|
STONE
DISEASE
Treatment
outcomes after endopyelotomy performed with or without simultaneous nephrolithotomy:
10-year experience
Berkman DS, Landman J, Gupta M
Department of Urology, Columbia University, College of Physicians and
Surgeons, New York, New York, USA
J Endourol. 2009; 23: 1409-13
-
Introduction:
The incidence of renal calculi associated with ureteropelvic junction
obstruction (UPJO) has been reported to be as high as 20%. Although
it has been suggested that simultaneous stone removal be performed
with endopyelotomy (EP) for patients with UPJO, no crossing vessel,
and renal calculi, there are no large series to date reporting in
a rigorous fashion the success rate for resolution of the UPJO. This
study intends to determine if stone extraction performed with EP increases
failure rate.
Materials and Methods: A retrospective review was performed for all
patients who underwent EP by a single surgeon between August 1996
and November 2006. One hundred forty-six procedures for UPJO were
done in 139 patients. Success rate was compared in 105 cases (72%)
of isolated UPJO and 41 (28%) cases with UPJO and ipsilateral calculi.
Determination of overall success required subjective improvement and
objective data based on intravenous pyelogram, computed tomography,
and/or nuclear scintigraphy.
Results: Overall success rate was 71% in patients undergoing EP only
and 90% in 41 patients who had simultaneous nephrolithotomy (p = 0.04).
The odds ratio of failure after EP was 2.9 for severe/massive preoperative
hydronephrosis. When considered alone and after adjusting for the
severity of preoperative hydronephrosis and/or renal function, simultaneous
nephrolithotomy did not increase the EP failure rate.
Conclusion: This study demonstrates that UPJO resolves at an equal
rate after EP performed with or without ipsilateral renal calculi.
Patients with UPJO and renal calculi should undergo stone extraction
and EP in the same setting with the expectation of excellent results.
-
Editorial
Comment
Traditionally a staged approach (stone extraction; re-evaluation;
endopyelotomy) has been recommended for stones at the ureteropelvic
junction as it is difficult to establish the presence of a primary
UPJ obstruction versus the possibility of secondary obstruction due
to edema that will resolve following stone extraction. Indeed, such
patients were excluded from analysis in this study. Concerns are raised
with regards to the possibility of fragment migration through the
endopyelotomy incision if the two procedures are performed simultaneously.
Unfortunately, the authors did not compare success rates for those
undergoing intracorporeal lithotripsy to those undergoing intact stone
removal, nor do they correlate success with stone size. Similarly,
the authors do not report the presence of residual fragments or fragments
in the retroperitoneum on postoperative imaging. The study could be
criticized due to the lack of standardization in preoperative and
postoperative imaging. The authors do not discuss their preoperative
imaging to assess for crossing vessels, and whether the identification
of crossing vessels impacted their treatment algorithm.
Dr.
Manoj Monga
Professor, Department of Urology
University of Minnesota
Edina, Minnesota, USA
E-mail: endourol@yahoo.com
|