty was 20, 20 and 19 months, respectively, with success rates of 60.2%, 88.8% and 100%, respectively. On univariable analysis only the presence of crossing vessels or a high insertion was significant for laparoscopic pyeloplasty. On multivariable analysis age was significant for endopyelotomy and the presence of crossing vessels was significant for pyeloplasty. On Kaplan-Meier analysis failures were noted to occur after 5 years in both groups. CONCLUSIONS: Laparoscopic pyeloplasty and robotic pyeloplasty are superior minimally invasive treatments for ureteropelvic junction obstruction. However, endopyelotomy can be used for select patients. Because of late failures patients who undergo either of these procedures should receive long-term followup.

Prevention of stone migration with the Accordion during endoscopic ureteral lithotripsy.

BACKGROUND AND PURPOSE: Endoscopic lithotripsy is often prolonged secondary to the retrograde migration of calculous fragments. Various balloons, baskets, and other devices have been used to prevent this migration. Our purpose is to analyze the effect of the Accordion(®) on stone migration and overall efficiency during lithotripsy. PATIENTS AND METHODS: We prospectively evaluated 21 patients with a total of 23 distal ureteral stones. Patients underwent lithotripsy using an endoscopic impact lithotriptor. The Accordion was randomly used in 11 of these 21 patients. Data were collected regarding stone migration, stone size, stone ablation, ureteral clearing, and lengths of time for various stages of each procedure. RESULTS: Patients who were treated with the Accordion device experienced significantly less retrograde migration during fragmentation (P=0.0064). When stone volume was taken into account (but not on a per stone basis), ablation and ureteral clearing were also expedited, and fewer lithotripter "hits" and basket "sweeps" were needed. CONCLUSION: The Accordion device is effective in preventing the migration of stone fragments during endoscopic ureteral lithotripsy. Our data suggest that this device may also increase efficiency of the fragmentation and clearance of ureteral calculi.

Robot-assisted laparoscopic pyeloplasty: technical considerations and outcomes.

BACKGROUND AND PURPOSE: Since first being described in 1993, laparoscopic pyeloplasty has proven to be less morbid but equally as effective as open pyeloplasty. The technical complexity of the procedure, however, has made it difficult for many surgeons to adopt. The da Vinci robot-assisted laparoscopic pyeloplasty (RP) was introduced to shorten the learning curve. We present our institutional experience with RP. PATIENTS AND METHODS: Between October 2005 and September 2006, 29 RPs were performed and prospectively recorded in a database. The patient population consisted of 18 (62%) women and 11 (38%) men with a mean age of 41.2 years (range 17-82 years). Outcomes were retrospectively reviewed. Procedures were performed transperitoneally in a modified flank position using a 4-port template. RESULTS: Mean follow-up was 11 months (range 6-17 months). Eighteen (62%) patients had ureteropelvic junction (UPJ) obstruction on the right, while 11 (38%) patients had obstruction on the left. Nine (31%) patients presented for secondary repair, all because of failed endopyelotomy. Mean operative time was 196 minutes (range 120-420 min), estimated blood loss was 39 mL (range 25-250 mL), and length of hospital stay was 2.2 days. Crossing vessels were encountered in 20 (69%) patients. Procedures in two patients, encountered early in our series, required open conversion. Both were secondary repairs after failed Acucise endopyelotomy. There were two readmissions, one for flank pain and another for pyelonephritis. There were no recurrences based on both subjective and radiologic measures. CONCLUSION: We demonstrate that RP is a technically feasible management option for UPJ obstruction with success rates comparable to those of conventional laparoscopic and open pyeloplasty.