Objective The available armamentaria for treating an obstructed pelvi-ureteric junction (PUJ) include open surgery, endourologic and laparoscopic procedures, each with a variable rate of success. Solid decisions about adopting one procedure over another for a particular case are frequently left for the surgeon’s preference. Through this study we tried to assess in a retrospective fashion our results with open surgery, ante-grade endoyelotomy and Acucise endopye-loomy. We hoped that evaluating these results would give some clues about the clinical situations in which each modality would work best.
Patients and Methods A retrospective ana-lysis of 75 patients with PUJ obstruction was carried out. They had been all ope-rated upon during a 3-year-period and completed at least 6 months of follow-up. Fifty-two patients had primary PUJ obstruc-tion, while 23 had a secondary obstruction. Twenty-five patients had open surgical pyeloplasty (Group I), 31 had antegrade endopyelotomy (Group II), while 19 under-went Acucise balloon endopyelotomy (Group III). The patients’ postoperative clinical data as well as their contrast studies, ultrasonograms and, in som

cases, radio-isotope renograms were com-pared to the preoperative status. Failure was defined as persistence of both or de-terioration of either of the patients’ symp-toms and imaging studies.
Results The success rates mounted to 88%, 79.9% and 79% in the three groups, re-spectively. In primary PUJ obstruction, the success rate was higher in the open surgery group (91.3%) versus the other groups (75% and 66.7%, respectively). Both endourologic procedures, on the other hand, fared well in secondary cases with success rates of 90.9% and 90%, re-spectively. The average hospital stay was in favour of the Acucise and the endopyelo-tomy procedures.
Conclusion Open pyeloplasty, we believe, still represents the first-choice line of therapy in primary PUJ obstruction unless it is contra-indicated by some mitigating circum-stances. Antegrade and Acucise endopye-lotomies yield excellent results in secondary PUJ obstruction and may provide accept-able results in primary cases in whom a short hospital stay is desired.
Key Words PUJ obstruction, open pyeloplasty, endopyelotomy, Acucise

INTRODUCTION

The main indications for active intervention in cases of pelviureteric junction (PUJ) obstruc-tion are to relieve pain, to correct physiolo-gically significant obstruction and/or to relieve pathologies secondary to such obstruction (e.g. stones and infection). Many open surgical corrective techniques have dominated urologic practice in this field for more than a century. With the advent of modern endoscopic tech-nology and inspired by the intubated Davis ureterotomy1, retrograde and percutaneous

antegrade endopyelotomy have become in common use throughout the last 2 decades. More recently, cautery-wire balloon incision has been described to treat PUJ obstruction.2 Although clear-cut situations may favour one approach over another, yet, many other condi-tions may be confronted in which adoption of one of these techniques is motivated by nothing but personal bias.

We embarked on this study to evaluate, in a retrospective fashion, our results with three different modalities in the management of PUJ

was removed after two weeks which made re-insertion necessary for another two weeks.

On removal, one stent was covered by encrustation, and on culture of this encrusta-tion Proteus mirabilis was grown.

The complications encountered are presented in Table 3.

All patients were continent except one who needed re-adjustment under local anaesthesia on the same day. The results of flowmetry showed a maximum flow rate (Qmax) ranging from 6.2 to 9.5 ml/s with a mean of 7.1 ml/s (Fig. 4). No significant residual urine was present in any patient. The results of urine culture done weekly are illustrated in Table 4. Three patients had symptomatic UTI (fre-quency, urgency and dysuria) (one patient twice), but no stent had to be removed. The symptoms of the patients were controlled within 48 hours with antibiotics and symp-tomatic treatment.

DISCUSSION

The intraurethral catheter as a temporary stent represents a new concept in patient management since Fabian1 introduced a stain-less-steel prostatic urospiral. When using this spiral there is no contact with the extra-corporeal surroundings, thus reducing the danger of an ascending infection to a mini-mum. In addition, it improves the quality of life of the patients as there are no external appliances and the patients void the way they are used to.

In our study, the correct insertion of the stent done in the outpatient clinic under local anaesthesia was successful in all patients. This means that the procedure was easy and did not add a significant burden on the patients or the department workload. In 37 patients the stents were left in place until the scheduled time of removal. This means that 88% of our patients could lead a normal daily life. This compares favorably with the success rate of

obstruction. These were namely, open surgical pyeloplasty, antegrade percutaneous endopye-lotomy and retrograde Acucise endopyelotomy. We hoped that such an evaluation would give clues to the question “which technique for which condition?”

PATIENTS AND METHODS

The study was carried out in a retrospective fashion at two urology centres: Al-Azhar Uni-versity Hospitals in Cairo, Egypt and Hôpital Edouard Herriot in Lyon, France. Patients who had been operated upon for correction of a PUJ obstruction during a 3-year period and who had completed at least 6 months of follow up were included into the study. A total of 75

Fig. 1: Fluoroscopic appearance of the inflated Acucise balloon as it straddles the PUJ immediately after cutting current application. Mild contrast extravasation can be noticed and ensures a full thickness incision

washout of the radiotracer material. Other patients had their diagnosis settled through diuretic urography and/or ultrasonography.

Methods:
Three operative procedures were adopted in the open surgery group. Anderson-Hyne’s pyeloplasty as described in 19493 was per-formed in 8 patients. Neither stents nor nephrostomy tubes were used except in one patient. Rotational flap pyeloplasty was done in 8 others following the guidelines laid by Scar-dino and Prince.4 Internal double-J (JJ) stents were used in all 8 patients. The remaining 9 patients underwent Foley’s Y-V pyeloplasty5, 4 with internal stents and 5 without.

The endopyelotomy group underwent either a classic antegrade cold knife endopyelotomy (6 patients) as described by Wickham and Kellet6 or an antegrade ureteropelvic invagina-tion with electro-incision (25 patients) as de-scribed by Gelet and associates.7 This last technique entailed the retrograde introduction of a guide wire up to the renal pelvis. A balloon dilator introduced over the guide wire is then inflated just below the PUJ under fluoroscopic guidance. The balloon is fixed to the guide wire externally by a Kocher clamp. An antegrade percutaneous access is then established and the nephroscope is used to visualize and grasp

patients were elligible including 45 males and 30 females aged between 3 and 81 years (mean 33.4 years). The majority of the patients (n=52) had primary PUJ obstruction while the remaining patients (n=23) had a secondary obstruction: 13 after previous pyeloplasty, 4 after open pyelolithotomy, 3 after endopyelo-tomy and 3 after previous PCNL. Twenty-five patients had open surgical pyeloplasty (Group I), 31 underwent antegrade endopyelotomy (Group II) and 19 patients underwent Acucise balloon electro-incision of the PUJ (Group III). The patients’ pre-operative criteria are sum-marized in Table1.

Data about pre-operative renal isotope studies were available in the files of 18 patients and confirmed the presence of delayed

the retrogradely introduced guide wire. Trac-tion on this wire would then drag cranially the inflated balloon invaginating the upper ureter into the renal pelvis. The Culling’s knife of the resectoscope is then used to incise the two layers of the invaginated segment at the dead lateral position. The procedure is terminated with fixation of a double-J stent and a nephro-stomy tube. The nephrostomy is clamped after 4 days and removed one day later if no fever or extravasation is encountered. JJ stents are retrieved after 6 weeks.

Acucise balloon electro-incision was carried out in 19 patients as first described by Chand-hoke and colleagues.2 After initial distal ure-teral dilatation, the Acucise balloon is intro-duced retrogradely under fluoroscopic guid-ance until it straddles the PUJ that has been opacified by retrograde contrast injection. The balloon is then rotated to bring the electric cutting wire facing dead laterally. The balloon is inflated with 1 ml of contrast material to ensure proper positioning across the PUJ. A pure cutting current at 75 W setting is then switched on for 3 seconds while the balloon is further inflated to 2 ml. The waist of the balloon is noted as it disappears under fluoroscopy (Fig.1). The balloon is then deflated and withdrawn before a JJ catheter is introduced to splint the incised segment. JJ catheters are removed 6 weeks later.

The patients’ records were revised for the early post-operative incidents. The patients were all surveyed post-operatively by clinical assessment, urinalysis, IVU and abdominal ultrasonography. Radioisotope renographies were performed in equivocal cases. The findings were compared to the pre-operative data. The severity of pain, its frequency and the need for analgesics were the criteria used to assess symptomatic progress. Imaging progress, on the other hand, was judged by the kidney size, the thickness of the parenchyma, the degree of pelvi-calyceal dilatation, the rate and the degree of contrast (or radio-isotope) excretion and wash out.

The results were considered successful when the patient showed improvement in both symptoms and imaging parameters. The results in patients who had either a subjective or objective improvement were considered satisfactory (or marginally successful). Those who had persistence of both or deterioration of either the symptoms or imaging criteria were judged as failures.

.
RESULTS

A mean of 26 months elapsed between the date of intervention and inclusion into this study (range 7-40). The mean hospital stay was 9, 6.2 and 4.9 days for the open, the endopyelotomy and the Acucise groups respectively. The significant early post-operative incidents are summarized in Table 2.

Results of the clinical, radiological and laboratory assessments are summarized in Table 3. The success rates of each procedure as a whole, in primary and secondary cases and as a factor of the degree of hydro-nephrosis are shown in Table 4. Fig. 2 demon-strates one of the successful cases.

DISCUSSION

One of the main targets of introducing endoscopic procedures into urologic practice has been to cut down hospital stay, con-valescence time and hence, expenditures. In this series, the average hospital stay after open surgery is clearly 50% longer than that after endourologic procedures. Acucise endo-pyelotomy, in particular, carries the potential of a single-day hospital admission as reported by Gill and Liao.8 Convalescence has been report-ed to be dramatically longer after open pyeloplasties.9 The argument that stent re-

Bleeding after endopyelotomy has been shown to prevail in about 8% of cases reported

trieval after all endourologic procedures would add to the “endo-bill” may be debated by the fact that such maneuvres are currently carried out on an outpatient basis with limited ex-penses.

On the other hand, early post-operative complications necessitating active interven-tions were fewer in the open surgery group: one patient requiring stent adjustment versus three and two in the endopyelotomy and Acu-cise groups, respectively. In addition, one pa-tient in each of the endo groups required per-cutaneous drainage of a perirenal urinoma. Stents were not resorted to in 50% of the open pyeloplasty patients and hence, stent-related complications were quite minimal in this group. Similarly, extrarenal drainage eliminated the chances for perirenal urinoma formation.

Infection-related complications such as fever and secondary haemorrhage were more frequently encountered early after open sur-gery. Although they were managed conserva-tively, they should motivate stricter aseptic measures in handling these plastic operations. Delayed positive urine cultures, on the con-trary, were more common after endourologic procedures. A closer follow up of these pa-tients may be mandatory for the early elimina-tion of bacteriuria.

by Kuenkel and Korth.10 A 4% incidence (2 out

.

of 50 patients) was also reported in another series11, but it was emphasized that both pa-tients involved required a considerable amount of blood transfusion (3 and 6 units respec-tively). The bleeding episode that we encoun-tered (3.3% of the cases of endopyelotomy) was practically negligible: a small perirenal haematoma that was followed by ultrasono-graphy as it shrank in size over a 2-month period. The upward invagination of the PUJ carries the advantage of executing the incision away from possible crossing vessels.

Acucise-induced bleeding was also minimal (5% incidence) as has been reported in other studies.7,12 The authors of the latter report, however, emphasized the need for more active measures to handle their patients including blood transfusion and selective angio-embo-lization, which they advocate as the method of choice in such circumstances. Directing the cutting wire to a dead lateral position is to be particularly stressed and the “blind” nature of the procedure mandates strict post-operative observation.

The overall success rates are comparable to other reported series: around 95% for open pyeloplasty13 versus 88% in ours; around 86% for antegrade endopyelotomy14 versus 80.6% in ours and 75-78% for Acucise endo-pyelotomy12, 15 versus 78.9% in ours.

Comparing the results between the three groups is restricted by the heterogeneity of the

patients included into each group. Patients in the open surgery group are apparently younger than those in the other two groups, include a higher ratio of contrast non-excreting kidneys and an evidently lower ratio of secondary cases. Meanwhile, the Acucise group included a higher percentage of severely hydronephrotic kidneys. This uneven distribution of the cases has been an expected drawback in this retro-spective study. Although it renders statistical evaluation fallacious, yet, a crude comparative overview may be worthwhile as it may have some implications on future prospective protocols.

It turned clear that open surgery appears to carry a lower failure rate (12%) than either antegrade or Acucise retrograde endopyelo-tomy (19.4% and 21.1% respectively). Primary cases, in particular, fared well after open pyeloplasty with a failure rate of 8.7% versus 25% and 33.3% in antegrade and Acucise endopyelotomy, respectively. On the other hand, secondary cases were quite successfully managed with either endourologic procedures (+/- 90% overall success rate). Having only two patients with secondary PUJ obstruction in Group I might represent a selection bias by surgeons who reverted such cases away from open surgery. Peripelvic fibrosis does not only make surgeons refrain from open surgical correction but it seems also to form a barrier against extensive extravasation and, hence, shares in the success of endourologic pro-cedures.

The role of crossing vessels could not be determined in our series due to the lack of suf-ficient angiographic and/or endoluminal ultra-

Endopyelotomy

Successful

18 (58.1%)

sonographic data. They have been demon-strated to jeopardize the outcome of both antegrade and Acucise endopyelotomy.15, 16

The severity of hydronephrosis has been previously reported to negatively influence success rates after endopyelotomy.17 We could not demonstrate such a relationship. In fact we agree with Le Chevallier et al.15 that the grade of obstruction had no impact on the results of Acucise endopyelotomy. Meanwhile, the se-vere degrees of hydronephrosis had a better success rate than milder ones after pyeloplasty in our hands.

In conclusion, the retrospective analysis of our results revealed that open pyeloplasty might yield better overall results in the treat-ment of PUJ obstruction than either antegrade or Acucise retrograde endopyelotomy, but on the expense of a clearly longer hospital stay. Antegrade endopyelotomy fared better with secondary cases. Acucise balloon endopyelo-

REFERENCES

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3. Anderson JC, Hynes W. Retrocaval ureter. Case diagnosed pre-operatively and treated successfully by plastic operation. Br J Urol 1949, 21;219.

4. Scardino PL, Prince CL. Vertical flap uretero-pelvioplasty – Preliminary report. South Med J 1953, 46:325.

5. Foley FEB. A new plastic operation for stricture at the ureteropelvic junction. Report of 20 operations. J Urol 1937, 38:643.

6. Wickham JE, Kellet MJ. Percutaneous pyelolysis. Eur Urol 1983, 9:122.

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tomy has been a promising innovation that is now a successful entity. Apart from the drawback that renal stones cannot be tackled simultaneously, the procedure carries the advantage of a shorter hospital stay and convalescence period. Complications after all three modalities are rarely a nuisance.

Randomized prospective studies including radioactive isotope renal studies and angio-graphy or spiral computerized tomography should be designed on a wide scale for con-firming the role of each of these modalities in different situations with PUJ obstruction.

ACKNOWLEDGEMENT

Special gratitude goes to Dr. A. Gelet and Professor J.M. Dubernard from Hôpital Edouard Herriot, Lyon, France for their support during a considerable part of this work.

9. Brooks JD, Kavoussi LR, Preminger GM, Schuessler WW, Moore RG. Comparison of open and endourologic approaches to the obstructed UPJ. Urology 1995, 46:791.

10. Kuenkel M, Korth K. Endopyelotomy: long term follow up of 143 patients. J Endourol 1990, 4:109.

11. Kletscher BA, Segura JW, Le Roy AJ, Petterson DE. Percutaneous antegrade endoscopic pyelo-tomy: review of 50 consecutive cases. J Urol 1995, 153:701.

12. Kim FJ, Herrell SD, Jahoda AE, Albala DM. Complications of Acucise endopyelotomy. J Endourol 1998, 12:433.

13. Clark WR, Malek RS. UPJ obstruction. I – Observations on the classic type in adults. J Urol 1987, 138:276.

14. Motola JA, Badlani GH, Smith AD. Results of 212 consecutive endopyelotomies: an 8-year follow up. J Urol 1993, 149:453.

15. Le Chevallier E, Eghazarian C, Ortega JC, Andre M, Gelsi E, Coulagne C. Retrograde Acucise endopyelotomy: long term results. J Endourol 1999, 13:575.