Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 188-192

Stented versusstentless open pyeloplasty in children


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of PediatricSurgery, Ministry of Health, Tanta, Gharbia, Egypt

Date of Submission07-Jan-2017
Date of Acceptance27-Feb-2017
Date of Web Publication14-Jun-2018

Correspondence Address:
Mohamed N Dorgham
23 Ebn el farid, Tanta
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_691_16

Rights and Permissions
  Abstract 


Objective
The aim of this study was to compare between stenting and nonstenting in dismembered pyeloplasty as regards outcome, early and late postoperative results, and complications.
Background
Ureteropelvicjunctionobstruction is a common congenital urologic anomaly. Open pyeloplasty is the standard surgical treatment. Drainage following pyeloplasty using a double J stent prevents subsequent stenosis and urine leakage.
Patients and methods
This study was conducted on 20 pediatric patients(maximum age 16years) with a primary diagnosis of ureteropelvic junction obstruction who were divided into two groups: Group1, the stented group double J(10cases). Group2, the nonstented group(10cases). Classic Anderson–Hynes pyeloplasty was performed for the two groups.
Results
A total of 20patients were included in the study. 16(80%) cases were male and four(20%) cases were female. Their ages ranged from 6months to 15years. The mean±SD age was 6.75±4.53years. All cases were unilateral; 10(50%) cases were right sided and 10(50%) cases were left sided. Postoperative complications included the following: urinary tract infection in only one case in group1, residual mild hydronephrosis in only one case in group1 and three(30%) cases in group2; clot formation in only one case in group2, and urinoma in only one case in group2.
Conclusion
Pyeloplasty with a diverting stent is technically feasible and safe. Only risks for multiple anesthesias and economic burden with stent removal are present. The specific indication when stented pyeloplasty needs to be performed is in redo pyeloplasty, solitary kidney, inflamed renal pelvis, and hugely distended renal pelvis.

Keywords: postoperative results, stented pyeloplasty, ureteropelvic junction obstruction


How to cite this article:
Loulah MA, Zeid NA, Dorgham MN. Stented versusstentless open pyeloplasty in children. Menoufia Med J 2018;31:188-92

How to cite this URL:
Loulah MA, Zeid NA, Dorgham MN. Stented versusstentless open pyeloplasty in children. Menoufia Med J [serial online] 2018 [cited 2019 Apr 19];31:188-92. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/188/234248




  Introduction Top


Ureteropelvic junction obstruction(UPJO) is a common congenital urologic anomaly that is commonly complicated by loin pain, urinary tract infection(UTI), renal deterioration, stone formation, and hypertension [1].

The incidence of UPJO is one in 1250 births and it occurs more commonly in the male population (male/female, 2:1) [2].

The incidence of a urological abnormality associated with UPJO has been reported in up to 50% of cases, with contralateral UPJO being the most common. Vesicoureteric reflux, multicystic dysplastic kidney, duplex collecting system, rotation and fusion anomalies, and association with VACTERL complex have also been reported in UPJO [3].

Reasons for UPJO are intrinsic factors such as aprestaltic uretral segment and true uretral stricture. In addition, extrinsic factors such as crossing vessels are included [4].

Drainage following pyeloplasty in children with a transanastomotic tube is believed to facilitate good drainage and is believed to be an effective guide for healing tissues by providing support and alignment. Nonetheless, the use of stents is not free of complications such as infection, stricture, or injury to the anastomosis or renal tissue by accidental dislodgement of the stent [5].


  Patients and Methods Top


The study protocol was approved by the ethical-committee of Menoufia university. A written consent was obtained from each participant. This study was conducted on pediatric patients from August 2014 to May 2016 with a primary diagnosis of UPJO. Patients were divided into two groups:

Group1, the stented group double J(DJ)(10cases).

Group2, the nonstented group(10cases).

Inclusion criteria

Inclusion criteria were as follows: primary UPJO and age 16years or younger.

Exclusion criteria

Exclusion criteria were as follows: secondary UPJO, associated major congenital anomalies, poor general condition, and recurrent cases.

All patients were subjected to the following: detailed perinatal history taking with special emphasis on mode of discovery of the disease and urological symptoms; full physical examination looking mainly for signs of urinary sepsis(general and abdominal) and the presence of a renal mass; necessary laboratory investigation; imaging study(abdominal ultrasonography and diuretic renogram); and full counseling for the patient's parents.

Surgical technique

Following induction of general anesthesia with endotracheal intubation, the patient was placed in the flank position and flexed. The approach described by Anderson and Hynes [6] was adopted.

An anterior subcostal incision was made. Thereafter, extraperitoneal exposure of the kidney was carried out. The lumbodorsal fascia was then divided, and Gerota's fascia was opened.

The lower pole and the entire renal pelvis were sharply dissected; the ureter was then identified and mobilized downward.

Three absorbable(Vicryl 5–0, Jiangsu huida medical instruments Yandong, Yancheng, Jiangsu Chin) stay sutures were placed to minimize handling of the tissues. The ureter was divided obliquely and the redundant pelvis was trimmed. The ureter was spatulated for∼0.5–1cm and a 5 Fr feeding tube was placed in the ureter. The ureter was then anastomosed to the most dependent portion. The feeding tube was removed in nonstented cases or replaced with the DJ stent. Thereafter, the pelviureteric wall was closed.

A tubal drain(12–14 Fr) was placed in the perirenal space. The musculofascial layers were closed using Vicryl 3–0. Thereafter, the subcutaneous tissues and the skin were reapproximated with Vicryl 5–0 in a subcuticular manner.

The wound was covered with transparent 3M Tegaderm.


  Results Top


A total of 20patients with UPJO patients were included and were divided into two groups:

Group1, the stented groupDJ(10cases).

Group2, the nonstented group(10cases).

Classic Anderson–Hynes pyeloplasty was performed for the two groups.

The age of the patients at the time of operation ranged from 6months to 15years, with a mean age of 6.75years. There was no significant difference between the two groups as regards age, sex, and laterality [Table1] and [Figure1], [Figure2], [Figure3].
Table 1: Age distribution in the studied groups

Click here to view
Figure 1: Identification of ureteropelvic junction obstruction.

Click here to view
Figure 2: Double J stenet insertion.

Click here to view
Figure 3: Closure of the pelviurertic wall.

Click here to view


Ultrasound scanning

Postoperative renal ultrasound scan(USS) of the kidney was performed in all cases during follow-up. The renal USS became normal in 14(70%) cases, four(20%) cases showed residual mild hydronephrosis, two(10%) cases showed no change in their preoperative findings, one of them still showed marked hydronephrosis, and the other showed moderate hydronephrosis. There was no significant difference in the postoperative USS results between the two groups[Table2].
Table 2: Postoperative ultrasonic finding in ureteropelvic junction obstruction

Click here to view


On comparing the results of preoperative and postoperative findings, we found that there was a highly significant change in the results in both groups(P=0.001).

Renogram

Postoperative diuretic renogram was performed during follow-up in all cases(at 3months visit).

In groupI, preoperative renogram showed a value (mean±SD) of 42.6±5.05 and postoperative renogram sowed a value(mean±SD) of 49.5±4.24 [Table 3] and [Table 4].
Table 3: Split renal function preoperatively in two groups

Click here to view
Table 4: Split renal function postoperatively in two groups

Click here to view


In groupII, preoperative renogram showed a value(mean±SD) of 44.80±4.93 and postoperative renogram showed a value(mean±SD) of 47.30±1.98; there was significant postoperative improvement [Table 3] and [Table 4].

On comparing the preoperative and postoperative split renal function, there was a significant postoperative improvement.

Hospital stay

As regards hospital stay, it ranged from 1 to 3days in the stented group with a mean±SD duration of 2.663±1.325days. In the nonstented group, it ranged from 4 to 7days with a mean±SD duration of 4.11±1.241[Table5].
Table 5: Comparison of hospital stay in the two groups

Click here to view


There was a significant difference between the two groups as regards hospital stay.

Postoperative complications

The overall incidence of complications in our results was 25%: 10% in the stented group and 15% in the nonstented group. There was no significant difference in the overall complications between the two groups.

Leakage

There was no leakage in the stented group, whereas leakage occurred in all patients in the nonstented group, but it was not prolonged and it varied from 3 to 6days; the mean±SD leakage time was 4.7±4days.

Clot formation

No clot formation occurred in the stented group, whereas one case suffered from clot formation in the nonstented group(10%), which occurred on the second day and was managed conservatively with intravenous fluids.

Urinoma

No urinoma occurred in the stented group, whereas one case suffered from urinoma in the nonstented group(10%), which occurred on the second week postoperatively and was managed conservatively by giving antibiotics, and it was absorbed spontaneously after 1week[Table6].
Table 6: Comparison of urinoma as a complication in the two groups

Click here to view


Urinary tract infection

One case suffered from postoperative UTI in the stented group(10%). It was managed conservatively by giving antibioticsaccordingto culture and sensitivity (third generation cephalosporin); this case was treated for UTI preoperatively. There was no UTI in the nonstented group[Table7].
Table 7: Incidence of postoperative urinary tract infection in the two groups

Click here to view


Recurrence

Our success rate was 90%, we had one recurrent case(5%) in the stented group and one case in the nonstented group(5%). Both cases needed a redo[Table8].
Table 8: Comparison of recurrence as a complication in the two groups

Click here to view



  Discussion Top


Numerous studies have investigated whether stents are needed during pediatric pyeloplasty, but the question remains unanswered. Although the original report of the gold standard operation by Anderson and Hynes [6] described a stentless procedure, currently one can find reports supporting no stents, external stents(percutaneous catheter), and internal(DJ) stents [7]. This plethora of studies proves all methods to be safe and effective, but conflicting summaries of the results have not proved any single method as superior. Definitive conclusions on this issue are difficult, as no study has ever compared all three methods directly and only one study has been randomized [8]. In addition, superiority depends not just on a single outcome, such as surgical success, but also on numerous other factors, such as patient discomfort, short-term complications including UTI and urinoma, and the requisite second procedure to remove an internal stent.

The age of our patients ranged from 6months to 15years with a mean±SD of 8.05±4.44years.

The male-to-female ratio in our study was 3:1, which correlates with published studies that indicate that male population is more affected compared with female population: Aminul and Khan [9], 3.4:1; Rasool etal. [10], 2.3:1; Elafifi etal. [11], 2.8:1; and Elmalik etal. [12], 2:1.

However, some documented that the male-to-female ratio was approximately equal. The distribution of the affected side was equal in our cases(right:left=1:1), with no bilateral cases. Most published series show predominance of the disease on the left side with a ratio of 2:1, and bilateral disease has been noted in 10–25% of cases. However, some series stated that the right side was more frequently affected [13]. The small number of our cases is statistically unreliable.

The preoperative renal function was normal in all our patients with no change postoperatively as we had no bilateral cases or cases with a single kidney.

In our study, UTI was recorded preoperatively in two cases, one case in each group, which was treated by giving culture-dependent antibiotics, whereas in postoperative follow-up there was one case in the stented group.

The operative time in the stented group was slightly prolonged than that in the nonstented group, but the difference was not statistically significant.

The duration of hospitalization has become an increasingly important issue in hospitals that have limited resources and lot of patient load [14]. The mean±SD hospital stay in our study in the stented group was 2.663±1.325days, and in the nonstented group it was 4.11±1.241days. There was a significant difference between the two groups.

This difference in our cases can be attributed to the discharge of stented cases after a hospital stay of 1–2days, and patients were given an appointment for removal of the stent, as it is proved in some studies; however, in the nonstented group the patients remained hospitalized until the stoppage of leakage and the perinephric drain was removed.

A major drawback of leaving a DJ stent indwelling in the pediatric population is that it usually requires reanesthesia for removal [15], which is a day-case procedure with a hospital stay of 4h. The cumulative length of hospital stay of stented patients for the two admissions remains shorter than that for those who underwent an unstented pyeloplasty [12].

Major drawbacks to ureteral stents(DJ stent) are infection, pain on voiding, stent migration, and forgotten stents [16]. In addition, stents may cause lower urinary tract symptoms and an increased risk for UTI.

The postoperative overall complications was found in three cases from 20(15%) cases: one(10%) case in the stented group and two(20%) cases in the nonstented group. The complications found in the nonstented group were as follows: urinoma in one case, clot formation in one case. In the stented group, one case had UTI. The rate of complications in our both groups was comparable.

The dismembered Anderson–Hynes pyeloplasty has remained the gold standard for the treatment of pelviureteric junction obstruction since it was first described in the late 1940s [6], with success rates of more than 90% in 234 pyeloplasties(227patients).

The most important aspect of successful outcome of this operation is to avoid unnecessary dissection around the upper ureter. This probably aids in resumption of pelvic and uretral peristalsis postoperatively and in avoiding holdup of urine and possible leak [17].

Our success rate was 90% in both groups, and failure was observed in one case in each group.

The use of DJ stents in children allows more rapid improvement and possible resolution ofpyelocaliectasis [17]. It minimizes complications and reduces postoperative hospital stay, and it is the safest mode of drainage during pyeloplasty in neonates, infants, and older children.


  Conclusion Top


Pyeloplasty with a diverting stent is technically feasible and safe. Only risks for multiple anesthesias and economic burden with stent removal are present. The specific indication when stented pyeloplasty needs to be performed is in redo pyeloplasty, solitary kidney, inflamed renal pelvis, and hugely distended renal pelvis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
BilenCY, BayazitY, Güdeloğlu A, AbatD, InciK, DoranS. Laparoscopic pyeloplasty in adults: stented versus stentless. JEndourol 2011; 25:645–650.  Back to cited text no. 1
    
2.
JoynerBD, MitchellME. Uretropelvic junction obstruction. In: GrosfeldJL, O'NeillJA, CoranAG, Fonkalsrud EW editors. Pediatric surgery. 6thed. Oxford, UK: Elsevier Health Sciences; 2006. pp.1723–1740.  Back to cited text no. 2
    
3.
KoffSA. Neonatal management of unilateral hydronephrosis. Role for delayed intervention. Urol Clin North Am 1998; 25:181–186.  Back to cited text no. 3
    
4.
BarnettJS, StephensFD. Role of lower pole segmental vessels in etiology of hydronephrosis. ANZ J Surg 1962; 31:201–213.  Back to cited text no. 4
    
5.
WollinM, DuffyPG, DiamondDA, AguirreJ, RattaBS, RansleyPG. Priorities in urinary diversion following pyeloplasty. JUrol 1989; 142:5–8.  Back to cited text no. 5
    
6.
AndersonJC, HynesW. Retrocaval ureter; a case diagnosed pre-operatively and treated successfully by a plastic operation. Br J Urol 1949; 21:209–214.  Back to cited text no. 6
    
7.
NinanGK, SinhaC, PatelR, MarriR. Dismembered pyeloplasty using double 'J' stent in infants and children. Pediatr Surg Int 2008; 25:191–194.  Back to cited text no. 7
    
8.
ArdaIS, OguzkurtP, SevmisS. Transanastomotic stents for dismembered pyeloplasty in children. Pediatr Surg Int 2002; 18:115–118.  Back to cited text no. 8
    
9.
AminulH, KhanI. Tubeless and stentless pyeloplasty. JPostgrad Med Inst 2003; 17:17–124.  Back to cited text no. 9
    
10.
RasoolM, SheikhHM, AliS, AhmedI. Pyeloplasty; Comparison of results of repair with and without stents. Professional Med J 2005; 12:159–165.  Back to cited text no. 10
    
11.
ElafifiM, EltatawyH, HaroonH, Gaber, M, Abo FarhaMA. Evaluation of non stented dismembered pyeloplasty in children suffering from pelvi-ureteric junction obstruction. Ann Pediatr Surg 2009; 5:52–57.  Back to cited text no. 11
    
12.
ElmalikK, ChowdhuryMM, CappsSNJ. Ureteric stents in pyeloplasty: a help or a hindrance?. JPediatr Urol 2008; 4:275–279.  Back to cited text no. 12
    
13.
QamarS, AmanullahA, FarrukhAK. Pyeloplasty; experience at Mayo Hospital, Lahore. Professional Med J 1999; 12:78–81.  Back to cited text no. 13
    
14.
BanielJ, LivnePM, SavirA, GillonG, ServadioC. Dismembered pyeloplasty in children with and without stents. Eur Urol 1996; 30:400–402.  Back to cited text no. 14
    
15.
SmithKE, HolmesN, LiebJI, MandellJ, BaskinLS, KoganBA, etal. Stented versus nonstented pediatric pyeloplasty: a modern series and review of the literature. JUrol 2002; 168:1127–1130.  Back to cited text no. 15
    
16.
RichterS, RingelA, ShalevM, NissenkornI. The indwelling ureteric stent: a 'friendly' procedure with unfriendly high morbidity. BJU Int 2000; 85:408–411.  Back to cited text no. 16
    
17.
EganSC, StockJA, HannaMK. Renal ultrasound changes after internal double-J stented pyeloplasty for ureteropelvic junction obstruction. Tech Urol 2002; 7:276–280.  Back to cited text no. 17
    


    Figures

  [Figure1], [Figure2], [Figure3]
 
 
    Tables

  [Table1], [Table2], [Table 3], [Table 4], [Table5], [Table6], [Table7], [Table8]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed279    
    Printed6    
    Emailed0    
    PDF Downloaded28    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]