Evaluation of Early and Late Clinical, Radiological and Scintigraphic Datas After Laparoscopic Pyeloplasty in Ureteropelvic Junction Obstruction

Öz

Ureteropelvic junction obstruction(UPJO) causes inadequate transport of urine from the renal pelvis to the ureter. Laparoscopic pyeloplasty(LP) is increasingly preferred in patients with UPJO. We aimed to compare the clinical, radiological and scintigraphic findings before the treatment and the early and late progress of the patients underwent LP for UPJO. Sixty-eight cases underwent LP for UPJO(January 2010-May 2016) were included. Demographic characteristics, clinical findings, intraoperative characteristics, data on preoperative and postoperative clinical, radiological and scintigraphic follow-ups of the cases were evaluated retrospectively. LP was performed in 68 patients(51 males, 17 females) for UPJO. Twenty-four patients with antenatal hydronephrosis, 46 patients with abdominal pain, hematuria and urinary tract infection(UTI) findings were diagnosed with UPJO. Patients were preoperatively followed up by USG and DTPA-MAG3 imaging. During surgery, aberrant vessel in 13(19.1%) patients, malrotation in 4(5.8%) and polyp in one(1.4%) patient were detected. Thirteen patients(19.1%) underwent surgery with the transmesoolic approach, 55 patients(80.8%) underwent retrocolic surgery, 33 patients underwent laparoscopy-assisted extracorporeal pyeloplasty. In postoperative period, patients were followed up at 1st, 3rd, 6th months and in the first year with USG and at 6th months with DTPA-MAG3 imaging. Postoperative USG follow up showed a decrease in hydronephrosis(p<0.001), an increase in parenchymal thickness(p<0.001), and a decrease in caliceal dilatation(p<0.001). In scintigraphic data, renal function was increased but it is not statistically significant(p>0.05) and activated half-time was decreased(p<0.05) in postoperative period. LP is a surgical treatment method with successful results when performed with appropriate indications in experienced clinics.

Anahtar Kelimeler

• Laparoscopic pyeloplasty
• Hydronephrosis
• Ureteropelvic junction obstruction
• Pediatric
• Differential kidney function

Üreteropelvik Darlıkta Klinik, Radyolojik ve Sintigrafik Verilerin Laparoskopik Piyeloplasti Sonrası Erken ve Geç Dönem Seyrinin Değerlendirilmesi

Öz

Üreteropelvik bileşke darlığı (ÜPBD), idrarın renal pelvisden üretere yetersiz transportununa neden olur. Laparoskopik piyeloplasti (LP), üreteropelvik bileşke darlığı (ÜPBD) olan hastalarda teknolojik gelişmelerle birlikte artan bir sıklıkta cerrahi yöntem olarak tercih edilmektedir. Bu çalışmada ÜPBD nedeniyle LP yapılan olguların tedavi öncesi klinik, radyolojik ve sintigrafik bulgularının, tedavi sonrası erken ve geç dönemdeki seyrinin karşılaştırarak sonuçların değerlendirilmesi amaçlanmıştır. Bu çalışmaya, Ocak 2010-Mayıs 2016 tarihleri arasında Eskişehir Osmangazi Üniversitesi Tıp Fakültesi Çocuk Cerrahisi Anabilim Dalı’nda ÜPBD nedeniyle LP uygulanan 68 olgu dahil edildi. Retrospektif olarak yapılan bu çalışmada olguların demografik özellikleri, klinik bulguları, intraoperatif özellikleri ve preoperatif ve postoperatif klinik, radyolojik ve sintigrafik incelemelerinin takipleriyle ilgili veriler değerlendirildi. ÜPBD nedeniyle 68 hastaya(51 erkek, 17 kız) LP yapıldı. Çalışmaya dahil edilen hastaların, 24’ü antenatal hidronefroz, 46’sı karın ağrısı, hematüri ve idrar yolu enfeksiyonu (İYE) bulguları sonrasında yapılan tetkikler sonucunda ÜPBD tanısı aldı. Hastalar ameliyat öncesi USG ve DTPA-MAG3 görüntülemeleriyle takip edildi. Cerrahi esnasında hastaların 13’ünde (%19.1) aberan damar basısı, 4’ünde(%5.8) malrotasyon ve birinde (%1.4) polip saptandı. Hastaların 13’ünde (%19.1) transmezokolik LP, 55’inde(%80.8) retrokolik LP uygulandı; 33 hastada laparoskopi yardımlı ekstrakorporeal piyeloplasti yapıldı. Hastalar postoperatif dönemde 1,3,6. ay ve 1. yılda USG ve 6. Ayda DTPA-MAG3 görüntülemeleriyle takip edildi. Postoperatif USG takiplerinde hidronefrozun gerilediği (p<0.001), parankim kalınlığının arttığı (p<0.001), kalisiyel dilatasyonun azaldığı (p<0.001) gözlendi. Sintigrafide, postoperatif dönemde böbrek fonksiyonlarının istatiksel olarak anlamlı olmamakla birlikte (p>0.05) arttığı ve aktivite yarılanma sürelerinin azaldığı (p>0.05) gözlendi. LP deneyimli kliniklerde uygun endikasyonlar ile yapıldığında başarılı sonuçları olan bir cerrahi tedavi yöntemidir.

Anahtar Kelimeler

• Laparoskopik piyeloplasti
• Hidronefroz
• Ürteropelvik bileşke darlığı
• Pediatrik
• Diferansiyel böbrek fonksiyonu

Kaynakça

1. 1. Lerman SE, McAleer IM, Kaplan GW. Renal vascularity and kidney. In: Kelalis King- Belman Pediatric Urology. Kelalis PP, King LR, Belman AB (eds). Habitat Publishing, Philadelphia 2013, p. 261-9.
2. 2. Demirkol MK, Barut O, Şahinkanat T, Resim S, Laparoscopic pyeloplasty in ureteropelvic junction obstruction: A single-center experience, Laparosc Endosc Surg Sci 2021;28(1):24-28, DOI: 10.14744/less.2021.58219
3. 3. Chevalier RL, Thornhill BA, Forbes MS, Kiley SC. Mechanisms of renal injury and progression of renal disease in congenital obstructive nephropathy. Pediatr Nephrol (Berlin, Germany) 2010;25:687–97.
4. 4. Groth TW, Mitchell ME. Urteropelvic junction obstruction. In: Coran AG, Adzick NS, Krummel TM, eds. Pediatric Surgery(7th ed). Philadephia: Elsevier Saunders, 2012, pp 1411-25
5. 5. Murokumo M, Nonomura K, Yamashıta T. Structural changes of collagen components and diminution of nerves in congenital ureteropelvic junction obstruction J Urol, 157:1963-97.
6. 6. Tekgül S, Riedmiller H, Gerharz E, et al. Guidelines on pediatric urology. ESPU 2008:44.
7. 7. Kogan BA. Ureter and ureteropelvic junction diseases. In: Smith General Urology (17th ed.) Tanagho EA, McAninch JW. Nobel Medicine Bookstores, Istanbul 2009, pp 559-73.
8. 8. Başaklar AC. Congenital malformations of the kidney and ureter. In: Surgical and Urological Diseases of Infants and Children. Palme Publishing, Ankara 2006b, p. 1199-257.

9. 9. Ebiloğlu T, Kaya E, Zor M, Sarıkaya S, Topuz B, Köprü B, Bedir S. The success of non-full-thickness endopyelotomy in secondary urethropelvic stenosis after open pyeloplasty and the factors affecting this success, Yeni Urology Journal, 2018; 13 (2): 14-19
10. 10. Stein RJ, Gill IS, Desai MM. Comparison of surgical approaches to ureteropelvic junction obstruction: Endopyeloplasty versus endopyelotomy versus laparoscopic pyeloplasty. Curr Urol Rep 2007;8:140–9
11. 11. Peter‟s CA, Schlussel RN, Retik AB, et al. Pedatric laparoscopic dismembered pyeloplasty. J Urol 1995;153:1962-5.
12. 12. Inagaki T, Rha KH, Ong AM, Kavoussi LR, Jarett TW. Laparoscpic pyeloplasty: current status. BJU Int. 2005 Mar;95 Suppl 2:102-5.
13. 13. Iwamura M, Sos S, Irie A, Kadowaki K, Matsusita Y, Fujioka T, Baba S. Laparoscopic pyeloplasty for ureteropelvic junction obstruction: outcome of initial 12 procedures. Int J Urol. 2004 Jul;11(7):449-55.
14. 14. Pattaras JG, Moore RG. Laparoscopic pyeloplasty. J Endourol 2000:14(10): 895-904. 2000.
15. 15. Başok ek Üreteropelvik birleşke darlık cerrahi tedavisinde laparoskopik piyeloplasti, Endoüroloji Bülteni, 2013:6-9
16. 16. Albqami N, Janetschek G. Laparoscopic pyeloplasty. Ann Urol 2006:40(6): 363-7.
17. 17. Baldwin DD, Dunbar JA, Wells N, McDougall EM. Single-center comparison of laparoscopic pyeloplasty, Acucise endopyelotomy, and open pyeloplasty. J Endourol 2003;17:155–60.
18. 18. Şahin S, Şeker KG, Yenice MG, Şener NC, Tuğcu V. Laparoskopik piyeloplasti: Hangi yaklaşım? Tek merkez deneyimi, Yeni Üroloji Dergisi, 2016; 11 (2): 22-29
19. 19. O’Reilly PH, Brooman PJ, Mak S, et al. The long-term results of Anderson Hynes pyeloplasty. BJU Int 2001;87:287- 9
20. 20. Jarrett TW, Chan DY, Charambura TC, Fugita O, Kavoussi LR. Laparoscopic pyeloplasty: the first 100 cases. J Urol 2002:167: 1253- 56.
21. 21. Lim DJ, Park JY, Kim JH, et al. Clinical characteristics and outcome of hydronephrosis detected by prenatal ultrasonography. J Korean Med Sci 2003;18(6):859-62.
22. 22. Livera LN, Bookfield DS, Egginton JA, et al. Antenatal ultrasonography to detect fetal abnormalities: a prospective screening programme. BMJ 1989;298(6685):1421-3.
23. 23. Ulman İ. Çocuklarda hidronefroz ve üriner obstrüksiyon. Türkiye Klinikleri J Pediatr Sci. 2005;1(12):1-4.
24. 24. Song SH, Lee SB, Park YS, et al. Is antibiotic prophylaxis necessary in infants with obstructive hydronephrosis? J Urol. 2007;177:1098-101
25. 25. Tolstrup RS, Pank MT, Sander L, Dørflinger T. Laparoscopic pyeloplasty for ureteropelvic junctions obstruction in adults: 6 years’ experience in one center. Biomed Res İnt 2017;2017:6743512.
26. 26. Demirdağ ÇÖ, Çitgez S, Önal B, Talat Z. Outcomes of laparoscopic transperitoneal pyeloplasty for the treatment of ureteropelvic junction obstruction in adult patients. J Urol Surg 2018;5:174–9.
27. 27. Park JM, Bloom DA. The pathophysiology of UPJ obstruction. Current concepts. Urol Clin North Am 1998;25:161–9
28. 28. Braga LH, Pace K, DeMaria J, Lorenzo AJ. Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: Effect on operative time, length of hospital stay, postoperative complications, and success rate. Eur Urol 2009;56:848–57.
29. 29. Nayyar R, Gupta NP, Hemal AK. Robotic management of complicated ureteropelvic junction obstruction. World J Urol 2010;28:599–602.
30. 30. Skolarikos A, Dellis A, Knoll T. Ureteropelvic obstruction and renal stones: Etiology and treatment. Urolithiasis 2015;43:5–12.
31. 31. Stasinou T, Bourdoumis A, Masood J. Forming a stone in pelviureteric junction obstruction: Cause or effect? Int Braz J Urol 2017;43:13–9.
32. 32. Greenfield SP, Williot P, Kaplan D. Gross hematuria in children: A ten-year rewiew. Urol. 2007;69:166-9.
33. 33. Apley J. The child with abdomnal pains. 2nd ed., Owford, Blackwell Scientific Publications. 1975.
34. 34. O‟ Donnell B. Abdominal pain in childhood. Oxford, Blackwell Scientific Publications. 1985.
35. 35. Van Cangh PJ, Nesa S, Galeon M, Tombal B, Wase FX, Dardenne AN, Opsomer R, Lorge F. Vessels around the ureteropelvic junction: significance and imaging by conventional radiology. J Endourol. 196 Apr;10(2):111-9.
36. 36. Iwatsuki S, Kojima Y, Mizuno K, Tozawa K,Kohri K, Hayashi Y. Laparoscopic management for fibroepithelial polyp causing ureteropelvic junction obstruction in a child. Urol. 2010;76:146-8.
37. 37. Demirelli E, Öğreden E, Oğuz U. Böbrek Rotasyon Anomalileri (Malrotasyon) ve Cerrahi. Derman Tıbbi Yayıncılık, Ankara 2015b, s. 45-53.
38. 38. Khan F, Ahmed K, Lee N, Challacombe B, Khan MS, Dasgupta P. Management of ureteropelvic junction obstruction in adults. Nat Rev Urol 2014;11:629–38.
39. 39. Khawaja AR, Dar TI, Bashir F, et al. Stentless laparoscopic pyeloplasty: A single center experience. Urol Ann. 2014 Jul;6(3):202-7.
40. 40. Smith KE, Holmes N, Lieb JI, Mandell J, Baskin LS, Kogan BA, Walker RD 3rd. J Urol. Stented versus nonstented pediatric pyeloplasty: a modern series and review of the literatüre. 2002 Sep:168(3):1127-30.
41. 41. Shoma AM, El Nahas AR, Bazeed MA. Laparoscopic pyeloplasty: A prospective randomized comparison between the transperitoneal approach and retroperitoneoscopy. J Urol 2007;178:2020–4; discussion 4.
42. 42. Moon DA, El-Shazly MA, Chang CM, Gianduzzo TR, Eden CG. Laparoscopic pyeloplasty: Evolution of a new gold standard. Urology 2006;67:932–6
43. 43. McNeil BK, Flanigan RC. Complications of open renal surgery. Complications Urol Surg Pract. 2007. Pp 65-80.
44. 44. Lim DJ, Walker 3rd RD. Managemet of the failed pyeloplasty. J Urol. 1996;156:738-40.
45. 45. Önen A. Hidronefrozların doğum sonrası doğal seyri ve takip-tedavi yaklaşımı Çocuk Cerr Derg. 2006;20(1):33-8