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UPJ obstruction in US is visualized
-as a large, medial sonolucent area
-surrounding by smaller,rounded sonolucent structures representing dilated calyces
Multicystic kidneys
-various sized sonolucent areas in random distribution
Confusion of Dx of UPJ stenosis and multicystic kidney when
-large,centrally located cyst
In the setting of large,centrally located cyst DD of UPJ and multicystic kidney
-nuclear renography
-Tc99m-diethylenetriamenepentacetic acid
DTPA and multicystic kidney
-rarely reveal concentration of this isotope
The common used study for DS of UPJ and ureteral obsrruction
-diuretic renography
Retrograde pyelography and UPJ obstruction should be performed
-whenever the UPJ obstruction requires acute decompression
-such as in the setting of infection or compromised renal function
Cystoscopic retrograde manipulation has been unsuccessful or many be hazardous
-particulary in neonates or infants
-percutaneous nephrostomy is preferred
Whitaker test
-continuously perused at 10 ml/min with N/S or diluted
Whitaker test results
-renal pelvic pressure up to 12 to 15 cm H2O nonobstructing system
-excess of 15 to 22 cm H2O are highly suggestive of a functional obstruction
-pressure between these extremes may be nondiagnostic
Contemporary indications for intervention for UPJ obstruction
-the presence of symptoms associated with the obstruction
-impairment of verall renal function
-progressive impairment of ipsilateral function
-development of stones or infection
-rarely causal hypertension
UPJ obstruction may not become apparent until
-middle age or later
Procedure of choice in the case of UPJ
-historically dismembered pyeloplasty
-however,less invasive endourologic approaches have a role as alternative in many centers
An open or laparotomic approach for pts
-who failed primary endourologic management
An endourologic management approach for pts
-who have failed open or laparoscopic repair
Percent of differential function of kidneys that are nonsalvageable in adults
-15%
Success rate of endopyelotomy vs open,laparoscopic or robotic pyeloplasty
-does not approach that of open,lap, robotic
The basic concept of endopyelotomy
-is a full thickness lateral incision through the obstructing proximal ureter
-from the ureteral lumen out to the peripelvic and periureteral fat
Contraindications for percutaneous endopyelotomy
-long segment more than 2 cm of obstruction
-activ einfection
-untreated coagulopathy
Percutaneous endopyelotomy indications
-for any pts with UPJ
-concomitant pyelocaliceal stones
An endopyelotomy can not be performed safely by any route until
-access across the UPJ is established
Establishing of access across the UPJ can be accomplished
-in a retrograde fashion cystoscopically, open end catheter and injection of contrast
-or in an antegrade manner percutaneously
The site fpr percutaneous access
-midposterior or superolateral calyx
The point that percutaneous access in complete
-there are working and safety wire both in place
Incision should generally be made
-laterally
-because this is the location devoid of crossing vessels
Postoperative care (stent removal)
-1 months later
-history
-physical
-urinalysis
-diuretic renography
If patient asympromatic and normal diuretic renography,reevaluation
-at 12 months
-than 2 and 3 year follow up
The majority of endopyelotomy failure
-within the first year
When percutaneous endopyelotomy does fail,options
-retrograde pyelotomy
-repeat percutaneous endopyelotomy
-lap,robotic,open operative intervention
The role for spiral CT in the case of failed perutaneous endopyelotomy
-to rule out a crossing vessel
The presence of a crossing vessel and endopyelotomy
-endopyelotomy is nor recommended
Management of hemorrhage after endopyelotomy
-bed res
-hydration
-transfusion
-
Irrigation of nephrostomy tube in management of hemorrhage after endopyelotomy
-should no be irrigated acutely
-it is preferable to allow the pyelocalyceal system to tamponade the bleeding
If bleeding does not respond to conservative measures,the next step is
-selective angiographic embolization
Clot obstruction of stent
-usualy resolves spontaneously
Simultaneous Percutaneous Endopyelotomy and Nephrolithotomy
-stone should be removed before the endopyelotomy
Retrograde Ureteroscopic endopyelotomy indications
-functionally significant obstruction
Contraindications for ureteroscopic endopyelotomy
-relatively long areas of obstruction
-upper tract stones (best managed simultaneously percutaneously or laparoscopically)
Success of retrograde balloon dilation
-42%
Postoperative care after ureteroscopic endopyelotomy
-diuretic renograpy is prformed 4 weeks after
-clinical and radiographic follow up is continued at 6 - to 12-month intervals for 24 to 32 months
Complications of ureteroscopic endopyelotomy
-ureteral strictures
-urinary leak
-stent migration
-infection
Retrograde cautery ballon endopyelotomy (preoperative recommendation)
-imaging for detecting of vessels
-this procedure may increase the risk of hemorrhage after activation of the cautery wire balloon
The major complication associated with cautery wire balloon incision
-hemorrhage
Lateral incision principles
-minimizes the risk of hemorrhage
Contemporary indications for intervention for UPJ obstruction
-symptoms associated with the obstruction
-impairment of overall renal function
-progressive impairment of ipsilateral function
-development of stones or infection
-rarely causal hypertension
In the case of failure of open,lap,robotic intervaention and decision of less invasive procedure the surgeon have to take into account
-the degree of hydronephrosis
-ipsilateral renal function
-concomitant calculi
-presence of crossing vessels
Contraindications for lap.pyeloplasty
-uncorrected coagulopathy
-the absence of adequate treatment of active UTI
-the presence of cardiopulmonary compromise
The objective of the laparoscopic surgery
-to provide a tension free,water tight repair
-with a funnel-shaped drainage product to relieve clinical symptoms and to preserve renal function
Four techiques of lap.pyeloplasty
-transperitoneal
-retroperitoneal
-anterior extraperitoneal
-robotic assisted
Transperitoneal approach
-large working space
-familiar anatomy
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