Primary obstructive megaureter: the role of high pressure balloon dilation.

BACKGROUND AND PURPOSE: There is a growing interest in minimally invasive treatment of primary obstructive megaureter (POM) in children. The absence of long-term follow-up data, however, makes it difficult to establish the indication for an endoscopic approach. The aim of our study is to determine the long-term efficacy of endourologic high-pressure balloon dilation of the vesicoureteral junction (VUJ) in children with POM that necessitates surgical treatment. METHODS: We retrospectively reviewed the clinical records from children with POM who were treated with endourologic high-pressure balloon dilation of the VUJ from March 2003 to April 2010. To determine the long-term, a cohort study was conducted in November 2011. Endourologic dilation of the VUJ was performed with a semicompliant high-pressure balloon (2.7 FG) with a minimum balloon size of 3 mm, followed by placement of a Double-J stent. RESULTS: We have treated 29 (32 renal units, left [n=16], right [n=10] and bilateral [n=3]) children with a diagnosis of POM within this period. The median age at the time of the endourologic treatment was 4.04 months (range 1.6-39 months). In three cases, an open ureteral reimplantation was needed, in two cases because of intraoperative technical failure and postoperative Double-J stent migration in one patient. The 26 children (29 renal units) who had a successful endourologic dilation of the VUJ were followed with ultrasonography and MAG-3-Lasix (furosemide) studies that showed a progressive improvement of both the ureterohydronephrosis and drainage in the first 18 months in 20 patients (23 renal units) (69%). In two patients who were treated with a 3 mm balloon, a further dilation was needed, with an excellent outcome. The cohort study (at a median follow-up of 47 months) showed that in all patients who had a good outcome at the 18-month follow-up after endourologic balloon dilation remained asymptomatic with resolution of ureterohydronephrosis on the US and good drainage on the renogram, in the children with some persistent hydronephrosis. CONCLUSIONS: Our study shows that children with POM who were treated with high-pressure ballon dilation of the VUJ who have satisfactory appearance at 18 months maintain these results over time.

Management of ureteropelvic junction obstruction with high-pressure balloon dilatation: long-term outcome in 50 children under 18 months of age.

OBJECTIVE: To analyze the usefulness of dilatation in the treatment of ureteropelvic junction obstruction (UPJ) in children <18 months of age, including newborns and infants. METHODS: Patients (n = 50; <18 months of age) were diagnosed using abdominal ultrasound, cystogram, and diuretic renography. Treatment was with endourologic retrograde balloon dilatation under fluoroscopic guidance. The balloons were, in all cases, semicompliant with a profile of 5 mm, 6 mm, or 7 mm. Follow-up was for 42.9 ± 23.2 months (mean ± SD). Double-J stents were inserted postdilatation, the caliber and length depending on the patient's body weight. RESULTS: Intervention duration was 22 ± 19 minutes. Dilatation was not possible in 5 patients, and pyeloplasty was the alternative treatment. Hospital stay was 24 hours in 44 patients. Analgesic needs were met exclusively by nonsteroidal anti-inflammatory drugs. The double-J stent was withdrawn using cystoscopy and the UPJ was calibrated.Residual stenosis was found in 7 patients. A second dilatation was required in 3 patients 6-18 months after surgery because of the lack of improvement of hydronephrosis. During follow-up, resolution of the hydronephrosis was observed in 45 cases (anterior-posterior diameter of the renal pelvis 7 ± 5 mm). The diuretic renography improved in 45 infants; the shape of the curve being normal in 44 cases and semi-obstructive in 1. CONCLUSION: We believe that high-pressure balloon dilatation could be a valid and safe option in the minimally invasive treatment of UPJ obstruction in infants. The outcome is acceptable with a low complication rate.

Is intraoperative surgeon's opinion an accurate tool to assess the outcome of endoscopic treatment for vesicoureteral reflux?

OBJECTIVE: Our experience in the endoscopic treatment of vesicoureteral reflux (VUR) has significantly increased during the last decade. To help develop diagnostic tests to check the success of this procedure, we evaluated the accuracy of surgeons' intraoperative observations as a predictor of treatment results. METHOD: We performed a prospective study of patients with VUR who were endoscopically treated during 1 year (106 renal units). Patients' age and gender, laterality, material used, grade of reflux, presence of ureteral duplication or associated pathology, and morphology of ureteral orifice were recorded as predictive factors related to the success rate. Surgeon and assistant indicated at the end of the endoscopic procedure whether the VUR was cured or not for each renal unit. These estimations were compared with postoperative voiding cystourethrogram results. RESULTS: Overall cure rate was 75.5%. Positive predictive value (PPV) for surgeon's opinion was 0.79 and negative predictive value (NPV) was 0.40. Statistical analysis demonstrated that the association between the surgeon's opinion and the cure rate was low with a Kappa value of 0.171 (p = 0.30). PPV of assistant's opinion was 0.80 and NPV was 0.40, with a Kappa value of 0.2 (p = 0.13). Concordance of surgeon and assistant's opinion resulted in PPV of 0.79 and NPV of 0.53 (Kappa = 0.261). Kappa value did not improve when surgeon's opinion was related to other factors such as the material employed, grade of reflux, presence of ureteral duplication or associated pathology and morphology of the ureteral orifice. CONCLUSION: In our experience, surgeon's opinion is not an accurate tool to predict the outcome of endoscopic treatment of VUR.

Endourological management in a newborn with incomplete bladder duplication.

We report an unusual case of a newborn with incomplete bladder duplication and a complete sagittal septum. This malformation was associated with dysplasia of the right kidney, right cryptorchidism, single urethra, and no other genital or gastrointestinal anomalies. At birth, we found severe ureterohydronephrosis in a solitary left kidney caused by the collapse of the left bladder when the right bladder was filled. We performed a neonatal puncture of the bladder septum. At 3 months of life, the patient underwent complete resection of the septum by cystoscopy with monopolar electrocautery. There are no previously reported cases of a newborn with obstructed uropathy. This is the first reported case of incomplete bladder duplication with endourological management.

Percutaneous endopyelotomy with electrocautery: modified techniques in the treatment of ureteropelvic junction obstruction in a child under 2 years.

OBJECTIVE: In recent years new techniques in minimally invasive treatment of congenital stenosis of ureteropelvic junction have been developed. We report the treatment of pyeloureteral stenosis in children by percutaneous endopyelotomy. METHODS: In the work up study of a child (18 months) with abdominal palpable mass, a severe left hydronephrosis with a renal pelvis diameter of 65 mm and severely thinned renal parenchyma was found. The diuretic renogram showed an obstructive pattern with impaired renal function. Initially, a retrograde dilatation balloon was placed in the ureteropelvic junction under cistoscopic control. With the patient in modified Valdivia position, percutaneous access to the renal pelvis was performed. By Seldinger technique and under fluoroscopy guide, a 5 mm laparoscopic trocar was placed in the renal pelvis. We performed a percutaneous electrical endopyelotomy of the pyeloureteral junction over the 6 mm retrograde balloon dilator passed through. We placed an antegrade double J stent that was removed at 4 weeks uneventfully. RESULT: Good results were assessed without perioperative or postoperative complications with great improvement in renal dilatation two years after the intervention. The renogram showed improvement in the pattern of the curve with a slight increase in differential renal function. CONCLUSIONS: Percutaneous endopyelotomy in children has important issues due to the lack of appropriate material. However it is possible to get good results as a minimally invasive technique. In fact, it could be the ideal technique in severe hydronephrosis with large renal pelvis that prevents the surgical or endourological approach.

Endopielotomía percutánea con electrobisturí en un lactante: modificaciones técnicas / Percutaneous endopyelotomy with electrocautery: modified techniques in the treatment of ureteropelvic junction obstruction in a child under 2 years

OBJETIVO: Las técnicas mínimamente invasivas de tratamiento de la estenosis pieloureteral desarrolladas en adultos tienen grandes dificultades para su aplicación en niños por la ausencia de material adecuado. Presentamos mejoras técnicas de la endopielotomía percutánea para su aplicación en un lactante. MÉTODO: Paciente de 18 meses con severa hidronefrosis izquierda que cruza línea media con pelvis renal de 65 mm. Se sitúa retrógradamente un balón de alta presión en unión pieloureteral tras pielografía retrógrada y paso de guía a pelvis renal. Con el paciente en posición de Valdivia modificado, se realiza el acceso percutáneo mediante técnica de Seldinger guiado por radioscopia hasta colocar un trocar de 5 mm en pelvis renal. Se realiza una endopielotomía percutánea con corte eléctrico sobre el balón. Se deja colocado un stent doble J anterógradamente que se retira a las 4 semanas. RESULTADO: Buena evolución postoperatoria sin complicaciones perioperatorias ni postoperatorias. Gran mejoría de la dilatación renal al año y dos años de la intervención. El renograma muestra clara mejoría en el patrón de la curva con leve ascenso de la función renal diferencial. CONCLUSIONES: La endopielotomía percutánea presenta dificultades en niños por la ausencia de material adecuado. Sin embargo es posible su realización con buenos resultados sin contraindicar otras técnicas posteriores. Podría ser la técnica ideal en severas hidronefrosis con grandes pelvis renales que dificultan su abordaje quirúrgico o endourológico(AU)

OBJECTIVE: In recent years new techniques in minimally invasive treatment of congenital stenosis of ureteropelvic junction have been developed. We report the treatment of pyeloureteral stenosis in children by percutaneous endopyelotomy. METHODS: In the work up study of a child (18 months) with abdominal palpable mass, a severe left hydronephrosis with a renal pelvis diameter of 65 mm and severely thinned renal parenchyma was found. The diuretic renogram showed an obstructive pattern with impaired renal function. Initially, a retrograde dilatation balloon was placed in the ureteropelvic junction under cistoscopic control. With the patient in modified Valdivia position, percutaneous access to the renal pelvis was performed. By Seldinger technique and under fluoroscopy guide, a 5 mm laparoscopic trocar was placed in the renal pelvis. We performed a percutaneous electrical endopyelotomy of the pyeloureteral junction over the 6 mm retrograde balloon dilator passed through. We placed an antegrade double J stent that was removed at 4 weeks uneventfully. RESULT: Good results were assessed without perioperative or postoperative complications with great improvement in renal dilatation two years after the intervention. The renogram showed improvement in the pattern of the curve with a slight increase in differential renal function. CONCLUSIONS: Percutaneous endopyelotomy in children has important issues due to the lack of appropriate material. However it is possible to get good results as a minimally invasive technique. In fact, it could be the ideal technique in severe hydronephrosis with large renal pelvis that prevents the surgical or endourological approach(AU)