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Endopyelotomy in the symptomatic older child
G Nicholls1, D Hrouda, M J Kellett
1Institute of Urology, The Middlesex Hospital, London, UK.
Insights
Endopyelotomy in children for pelvi-ureteric junction obstruction showed limited success, with only half of patients achieving symptom resolution. Careful preoperative assessment is crucial, especially for cases involving crossing lower pole vessels.
Area of Science:
- Pediatric Urology
- Endourology
- Surgical Outcomes
Background:
- Pelvi-ureteric junction (PUJ) obstruction is a common condition in children.
- Endopyelotomy is an established treatment for PUJ obstruction in adults.
- Its efficacy in pediatric patients requires further evaluation.
Purpose of the Study:
- To assess the outcomes of endopyelotomy in pediatric patients with PUJ obstruction.
- To identify factors influencing treatment success or failure.
Main Methods:
- Retrospective review of 13 pediatric patients (age > 5 years) undergoing endopyelotomy between 1992-1999.
- Exclusion of patients with crossing vessels (identified by CT) who underwent open pyeloplasty.
- Standard endopyelotomy technique with a 6-week stent placement.
Main Results:
- Successful symptom resolution and obstruction relief in 6 out of 13 patients (46%).
- Seven patients experienced treatment failure, necessitating open pyeloplasty.
- Complications included urinoma and retained stent fragment; crossing lower pole vessels were noted in 3 failed cases.
Conclusions:
- Endopyelotomy in symptomatic children has a suboptimal success rate.
- Thorough preoperative evaluation is essential.
- Open pyeloplasty is recommended for pediatric patients with crossing lower pole vessels.
Objective:
To evaluate the results of endopyelotomy in children, an established method in adult practice as a treatment for pelvi-ureteric junction (PUJ) obstruction.
Patients And Methods:
Endopyelotomies undertaken between 1992 and 1999 by one surgeon in an established endourology unit were reviewed retrospectively. Children aged > 5 years presenting with pain and obstruction on isotope renography were selected for endopyelotomy. Patients with crossing vessels detectable on spiral computed tomography were treated by open pyeloplasty. Access to the renal pelvis was provided by a uroradiologist. Endopyelotomy was carried out through an Amplatz sheath of (median) 26 F. After applying traction to invaginate the PUJ an incision was made postero-laterally using electrocautery via an 11 F paediatric resectoscope. Stenting was maintained for 6 weeks. In all, 13 patients (median age 10 years, range 5-14) were treated; two had associated calculi.
Results:
The symptoms resolved and the obstruction was relieved in only six patients, with a median (range) follow-up of 50 (26-68) months. The seven patients in whom endopyelotomy failed, as indicated by persistent pain, proceeded to open pyeloplasty at a median (range) of 4 (1.3-79) months. Of these, two had presented with associated multiple calculi and significant hydronephrosis (one with an associated duplex system) and three had crossing lower pole vessels at open operation. One developed a urinoma after the original endopyelotomy and one had a retained stent fragment removed at the time of pyeloplasty.
Conclusions:
Endopyelotomy in the symptomatic child requires a careful preoperative evaluation. Crossing lower pole vessels warrant an open pyeloplasty.