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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 31
| Issue : 1 | Page : 188-192 |
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Stented versus stentless open pyeloplasty in children
Magdy A Loulah1, Nehad A Zeid1, Mohamed N Dorgham2
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Department of Pediatric Surgery, Ministry of Health, Tanta, Gharbia, Egypt
| Date of Submission | 07-Jan-2017 |
| Date of Acceptance | 27-Feb-2017 |
| Date of Web Publication | 14-Jun-2018 |
Correspondence Address:
Mohamed N Dorgham
23 Ebn el farid, Tanta
Egypt
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mmj.mmj_691_16
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
Ureteropelvic junction obstruction 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 16 years) with a primary diagnosis of ureteropelvic junction obstruction who were divided into two groups: Group 1, the stented group double J (10 cases). Group 2, the nonstented group (10 cases). Classic Anderson–Hynes pyeloplasty was performed for the two groups.
Results
A total of 20 patients were included in the study. 16 (80%) cases were male and four (20%) cases were female. Their ages ranged from 6 months to 15 years. The mean ± SD age was 6.75 ± 4.53 years. 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 group 1, residual mild hydronephrosis in only one case in group 1 and three (30%) cases in group 2; clot formation in only one case in group 2, and urinoma in only one case in group 2.
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 versus stentless open pyeloplasty in children. Menoufia Med J 2018;31:188-92 |
| Introduction | |  |
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 | | |
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:
Group 1, the stented group double J (DJ) (10 cases).
Group 2, the nonstented group (10 cases).
Inclusion criteria
Inclusion criteria were as follows: primary UPJO and age 16 years 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 ∼0.5–1 cm 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 | | |
A total of 20 patients with UPJO patients were included and were divided into two groups:
Group 1, the stented group DJ (10 cases).
Group 2, the nonstented group (10 cases).
Classic Anderson–Hynes pyeloplasty was performed for the two groups.
The age of the patients at the time of operation ranged from 6 months to 15 years, with a mean age of 6.75 years. There was no significant difference between the two groups as regards age, sex, and laterality [Table 1] and [Figure 1], [Figure 2], [Figure 3].
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 [Table 2]. | Table 2: Postoperative ultrasonic finding in ureteropelvic junction obstruction
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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 3 months visit).
In group I, 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].
In group II, 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 3 days in the stented group with a mean ± SD duration of 2.663 ± 1.325 days. In the nonstented group, it ranged from 4 to 7 days with a mean ± SD duration of 4.11 ± 1.241 [Table 5].
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 6 days; the mean ± SD leakage time was 4.7 ± 4 days.
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 1 week [Table 6].
Urinary tract infection
One case suffered from postoperative UTI in the stented group (10%). It was managed conservatively by giving antibiotics according to culture and sensitivity (third generation cephalosporin); this case was treated for UTI preoperatively. There was no UTI in the nonstented group [Table 7]. | Table 7: Incidence of postoperative urinary tract infection in the two groups
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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 [Table 8].
| Discussion | | |
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 6 months to 15 years with a mean ± SD of 8.05 ± 4.44 years.
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 et al. [10], 2.3:1; Elafifi et al. [11], 2.8:1; and Elmalik et al. [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 ± 1.325 days, and in the nonstented group it was 4.11 ± 1.241 days. 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 1–2 days, 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 4 h. 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 (227 patients).
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 of pyelocaliectasis [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 | | |
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.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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