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PEDIATRIC
UROLOGY
Failed
pyeloplasty in children: comparative analysis of retrograde endopyelotomy
versus redo pyeloplasty
Braga LH, Lorenzo AJ, Skeldon S, Dave S, Bagli DJ, Khoury AE, Pippi Salle
JL, Farhat WA
Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
J Urol. 2007; 178: 2571-5; discussion 2575
- Purpose:
We compared retrograde endopyelotomy to redo pyeloplasty for the treatment
of failed pyeloplasty in children.
- Materials
and Methods: Of 32 patients with recurrent ureteropelvic junction
obstruction retrograde endopyelotomy was performed in 18 and redo pyeloplasty
was performed in 14. Patient age, gender, side, stent placement at initial
pyeloplasty, presentation of secondary ureteropelvic junction obstruction,
hospital stay, complications and success rates were compared. Success
was defined as radiographic relief of obstruction as determined by ultrasound
or diuretic renography at latest followup.
-
Results: Median
patient age was 6 years (range 2 to 14) at retrograde endopyelotomy
and 7.2 years (1 to 17) at redo pyeloplasty. Retrograde endopyelotomy
technique consisted of holmium laser in 10 patients and cautery/balloon
dilation in 8. Redo pyeloplasty was performed through a flank incision
in 12 patients and by laparoscopy in 2. Retrograde endopyelotomy was
successful in 39% of the patients, while redo pyeloplasty had a 100%
success rate (p = 0.002). Of the patients with failed retrograde endopyelotomy
5 had a stricture greater than 1 cm and 7 were younger than 4 years.
Mean length of the narrowed ureteral segment was 10.1 mm in the failed
retrograde endopyelotomy group vs. 5.8 mm in the successful group (p
< 0.01). Only 1 of 8 children (13%) had a successful retrograde endopyelotomy
using cautery followed by balloon dilation. Hospital stay was 1.3 days
for the retrograde endopyelotomy group and 2.9 days for the redo pyeloplasty
group (p < 0.01). Mean followup was 47 months (range 15 to 132) after
retrograde endopyelotomy and 33.1 months (12 to 78) after redo pyeloplasty.
-
Conclusions:
Retrograde endopyelotomy had a significantly lower success rate than
redo pyeloplasty for correction of recurrent ureteropelvic junction
obstruction after failed pyeloplasty in children. Patient age less than
4 years and narrowed ureteral segment greater than 10 mm were associated
with a poor outcome after retrograde endopyelotomy.
- Editorial
Comment
Redo pyeloplasty was remarkably successful with an average of a 3 day
stay in the hospital. One wonders about patient selection in a study
such as this, as obviously that could make a great difference in the
outcome.
These authors suggested that patients under 4 and strictures longer
than a centimeter were not as well treated with endoscopic techniques.
An interesting thought suggested by the authors was that patients, who
did not have an initial ureteral stent and then subsequently had failure,
perhaps had more urine leakage and fibrosis and were better treated
by redo pyeloplasty than endoscopic techniques. The authors did not
comment on whether the endoscopic techniques made redo pyeloplasty afterwards
any more difficult but all their open pyeloplasties were successful
after their endoscopic procedures. This is a difficult segment of patients
to deal with and all of the urologic techniques should be considered.
In these authors’ hands, the retrograde endopyelotomy with electrocautery
was not very successful.
Dr.
Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu |