Int Urol Nephrol DOI 10.1007/s11255-013-0594-9
UROLOGY - ORIGINAL PAPER
External extension of double-J ureteral stent during pyeloplasty: inexpensive stent and non-cystoscopic removal Abdol-Mohammad Kajbafzadeh • Atefeh Zeinoddini Maryam Ebadi • Reza Heidari • Afshin Tajalli
•
Received: 15 August 2013 / Accepted: 22 October 2013 Ó Springer Science+Business Media Dordrecht 2013
Abstract Purpose The purpose of the study is to describe our experience with the application of externalized double-J ureteral stent (DJUS) during pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in order to avoid cystoscopy for stent removal. Materials and methods Pyeloplasty was performed in 523 infants with UPJO using miniature pyeloplasty technique. After removing the obstructed segment, a 3-Fr. DJUS was placed into the ureter. In order to avoid cystoscopy for the removal of the stent, a feeding tube was passed through the skin and renal pelvis via a separate stab incision, connected to the DJUS and secured to the external body surface (skin), and the pyeloplasty was completed. The feeding tube along with the stent was removed after 3–4 weeks, respectively. Postoperative follow-up visits were performed 1, 3, and 6 months after the procedure. Results The mean operative time was 49 min (range 41–79). Patients were discharged after 17 ± 2 h (mean ± SD). No patient experienced bladder spasm or anticholinergic administration. Forty-four patients (8.4 %) experienced minor complications including non-febrile urinary tract infections and mild hematuria. No major complication including urinoma, leakage, and stent migration or displacement was observed during the followup period. Stent removal was tolerated by 99.8 % of A.-M. Kajbafzadeh (&) A. Zeinoddini M. Ebadi R. Heidari A. Tajalli Pediatric Urology Research Center, Section of Tissue Engineering and Stem Cell Therapy, Department of Pediatric Urology, Children’s Pediatric Center of Excellence, Children’s Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib’s Street, Keshavarz Bolvard, 1419433151 Tehran, Islamic Republic of Iran e-mail: [email protected]
patients in an outpatient setting with minimal discomfort without performing cystoscopy. Conclusions Using external DJUS along with a pyelocutaneous stent extension during pyeloplasty is a safe, feasible, and beneficial technique. This technique resulted in high success rate with minimal cost and no renal injury. The non-cystoscopic stent removal and elimination of urethral catheterization following pyeloplasty are the other advantages of this technique. Keywords Pyeloplasty Ureteral obstruction Hydronephrosis Infant Stents Complication
Introduction Ureteropelvic junction obstruction (UPJO) is the leading cause of obstructive uropathy in children; additionally, it is regarded as the most common underlying etiology of antenatal hydronephrosis; therefore, appropriate management is of utmost importance [1]. Conservative therapy is effective in almost 80 % of those diagnosed antenatally; however, surgical correction is mandatory in a significant number of cases. Open-dismembered pyeloplasty remains the mainstay of surgical correction [2]. In addition, laparoscopic/robotic pyeloplasty is widely applied in pediatrics [3]. Regardless of the technique of pyeloplasty, the necessity of applying a stent for urinary drainage during operation is controversial; there are various favorable reports on each stentless procedure, internalized (double-J) stent, and also externalized (percutaneous catheters). Notably, the benefit of applying an externalized stent is superior to the outcome of an internalized stent or no stent at all [4]. A disadvantage of stent insertion is the need to perform cystoscopy for stent removal [4]. To overcome this
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limitation, the authors applied a novel technique for stent insertion during miniature pyeloplasty, using an externalized double-J ureteral stent (DJUS). Herein, we aim to report our preliminary results with this technique.
Table 1 Patient demographics Total no. of patients Female, N (%)
210 (40.2 %)
Male, N (%)
313 (59.8 %)
Mean age at surgery (months)
Patients and methods Between 2005 and 2012, a total of 1,673 children presented with UPJO to the Children Center of Excellence (the national referral center for pediatric urology). Patients who underwent conservative management and patient with concomitant vesicoureteral reflux (VUR) or ureterovesical junction obstruction (UVJO) were excluded from the study; finally, 523 patients with hugely dilated pelvises were included and underwent miniature pyeloplasty. Patients’ presentations are summarized in Table 1. No patient had undergone prior surgical correction. Serum biochemical analysis, urine analysis and culture, renal function tests, renal ultrasound, voiding cystourethrogram, and renal 99mTc-DTPA scan were performed in all patients prior to intervention. Magnetic resonance imaging was indicated in selected cases in whom a dilated ureter was present and concomitant UVJO was suspected. Duplex study or computed tomographic (CT) angiography was not performed on any patient for the exploration of crossing vessels at the level of ureteropelvic junction. Indications for surgery included severe hydronephrosis (Society for Fetal Urology grade III or IV), abdominal mass, decline in differential renal function (\40 %), signs of obstruction, and recurrent urinary tract infections (UTIs). A total of 31 patients were found to have concurrent inguinal hernia (19 ipsilateral and 12 contralateral) in whom the ipsilateral inguinal hernia was repaired at the time of pyeloplasty through the same incision as previously described [5]. Detailed description on the procedure was given to parents, and informed consent was obtained from them. Miniature pyeloplasty was performed as previously described [6]. The ipsilateral flank was elevated to 30° under general anesthesia and at supine position. Since the position and size of renal pelvis may alter during hydration, intraoperative ultrasonography was performed to investigate the exact site of incision. In order to expose the UPJ retroperitoneally, an oblique incision through the Gerota’s fascia was made at the most dependent part of the lower quadrant. A stay suture was performed on the ureter apex; then two traction sutures were put to fix the UPJO and renal pelvis (Fig. 1b); the ureter was released and the UPJO was pulled out from the incision. After dissection and resection of the obstructed ureter, a 3-Fr. double-J ureteral stent (DJUS) with 12–16 cm length (according to the patient’s age) was placed into the proximal end of the ureter in such a way
123
523
6 (1–23)
Age B 1 year
486 (92.9 %)
Age [ 1 year
37 (7.1 %)
Mean follow-up period (months)
32 (8–67)
Mode of presentation Antenatal diagnosis
433 (82.8 %)
Postnatal diagnosis
90 (17.2 %)
Flank pain
18 (3.4 %)
Significant vomiting Abdominal mass
12 (2.2 %) 19 (3.6 %)
Others (incidental finding, UTI, hematuria,)
42 (8.0 %)
that one end was inserted into the ureteropelvic junction, while the blind end was inserted into the bladder. In order to avoid cystoscopy for the removal of the stent, a feeding tube with an appropriate size, according to the patient’s age, was connected to the DJUS (Fig. 1a, c, d, e). The tube was passed through the skin, all muscle layers, and the stab wound of the pelvis. Thereafter, the feeding tube was secured to DJUS by 3 sutures made by 5–0 polypropylene string. Pyeloplasty was completed and anastomosis was completed by a 6–0 PDS suture. Finally, the UPJ was placed into the retroperitoneal cavity. All layers were closed; the feeding tube was fixed to the flank and a mini suction drain was inserted through a stab incision. A first-generation Cephalosporin was given postoperatively. Oral fluid intake was started 3–4 h after complete recovery from the general anesthesia. After a week, the cap of the feeding tube was closed and placed under bandage; after closing the cap for 7–8 h, the tube drain was removed. The feeding tube along with the stent was removed 3–4 weeks, postoperatively, providing that urine analysis and urine culture were negative and no pathology was detected on abdominopelvic sonography. In cases with asymptomatic bacteriuria, prophylactic antibiotics were administered and the tube was resected. The pain control protocol of our center was used to control pain [7]. Patients were followed by ultrasonography 1, 3, and 6 months postoperatively. Renal 99mTc-DTPA scan was performed at the 6-month follow-up visit, and yearly assessment was performed using clinical observation and ultrasonography thereafter. Success was defined as comfortable stent removal in an outpatient setting without performing cystoscopy, no displacement and migration of the stent, and no major complication including urinoma formation, leakage, and ureteral stricture.
Int Urol Nephrol Fig. 1 a Instruments including double-j ureteral stent and a feeding tube, b Pelvis is being connected with ureter with 3 golden sutures. c Feeding tube is passed lateral wall of pelvis and is anatomized to DJUS, which is inserted in ureter. d Inserting DJUS in feeding tube, e Feeding tube is fixed to double-J with proline sutures
Statistical analysis
Results
The Statistical Package of Social Science software (SPSS) version 16 was used for the statistical analysis. Paired Student’s t test was used to compare means of continuous variables pre- and postoperatively. Categorical variables are presented as number (percentage). Data are presented as mean ± SD (standard deviation), and a p \ 0.05 was considered statistically significant.
The procedure was performed successfully in all patients with no intraoperative complication. Demographics of patients are shown in Table 1. Mean of operative time was 49 min (range 41–79), and mean of incision length was 14 mm (range 11–16). No patient experienced bladder spasm postoperatively, and anticholinergic medication was not required. Injection of Bupivacaine at the site of incision
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prior to skin closure was avoided due to possible side effects in children and miniature size of skin incision and muscle splitting technique. Narcotic analgesics were not needed in any patient. A single dose of acetaminophen (15 mg/kg) was taken by 35 (6.7 %) patients, and two doses of acetaminophen were taken by 20 (3.8 %) patients intravenously for the postoperative pain. Patients were discharged after 17 ± 2 h (range 14–23). The mean of anterior–posterior pelvic diameter (APPD) decreased significantly from 45.10 ± 11.07 preoperatively to 9.80 ± 4.85 mm at 6 months postoperatively (p \ .0001) with a mean difference of 35.29 ± 11.84, indicating 78 % decrease in APPD diameter. In our experience, 99.8 % of patients tolerated stent removal comfortably in an outpatient setting without requiring cystoscopy; one patient required cystoscopy due to the application of absorbable string, in whom the string was absorbed and the feeding tube was separated from the DJUS. This patient underwent cystoscopy for DJUS removal. Following our experience of the usage of an absorbable string, non-absorbable string was employed in all cases. No major complication including urinoma, leakage, and stent migration or displacement was observed during the follow-up period. Forty-four patients (8.4 %) experienced minor complications, including non-febrile UTI in 24 patients (4.6 %) and mild hematuria in 20 patients (3.8 %) during the mean follow-up of 32 months (range 8–67). Asymptomatic UTIs resolved in all cases following stent removal. Hematuria was managed medically.
Discussions In the present study, we introduced a novel and safe technique for stent insertion during pyeloplasty using externalized DJUS in order to obviate the need for second hospitalization and cystoscopy for stent removal. The authors showed that 99.8 % of patients tolerated stent removal comfortably in an outpatient setting without requiring cystoscopy; only one patient required cystoscopy due to the application of absorbable string. There is consensus that dismembered pyeloplasty remains the gold standard treatment of UPJO. However, controversy exists regarding the optimum method of urinary drainage following pyeloplasty. It is reported that stenting reduces hospital stay, decreases postoperative morbidities and the need for additional procedures, and results in earlier improvement compared to non-stented pyeloplasty [8, 9]. The advantages of stent insertion include decreasing postoperative leakage and maintaining reliable urinary drainage. A variety of stents have been described in the literature including a nephrostomy tube with or without a
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transanastomic stent, internal stents (double-j stent), and an external–internal stent [9–12]. DJUS is one of the most popular stents and many pediatric urologists favor it rather than nephrostomy. Sibley et al. [13] showed that DJUS reduces hospital stay and postoperative morbidity compared to those with external drainage technique. DJUS resulted in maintaining ureteral caliber, preserving the anastomosis alignment, and avoiding ureteral kinking. Despite all its advantages, it is associated with some shortcoming as it poses a second hospitalization and general anesthesia for catheter removal. Moreover, there is the risk of stent displacement and migration. This second procedure is considered a minor procedure; yet, Yiee et al. [4] indicated that this minor procedure poses major cost. Therefore, developing a technique that favors all the DJUS benefits without the need for secondary hospitalization and with lower risk of stent displacement is highly desirable. Here, we developed an external DJUS technique that poses all DJUS benefits, without the need to general anesthesia for catheter removal. The stent could be removed safely and easily in an outpatient setting. This new method requires an additional feeding tube compared to standard DJUS, which costs 5,000 Iranian Rials (equal to 0.2 United Stated dollars) in our country. This cost is negligible compared to the cost of secondary hospitalization and cystoscopy for stent removal. In this method, there is no need to a manufactured externalized DJUS, a feeding tube is connected to a DJUS by a 5–0 polypropylene suture as it is shown in the video and subsequently it is fixed to the flank. This newly developed technique also associated with other benefits. Stent migration upward or downward is not an infrequent complication in using DJUS, which is reported in up to 14 % of cases [8, 14]. In the present technique, the stent is secured to the external body surface (skin);hence, the risk of displacement and migration and the need to perform subsequent ureteroscopy and other additional procedures is diminished. No stent migration was found in this series of 523 patients. Furthermore, in our series, no Foley catheter was employed. The authors believe that the externalized DJUS also works as a Foley catheter, the urine of the contralateral ureter, and bladder could be drained freely upward through the double-J stent to the urine bag during the first week postoperatively. By avoiding the administration of a Foley catheter, the risk of urethral injury was eliminated and the patients felt more comfortable following dismembered pyeloplasty. The authors believe that since this method allows the urine to be drained freely, the risk of leakage and subsequent stricture is reduced; accordingly, no patient experienced leakage in this study. Furthermore, this would lead to free urine drainage upwards, in patients with UTI or obstruction. Mean hospital stay in this series was 17 h, which is shorter
Int Urol Nephrol Table 2 Series that developed an alternative stent to DJUS to eliminate secondary hospitalization Reference
Salle et al. [11]
Walid et al. [17]
Yucel et al. [10]
Capolicchio [19]
Hadley et al. [18]
Present study
Procedure
Open internal pyeloplasty
Transperitoneal laparoscopic pyeloplasty
Transperitoneal laparoscopic pyeloplasty
Laparoscopic Anderson–Hynes pyeloplasty
Laparoscopic Anderson–Hynes pyeloplasty
Miniature pyeloplasty
No. of patients
228
4
20
14
10
523
Stent type
Externalized DJUS (SIPS)
Internal–external stent
DJUS with dangler
A modified SIPS stent (Cook)
Kidney internal splint stent (KISS) catheter
Externalized DJUS (using feeding tube)
than the length of hospital stay in previous reports of using an external–internal stent as it is shown in Table 2. Up to now, some alternatives have been developed to eliminate secondary procedures (Table 2). Magnetic ureteral stent eliminated the need to general anesthesia for stent removal. However, it was disfavored by the difficulties faced during catheter removal [15, 16]. Yucel et al. [10] used dangler to avoid general anesthesia for DJUS removal; the dangler was secured to penile shaft in boys, which might be uncomfortable for the patient and could cause urgency and urethral discomfort. Additionally, the operative time was long (mean: 263 min) due to the need to cystoscopy, retrograde stent insertion, and repositioning of the patient before the procedure. In their study, 6 (30 %) patients needed secondary procedure and 3 patients underwent a third procedure, implying that the procedure failed to obviate the need for additional procedures. In our study, an anterograde approach is employed to avoid the extra time needed for repositioning of the patient and cystoscopy application. In our study, stent removal was tolerated by 99.8 % of patients in an outpatient setting with minimal discomfort without performing cystoscopy. No patient experienced major complication including urinoma formation, leakage, and ureteral stricture occurred. Only 44 patients (8.4 %) experienced minor complications including non-febrile UTI and mild hematuria. Walid et al. [17] presented the results of applying an internal–external stent in 4 children. An angiocatheter was used to provide a percutaneous access allowing the guide wire and subsequently the Salle stent to advance downward into the ureter. The stent access retrieved percutaneously following insertion of another angiocatheter into the lower pole by penetrating the kidney. While describing the stent, the authors acknowledged the risk of bleeding due to the risk parenchymal injury. Moreover, this method was associated with the risk of bowel injury, and considering the small diameter of stent, any clot formation could disrupt proper drainage. In this present technique, we placed and fixed the feeding tube into the renal pelvis to eliminate the risk of parenchymal injury and subsequent bleeding.
Hardley et al. [18] described the application of kidney internal splint stent (KISS) catheter. They performed nephroureteral stenting in 9 children in whom the sting needle passed through epigastric midline port and penetrated through renal parenchyma. After dilating the collecting system, a KISS catheter passes down the ureter through the dilator. However, the risk of renal injury and bleeding could not be eliminated in this method. Braga et al. [11] compared the results of an externalized DJUS called SIPS (in 228 patients) and double-J stent (in 242 patients); the overall complication and success rate was comparable between the two groups. They described that SIPS was more cost-effective, mostly because of eliminating the need to perform secondary anesthesia for catheter removal. However, this stent (SIPS) costs much more than DJUS (169.90 vs. 99.50 canadaion$). Furthermore, it was associated with the risk of parenchymal injury and significant bleeding. The stent applied in our technique only costs 0.2 US dollars more than a DJUS alone and provided no risk of parenchymal injury. This externalized DJUS possess the advantages of DJUS insertion without the need for second general anesthesia, avoiding its cost and morbidities, and without the risk of stent migration. Additionally, the risk of parenchymal injury is eliminated by the placement of the feeding tube in the renal pelvis. Additionally, in this technique, taking a bath is not contraindicated once the cap of feeding is closed 1 week postoperatively. In our study, the mean of hospital stay was less than 1 day and no patient needed narcotic analgesia. Furthermore, miniature pyeloplasty as a safe and successful technique was performed for UPJO to avoid long operative time with minimum postoperative pain and enhanced cosmetic results compared to conventional open pyeloplasty. As the strength of this study, the authors can point to the large study population. To the best of our knowledge, this study presented the largest series regarding the application of an external–internal stent leading to more reliable and applicable results. Of note is that complications observed in our series, including infection and mild hematuria, are not
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exclusive to this technique of stent insertion and can occur following any technique or any type of stent. Limitations of this study bear mention. Since the urine is freely drained from the bladder in a neonate with postoperative flat position, the baby’s diaper may remain dry and intact; this could result in parents concern regarding their child’s renal function. Additionally, due to the lack of a control group and the measurement of patients’ healthrelated quality of life, a comprehensive conclusion could not be drawn; further, large randomized trials are required prior to recommending this technique in daily practice.
Conclusion Miniature pyeloplasty with the application of externalized DJUS provides a safe, feasible, and reproducible costeffective technique. This method resulted in high success rate with minimal cost, without the risk of renal injury. Furthermore, it exempted the need to perform cystoscopy and a second anesthesia for catheter removal and avoid any Foley urethral catheter insertion following pyeloplasty. Conflict of interest
None.
References 1. Ebadi M, Kajbafzadeh AM, Tourchi A et al (2013) Endoureterotomy as the initial management of concurrent ureteropelvic and ureterovesical junction obstruction after failed conservative therapy. Urology 82:214–219 2. Subotic S, Weiss H, Wyler S et al (2013) Dismembered and nondismembered retroperitoneoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction in children. World J Urol 31:689–695 3. Yanke BV, Lallas CD, Pagnani C et al (2008) The minimally invasive treatment of ureteropelvic junction obstruction: a review of our experience during the last decade. J Urol 180:1397–1402 4. Yiee JH, Baskin LS (2011) Use of internal stent, external transanastomotic stent or no stent during pediatric pyeloplasty: a decision tree cost-effectiveness analysis. J Urol 185:673–680
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5. Kajbafzadeh AM, Tourchi A, Bazargani S et al (2010) Single incision miniature pyeloplasty and ipsilateral inguinal herniorrhaphy in infants. J Urol 183:1545–1549 6. Kajbafzadeh AM, Tourchi A, Nezami BG et al (2011) Miniature pyeloplasty as a minimally invasive surgery with less than 1 day admission in infants. J Pediatr Urol 7:283–288 7. Buttner W, Finke W (2000) Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies. Paediatr Anaesth 10:303–318 8. Elmalik K, Chowdhury MM, Capps SN (2008) Ureteric stents in pyeloplasty: a help or a hindrance? J Pediatr Urol 4:275–279 9. Smith KE, Holmes N, Lieb JI et al (2002) Stented versus nonstented pediatric pyeloplasty: a modern series and review of the literature. J Urol 168:1127–1130 10. Yucel S, Samuelson ML, Nguyen MT, et al. (2007) Usefulness of short-term retrievable ureteral stent in pediatric laparoscopic pyeloplasty. J Urol 177:720–725; discussion 5 11. Braga LH, Lorenzo AJ, Farhat WA, et al. (2008) Outcome analysis and cost comparison between externalized pyeloureteral and standard stents in 470 consecutive open pyeloplasties. J Urol 180:1693–1698; discussion 8–9 12. Austin PF, Cain MP, Rink RC (2000) Nephrostomy tube drainage with pyeloplasty: is it necessarily a bad choice? J Urol 163:1528–1530 13. Sibley GN, Graham MD, Smith ML et al (1987) Improving splintage techniques in pyeloplasty. Br J Urol 60:489–491 14. El-Ghoneimi A, Farhat W, Bolduc S, et al. (2003) Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children. BJU Int 92:104–108; discussion 8 15. Mykulak DJ, Herskowitz M, Glassberg KI (1994) Use of magnetic internal ureteral stents in pediatric urology: retrieval without routine requirement for cystoscopy and general anesthesia. J Urol 152:976–977 16. Macaluso JN Jr, Deutsch JS, Goodman JR et al (1989) The use of the magnetip double-J ureteral stent in urological practice. J Urol 142:701–703 17. Taveres A, Manaboriboon N, Lorenzo AJ et al (2008) Insertion of an internal-external nephroureteral stent during pediatric laparoscopic pyeloplasty: description of the technique. Urology 71:1199–1202 18. Hadley DA, Wicher C, Wallis MC (2009) Retrograde percutaneous access for kidney internal splint stent catheter placement in pediatric laparoscopic pyeloplasty: avoiding stent removal in the operating room. J Endourol 23:1991–1994 19. Eassa W, Al Zahrani A, Jednak R et al (2012) A novel technique of stenting for laparoscopic pyeloplasty in children. J Pediatr Urol 8:77–82
UROLOGY - ORIGINAL PAPER
External extension of double-J ureteral stent during pyeloplasty: inexpensive stent and non-cystoscopic removal Abdol-Mohammad Kajbafzadeh • Atefeh Zeinoddini Maryam Ebadi • Reza Heidari • Afshin Tajalli
•
Received: 15 August 2013 / Accepted: 22 October 2013 Ó Springer Science+Business Media Dordrecht 2013
Abstract Purpose The purpose of the study is to describe our experience with the application of externalized double-J ureteral stent (DJUS) during pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in order to avoid cystoscopy for stent removal. Materials and methods Pyeloplasty was performed in 523 infants with UPJO using miniature pyeloplasty technique. After removing the obstructed segment, a 3-Fr. DJUS was placed into the ureter. In order to avoid cystoscopy for the removal of the stent, a feeding tube was passed through the skin and renal pelvis via a separate stab incision, connected to the DJUS and secured to the external body surface (skin), and the pyeloplasty was completed. The feeding tube along with the stent was removed after 3–4 weeks, respectively. Postoperative follow-up visits were performed 1, 3, and 6 months after the procedure. Results The mean operative time was 49 min (range 41–79). Patients were discharged after 17 ± 2 h (mean ± SD). No patient experienced bladder spasm or anticholinergic administration. Forty-four patients (8.4 %) experienced minor complications including non-febrile urinary tract infections and mild hematuria. No major complication including urinoma, leakage, and stent migration or displacement was observed during the followup period. Stent removal was tolerated by 99.8 % of A.-M. Kajbafzadeh (&) A. Zeinoddini M. Ebadi R. Heidari A. Tajalli Pediatric Urology Research Center, Section of Tissue Engineering and Stem Cell Therapy, Department of Pediatric Urology, Children’s Pediatric Center of Excellence, Children’s Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Gharib’s Street, Keshavarz Bolvard, 1419433151 Tehran, Islamic Republic of Iran e-mail: [email protected]
patients in an outpatient setting with minimal discomfort without performing cystoscopy. Conclusions Using external DJUS along with a pyelocutaneous stent extension during pyeloplasty is a safe, feasible, and beneficial technique. This technique resulted in high success rate with minimal cost and no renal injury. The non-cystoscopic stent removal and elimination of urethral catheterization following pyeloplasty are the other advantages of this technique. Keywords Pyeloplasty Ureteral obstruction Hydronephrosis Infant Stents Complication
Introduction Ureteropelvic junction obstruction (UPJO) is the leading cause of obstructive uropathy in children; additionally, it is regarded as the most common underlying etiology of antenatal hydronephrosis; therefore, appropriate management is of utmost importance [1]. Conservative therapy is effective in almost 80 % of those diagnosed antenatally; however, surgical correction is mandatory in a significant number of cases. Open-dismembered pyeloplasty remains the mainstay of surgical correction [2]. In addition, laparoscopic/robotic pyeloplasty is widely applied in pediatrics [3]. Regardless of the technique of pyeloplasty, the necessity of applying a stent for urinary drainage during operation is controversial; there are various favorable reports on each stentless procedure, internalized (double-J) stent, and also externalized (percutaneous catheters). Notably, the benefit of applying an externalized stent is superior to the outcome of an internalized stent or no stent at all [4]. A disadvantage of stent insertion is the need to perform cystoscopy for stent removal [4]. To overcome this
123
Int Urol Nephrol
limitation, the authors applied a novel technique for stent insertion during miniature pyeloplasty, using an externalized double-J ureteral stent (DJUS). Herein, we aim to report our preliminary results with this technique.
Table 1 Patient demographics Total no. of patients Female, N (%)
210 (40.2 %)
Male, N (%)
313 (59.8 %)
Mean age at surgery (months)
Patients and methods Between 2005 and 2012, a total of 1,673 children presented with UPJO to the Children Center of Excellence (the national referral center for pediatric urology). Patients who underwent conservative management and patient with concomitant vesicoureteral reflux (VUR) or ureterovesical junction obstruction (UVJO) were excluded from the study; finally, 523 patients with hugely dilated pelvises were included and underwent miniature pyeloplasty. Patients’ presentations are summarized in Table 1. No patient had undergone prior surgical correction. Serum biochemical analysis, urine analysis and culture, renal function tests, renal ultrasound, voiding cystourethrogram, and renal 99mTc-DTPA scan were performed in all patients prior to intervention. Magnetic resonance imaging was indicated in selected cases in whom a dilated ureter was present and concomitant UVJO was suspected. Duplex study or computed tomographic (CT) angiography was not performed on any patient for the exploration of crossing vessels at the level of ureteropelvic junction. Indications for surgery included severe hydronephrosis (Society for Fetal Urology grade III or IV), abdominal mass, decline in differential renal function (\40 %), signs of obstruction, and recurrent urinary tract infections (UTIs). A total of 31 patients were found to have concurrent inguinal hernia (19 ipsilateral and 12 contralateral) in whom the ipsilateral inguinal hernia was repaired at the time of pyeloplasty through the same incision as previously described [5]. Detailed description on the procedure was given to parents, and informed consent was obtained from them. Miniature pyeloplasty was performed as previously described [6]. The ipsilateral flank was elevated to 30° under general anesthesia and at supine position. Since the position and size of renal pelvis may alter during hydration, intraoperative ultrasonography was performed to investigate the exact site of incision. In order to expose the UPJ retroperitoneally, an oblique incision through the Gerota’s fascia was made at the most dependent part of the lower quadrant. A stay suture was performed on the ureter apex; then two traction sutures were put to fix the UPJO and renal pelvis (Fig. 1b); the ureter was released and the UPJO was pulled out from the incision. After dissection and resection of the obstructed ureter, a 3-Fr. double-J ureteral stent (DJUS) with 12–16 cm length (according to the patient’s age) was placed into the proximal end of the ureter in such a way
123
523
6 (1–23)
Age B 1 year
486 (92.9 %)
Age [ 1 year
37 (7.1 %)
Mean follow-up period (months)
32 (8–67)
Mode of presentation Antenatal diagnosis
433 (82.8 %)
Postnatal diagnosis
90 (17.2 %)
Flank pain
18 (3.4 %)
Significant vomiting Abdominal mass
12 (2.2 %) 19 (3.6 %)
Others (incidental finding, UTI, hematuria,)
42 (8.0 %)
that one end was inserted into the ureteropelvic junction, while the blind end was inserted into the bladder. In order to avoid cystoscopy for the removal of the stent, a feeding tube with an appropriate size, according to the patient’s age, was connected to the DJUS (Fig. 1a, c, d, e). The tube was passed through the skin, all muscle layers, and the stab wound of the pelvis. Thereafter, the feeding tube was secured to DJUS by 3 sutures made by 5–0 polypropylene string. Pyeloplasty was completed and anastomosis was completed by a 6–0 PDS suture. Finally, the UPJ was placed into the retroperitoneal cavity. All layers were closed; the feeding tube was fixed to the flank and a mini suction drain was inserted through a stab incision. A first-generation Cephalosporin was given postoperatively. Oral fluid intake was started 3–4 h after complete recovery from the general anesthesia. After a week, the cap of the feeding tube was closed and placed under bandage; after closing the cap for 7–8 h, the tube drain was removed. The feeding tube along with the stent was removed 3–4 weeks, postoperatively, providing that urine analysis and urine culture were negative and no pathology was detected on abdominopelvic sonography. In cases with asymptomatic bacteriuria, prophylactic antibiotics were administered and the tube was resected. The pain control protocol of our center was used to control pain [7]. Patients were followed by ultrasonography 1, 3, and 6 months postoperatively. Renal 99mTc-DTPA scan was performed at the 6-month follow-up visit, and yearly assessment was performed using clinical observation and ultrasonography thereafter. Success was defined as comfortable stent removal in an outpatient setting without performing cystoscopy, no displacement and migration of the stent, and no major complication including urinoma formation, leakage, and ureteral stricture.
Int Urol Nephrol Fig. 1 a Instruments including double-j ureteral stent and a feeding tube, b Pelvis is being connected with ureter with 3 golden sutures. c Feeding tube is passed lateral wall of pelvis and is anatomized to DJUS, which is inserted in ureter. d Inserting DJUS in feeding tube, e Feeding tube is fixed to double-J with proline sutures
Statistical analysis
Results
The Statistical Package of Social Science software (SPSS) version 16 was used for the statistical analysis. Paired Student’s t test was used to compare means of continuous variables pre- and postoperatively. Categorical variables are presented as number (percentage). Data are presented as mean ± SD (standard deviation), and a p \ 0.05 was considered statistically significant.
The procedure was performed successfully in all patients with no intraoperative complication. Demographics of patients are shown in Table 1. Mean of operative time was 49 min (range 41–79), and mean of incision length was 14 mm (range 11–16). No patient experienced bladder spasm postoperatively, and anticholinergic medication was not required. Injection of Bupivacaine at the site of incision
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prior to skin closure was avoided due to possible side effects in children and miniature size of skin incision and muscle splitting technique. Narcotic analgesics were not needed in any patient. A single dose of acetaminophen (15 mg/kg) was taken by 35 (6.7 %) patients, and two doses of acetaminophen were taken by 20 (3.8 %) patients intravenously for the postoperative pain. Patients were discharged after 17 ± 2 h (range 14–23). The mean of anterior–posterior pelvic diameter (APPD) decreased significantly from 45.10 ± 11.07 preoperatively to 9.80 ± 4.85 mm at 6 months postoperatively (p \ .0001) with a mean difference of 35.29 ± 11.84, indicating 78 % decrease in APPD diameter. In our experience, 99.8 % of patients tolerated stent removal comfortably in an outpatient setting without requiring cystoscopy; one patient required cystoscopy due to the application of absorbable string, in whom the string was absorbed and the feeding tube was separated from the DJUS. This patient underwent cystoscopy for DJUS removal. Following our experience of the usage of an absorbable string, non-absorbable string was employed in all cases. No major complication including urinoma, leakage, and stent migration or displacement was observed during the follow-up period. Forty-four patients (8.4 %) experienced minor complications, including non-febrile UTI in 24 patients (4.6 %) and mild hematuria in 20 patients (3.8 %) during the mean follow-up of 32 months (range 8–67). Asymptomatic UTIs resolved in all cases following stent removal. Hematuria was managed medically.
Discussions In the present study, we introduced a novel and safe technique for stent insertion during pyeloplasty using externalized DJUS in order to obviate the need for second hospitalization and cystoscopy for stent removal. The authors showed that 99.8 % of patients tolerated stent removal comfortably in an outpatient setting without requiring cystoscopy; only one patient required cystoscopy due to the application of absorbable string. There is consensus that dismembered pyeloplasty remains the gold standard treatment of UPJO. However, controversy exists regarding the optimum method of urinary drainage following pyeloplasty. It is reported that stenting reduces hospital stay, decreases postoperative morbidities and the need for additional procedures, and results in earlier improvement compared to non-stented pyeloplasty [8, 9]. The advantages of stent insertion include decreasing postoperative leakage and maintaining reliable urinary drainage. A variety of stents have been described in the literature including a nephrostomy tube with or without a
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transanastomic stent, internal stents (double-j stent), and an external–internal stent [9–12]. DJUS is one of the most popular stents and many pediatric urologists favor it rather than nephrostomy. Sibley et al. [13] showed that DJUS reduces hospital stay and postoperative morbidity compared to those with external drainage technique. DJUS resulted in maintaining ureteral caliber, preserving the anastomosis alignment, and avoiding ureteral kinking. Despite all its advantages, it is associated with some shortcoming as it poses a second hospitalization and general anesthesia for catheter removal. Moreover, there is the risk of stent displacement and migration. This second procedure is considered a minor procedure; yet, Yiee et al. [4] indicated that this minor procedure poses major cost. Therefore, developing a technique that favors all the DJUS benefits without the need for secondary hospitalization and with lower risk of stent displacement is highly desirable. Here, we developed an external DJUS technique that poses all DJUS benefits, without the need to general anesthesia for catheter removal. The stent could be removed safely and easily in an outpatient setting. This new method requires an additional feeding tube compared to standard DJUS, which costs 5,000 Iranian Rials (equal to 0.2 United Stated dollars) in our country. This cost is negligible compared to the cost of secondary hospitalization and cystoscopy for stent removal. In this method, there is no need to a manufactured externalized DJUS, a feeding tube is connected to a DJUS by a 5–0 polypropylene suture as it is shown in the video and subsequently it is fixed to the flank. This newly developed technique also associated with other benefits. Stent migration upward or downward is not an infrequent complication in using DJUS, which is reported in up to 14 % of cases [8, 14]. In the present technique, the stent is secured to the external body surface (skin);hence, the risk of displacement and migration and the need to perform subsequent ureteroscopy and other additional procedures is diminished. No stent migration was found in this series of 523 patients. Furthermore, in our series, no Foley catheter was employed. The authors believe that the externalized DJUS also works as a Foley catheter, the urine of the contralateral ureter, and bladder could be drained freely upward through the double-J stent to the urine bag during the first week postoperatively. By avoiding the administration of a Foley catheter, the risk of urethral injury was eliminated and the patients felt more comfortable following dismembered pyeloplasty. The authors believe that since this method allows the urine to be drained freely, the risk of leakage and subsequent stricture is reduced; accordingly, no patient experienced leakage in this study. Furthermore, this would lead to free urine drainage upwards, in patients with UTI or obstruction. Mean hospital stay in this series was 17 h, which is shorter
Int Urol Nephrol Table 2 Series that developed an alternative stent to DJUS to eliminate secondary hospitalization Reference
Salle et al. [11]
Walid et al. [17]
Yucel et al. [10]
Capolicchio [19]
Hadley et al. [18]
Present study
Procedure
Open internal pyeloplasty
Transperitoneal laparoscopic pyeloplasty
Transperitoneal laparoscopic pyeloplasty
Laparoscopic Anderson–Hynes pyeloplasty
Laparoscopic Anderson–Hynes pyeloplasty
Miniature pyeloplasty
No. of patients
228
4
20
14
10
523
Stent type
Externalized DJUS (SIPS)
Internal–external stent
DJUS with dangler
A modified SIPS stent (Cook)
Kidney internal splint stent (KISS) catheter
Externalized DJUS (using feeding tube)
than the length of hospital stay in previous reports of using an external–internal stent as it is shown in Table 2. Up to now, some alternatives have been developed to eliminate secondary procedures (Table 2). Magnetic ureteral stent eliminated the need to general anesthesia for stent removal. However, it was disfavored by the difficulties faced during catheter removal [15, 16]. Yucel et al. [10] used dangler to avoid general anesthesia for DJUS removal; the dangler was secured to penile shaft in boys, which might be uncomfortable for the patient and could cause urgency and urethral discomfort. Additionally, the operative time was long (mean: 263 min) due to the need to cystoscopy, retrograde stent insertion, and repositioning of the patient before the procedure. In their study, 6 (30 %) patients needed secondary procedure and 3 patients underwent a third procedure, implying that the procedure failed to obviate the need for additional procedures. In our study, an anterograde approach is employed to avoid the extra time needed for repositioning of the patient and cystoscopy application. In our study, stent removal was tolerated by 99.8 % of patients in an outpatient setting with minimal discomfort without performing cystoscopy. No patient experienced major complication including urinoma formation, leakage, and ureteral stricture occurred. Only 44 patients (8.4 %) experienced minor complications including non-febrile UTI and mild hematuria. Walid et al. [17] presented the results of applying an internal–external stent in 4 children. An angiocatheter was used to provide a percutaneous access allowing the guide wire and subsequently the Salle stent to advance downward into the ureter. The stent access retrieved percutaneously following insertion of another angiocatheter into the lower pole by penetrating the kidney. While describing the stent, the authors acknowledged the risk of bleeding due to the risk parenchymal injury. Moreover, this method was associated with the risk of bowel injury, and considering the small diameter of stent, any clot formation could disrupt proper drainage. In this present technique, we placed and fixed the feeding tube into the renal pelvis to eliminate the risk of parenchymal injury and subsequent bleeding.
Hardley et al. [18] described the application of kidney internal splint stent (KISS) catheter. They performed nephroureteral stenting in 9 children in whom the sting needle passed through epigastric midline port and penetrated through renal parenchyma. After dilating the collecting system, a KISS catheter passes down the ureter through the dilator. However, the risk of renal injury and bleeding could not be eliminated in this method. Braga et al. [11] compared the results of an externalized DJUS called SIPS (in 228 patients) and double-J stent (in 242 patients); the overall complication and success rate was comparable between the two groups. They described that SIPS was more cost-effective, mostly because of eliminating the need to perform secondary anesthesia for catheter removal. However, this stent (SIPS) costs much more than DJUS (169.90 vs. 99.50 canadaion$). Furthermore, it was associated with the risk of parenchymal injury and significant bleeding. The stent applied in our technique only costs 0.2 US dollars more than a DJUS alone and provided no risk of parenchymal injury. This externalized DJUS possess the advantages of DJUS insertion without the need for second general anesthesia, avoiding its cost and morbidities, and without the risk of stent migration. Additionally, the risk of parenchymal injury is eliminated by the placement of the feeding tube in the renal pelvis. Additionally, in this technique, taking a bath is not contraindicated once the cap of feeding is closed 1 week postoperatively. In our study, the mean of hospital stay was less than 1 day and no patient needed narcotic analgesia. Furthermore, miniature pyeloplasty as a safe and successful technique was performed for UPJO to avoid long operative time with minimum postoperative pain and enhanced cosmetic results compared to conventional open pyeloplasty. As the strength of this study, the authors can point to the large study population. To the best of our knowledge, this study presented the largest series regarding the application of an external–internal stent leading to more reliable and applicable results. Of note is that complications observed in our series, including infection and mild hematuria, are not
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exclusive to this technique of stent insertion and can occur following any technique or any type of stent. Limitations of this study bear mention. Since the urine is freely drained from the bladder in a neonate with postoperative flat position, the baby’s diaper may remain dry and intact; this could result in parents concern regarding their child’s renal function. Additionally, due to the lack of a control group and the measurement of patients’ healthrelated quality of life, a comprehensive conclusion could not be drawn; further, large randomized trials are required prior to recommending this technique in daily practice.
Conclusion Miniature pyeloplasty with the application of externalized DJUS provides a safe, feasible, and reproducible costeffective technique. This method resulted in high success rate with minimal cost, without the risk of renal injury. Furthermore, it exempted the need to perform cystoscopy and a second anesthesia for catheter removal and avoid any Foley urethral catheter insertion following pyeloplasty. Conflict of interest
None.
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