Balloon dilation for failed pyeloplasty in children?

Haifeng Duan Wei Zhu Wen Zhong Xiaohang Li Guohua Zeng About the authors

ABSTRACT

Objective:

Pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). However, the failure rate of pyeloplasty is as high as 10% and repeat pyeloplasty is more difficult. This study aimed to evaluate the efficacy of balloon dilatation for failed pyeloplasty in children.

Materials and Methods:

Between 2011 and 2017, 15 patients, aged 6 months to 14 years, were treated with balloon dilation for restenosis of UPJO after a failed pyeloplasty. Ultrasound and intravenous urography were used to evaluate the primary outcome. Success was defined as the relief of symptoms and improvement of hydronephrosis, which was identified by ultrasound at the last follow-up.

Results:

All patients successfully completed the operation, 13 patients by retrograde approach and 2 patients by antegrade approach. Thirteen patients were followed for a median of 15 (4 to 57) months and 2 patients were lost to follow-up. Resolution of the hydronephrosis was observed in 5 cases. The anteroposterior diameter (APD) of the pelvis decreased by an average of 12.4 ± 14.4mm. Eight patients needed another surgery. The average postoperative hospital stay was 1.78 ± 1.4 days. Two patients experienced fever after balloon dilation. No other complications were found.

Conclusions:

Balloon dilatation surgery is safe for children, but it is not recommended for failed pyeloplasty in that group of patients, owing to the low success rate.

Keywords:
Dilatation; Kidney; Child

INTRODUCTION

UPJO is the most common pathological cause of neonatal hydronephrosis (11. Lebowitz RL, Griscom NT. Neonatal hydronephrosis: 146 cases. Radiol Clin North Am. 1977;15:49-59.), with an overall incidence of 1: 1500. UPJO may lead to lumbago, urinary infection and renal dysfunction. The European Association of Urology Guidelines recommend pyeloplasty as the gold standard treatment for UPJO. Nevertheless, the failure rate of pyeloplasty may exceed 10% (22. Eden CG. Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results. Eur Urol. 2007;52:983-9.). Dy (33. Dy GW, Hsi RS, Holt SK, Lendvay TS, Gore JL, Harper JD. National Trends in Secondary Procedures Following Pediatric Pyeloplasty. J Urol. 2016;195(4 Pt 2):1209-14.) reported a large survey in which approximately 11.4% of children required reoperations after pyeloplasty. Balloon dilatation is a minimally invasive treatment which is associated with low complications rate, and affords early recovery. Balloon dilations has a success rate of approximately 25-83% for the treatment of primary UPJO (22. Eden CG. Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results. Eur Urol. 2007;52:983-9., 44. Osther PJ, Geertsen U, Nielsen HV. Ureteropelvic junction obstruction and ureteral strictures treated by simple high-pressure balloon dilation. J Endourol. 1998;12:429-31., 55. Parente A, Angulo JM, Romero RM, Rivas S, Burgos L, Tardáguila A. Management of ureteropelvic junction obstruction with high-pressure balloon dilatation: long-term outcome in 50 children under 18 months of age. Urology. 2013;82:1138-43.). Nevertheless, studies of balloon dilatation for failed pyeloplasty in children have been rare. Therefore, we conducted this study to assess whether balloon dilation is effective in treating failed pyeloplasty in children.

MATERIALS AND METHODS

Between 2011 and 2017, 15 patients (14 boys, 1 girl), with a mean age of 3.4 years (range 0.5-14 years), were treated with balloon dilation for restenosis after pyeloplasty. Twelve cases were on the left side and 3 were on the right. Ten cases were open pyeloplasties, 4 were laparoscopic and 1 was robot-assisted.

The surgical indications were as follows: 1 - two ultrasounds (with a 1-week interval) showing increased hydronephrosis; 2 - intravenous urography revealing that the contrast agent was blocked at the UPJ. An examination of urine culture, urine routine and blood tests were performed before the operation. If patients had a positive urine culture, they would receive sensitive antibiotic therapy for one week, depending on the urine culture results.

Technique: patients were placed in the lithotomy position and all surgeries were done under general anesthesia. First, a 5-Fr ureteral catheter was inserted under the guidance of an ureteroscope to perform retrograde pyelography. Second, a 0.014” guidewire was inserted through the UPJ retrogradely or anterogradely (if retrograde insertion failed). A 6-Fr balloon catheter (X--Force U30, Bard, USA) with a 4cm balloon was introduced, and the balloon was placed across the stenotic segment with a guidewire, under X-ray guidance. The UPJ was fully expanded by injecting a radiopaque contrast medium when the pressure rose to 25-30 atm, and the pressure was maintained for 3-5 minutes. Finally, a 7-Fr double J stent was inserted into the ureter and was withdrawn by cystoscopy after 3 months. Broad-spectrum antibiotics were used to prevent urinary tract infection before and after the surgery.

The efficacy evaluation was as follows: ultrasound and intravenous urography were performed for all patients. Success was defined as the improvement of hydronephrosis after the double J (DJ) stent was withdrawn and a lack of recurrence during follow-up. Failure was defined as the need for another surgical intervention, including stent placement, endopyelotomy or pyeloplasty.

RESULTS

Fifteen patients were treated with balloon dilation for the restenosis of UPJO. The mean age was 3.4 ± 3.7 years. The median time of the recurrence was 5 (From 1 to 35) months. Two patients were lost to follow-up. Thirteen patients were followed for an average of 21 months. Seven patients had low back pain and 2 patients had fever before surgery. Eight (61.5%) patients had positive preoperative urine cultures among which gram-negative bacteria predominated.

Thirteen children underwent retrograde balloon dilation, and 2 underwent the procedure via an anterograde percutaneous approach because of failure of retrograde guidewire insertion. Two patients experienced postoperative fever (> 38.5 degrees centigrade). The average postoperative hospital stay was 1.78 ± 1.4 days. Four patients had low back pain relief.

The improvement of renal hydronephrosis was observed in 5 cases (38.5%, after withdrawal of DJ stent, at 38, 30, 13, 5 and 4 months). The anteroposterior diameter (APD) of the pelvis decreased by an average of 12.4 ± 14.4mm.

Failures were observed in 8 cases. Among the 8 failure cases, 1 patient underwent another laparoscopic pyeloplasty and had a good result. Three patients chose another balloon dilation, and 3 patients underwent placement of an indwelling DJ stent. Currently, these 6 patients still have their DJ stents, because the APD increased substantially after withdrawal of the DJ stent. Nephrectomy was performed in 1 case in a different hospital.

DISCUSSION

UPJ is defined as impaired urine flow from the pelvis into the proximal ureter with subsequent dilatation of the collecting system and potential damage to the kidney. The causes of UPJO can be classified into three types: 1 - stenosis in the lumen (the most common cause); 2 - dynamic obstruction; and 3 - outer lumen compression (common in ectopic vascular riding).

There are two types of treatments for UPJO: 1 - pyeloplasty (open, laparoscopic, robotic- -assisted); and 2 - endourological (anterogradely or retrogradely balloon dilatation, indwelling DJ tube, cold-knife, electrocautery or laser incision). Open pyeloplasty is the gold standard treatment of UPJO because of its high success rate of 90-100%. Laparoscopic and robotic-assisted pyeloplasty are becoming more popular, with advantages of minimal invasiveness and similar success rates (22. Eden CG. Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results. Eur Urol. 2007;52:983-9., 66. Autorino R, Eden C, El-Ghoneimi A, Guazzoni G, Buffi N, Peters CA, et al. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis. Eur Urol. 2014;65:430-52.).

Robotic-assisted pyeloplasty has an advantage of shorter operation time and hospital stays (77. Riachy E, Cost NG, Defoor WR, Reddy PP, Minevich EA, Noh PH. Pediatric standard and robot-assisted laparoscopic pyeloplasty: a comparative single institution study. J Urol. 2013;189:283-7., 88. Braga LH, Pace K, DeMaria J, Lorenzo AJ. Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate. Eur Urol. 2009;56:848-57.). Lucas et al. collected 865 cases and concluded that previous endopyelotomy and intraoperative crossing vessels increased the need for secondary procedures (99. Lucas SM, Sundaram CP, Wolf JS Jr, Leveillee RJ, Bird VG, Aziz M, et al. Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group. J Urol. 2012;187:522-7.). Niver et al. compared the outcomes of robotic-assisted surgery for primary UPJO and secondary UPJO. They included 117 patients and concluded that robotic-assisted laparoscopic pyeloplasty was a safe and effective option for secondary UPJO repair (1010. Niver BE, Agalliu I, Bareket R, Mufarrij P, Shah O, Stifelman MD. Analysis of robotic-assisted laparoscopic pyleloplasty for primary versus secondary repair in 119 consecutive cases. Urology. 2012;79:689-94.).

Endourological surgery (including retrograde balloon dilatation, indwelling DJ tube, cold-knife and laser incision) can be performed through the urinary tract without any incision and therefore with faster recovery (1111. Brooks JD, Kavoussi LR, Preminger GM, Schuessler WW, Moore RG. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology. 1995;46:791-5., 1212. Gerber GS, Kim JC. Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction. Urology. 2000;55:198-202;discussion 202-3.), an attractive option for urologists. The reported success rates of endourological surgeries are inconsistent. Lewis-Russell reported a success rate of 83% in 40 patients based on renogram, after balloon dilation (1313. Lewis-Russell JM, Natale S, Hammonds JC, Wells IP, Dickinson AJ. Ten years'experience of retrograde balloon dilatation of pelvi-ureteric junction obstruction. BJU Int. 2004;93:360-3.7). However, Lin et al. (1414. Lin DW, Bush WH, Mayo ME. Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy. J Urol. 1999 Sep;162(3 Pt 1):696-8.). reported a success rate of only 30% in 9 patients. Cohen (1515. Cohen TD, Gross MB, Preminger GM. Long-term follow-up of Acucise incision of ureteropelvic junction obstruction and ureteral strictures. Urology. 1996;47:317-23.) reported a success rate (defined as resolution of obstruction radiographically or disappearance of symptoms) of 73% in 15 patients. Osther (1616. Osther PJ, Geertsen U, Nielsen HV. Ureteropelvic junction obstruction and ureteral strictures treated by simple high-pressure balloon dilation. J Endourol. 1998;12:429-31.) showed that the balloon dilation success rate was 57% in 29 patients with congenital UPJO, but the success rate was only 25% in children. Factors such as presence of crossing vessels, stricture greater than 1.5cm and poor renal function are considered to be undesirable (1717. Van Cangh PJ, Nesa S, Galeon M, Tombal B, Wese FX, Dardenne AN, et al. Vessels around the ureteropelvic junction: significance and imaging by conventional radiology. J Endourol. 1996;10:111-9.). For the treatment of patients with restenosis after pyeloplasty, Braga (1818. Braga LH, Lorenzo AJ, Skeldon S, Dave S, Bagli DJ, Khoury AE, et al. Failed pyeloplasty in children: comparative analysis of retrograde endopyelotomy versus redo pyeloplasty. J Urol. 2007;178:2571-5; discussion 2575.) reported that 18 children were treated with endourological treatment (including holmium laser and balloon dilation) and the success rate was 39%, similar to the value in the present study.

We chose ultrasound as the main follow-up and efficacy judgment tool for the dynamic evaluation of changes in hydronephrosis, as well as for postoperative follow-up, because ultrasound lacks radiation, and it is convenient and affordable; therefore, ultrasound is easily approved by parents. Park et al. followed up 215 patients at least 5 years by B ultrasound and reported that once hydronephrosis showed improvement, no recurrences were observed (1919. Park K, Baek M, Cho SY, Choi H. Time course of hydronephrotic changes following unilateral pyeloplasty. J Pediatr Urol. 2013;9(6 Pt A):779-83.). Nevertheless, their results could have been affected by the subjectivity of the sonographer. Kurtz (2020. Kurtz MP, Chow JS, Johnson EK, Rosoklija I, Logvinenko T, Nelson CP Imaging after urinary tract infection in older children and adolescents. J Urol. 2015;193(5 Suppl):1778-82.) also found that urinary tract infections could lead to the increased hydronephrosis. If urinary B ultrasound shows increased hydronephrosis, we suggest repeating the B ultrasound, not performing surgery immediately.

Song et al. (2121. Song SH, Lee SB, Park YS, Kim KS. Is antibiotic prophylaxis necessary in infants with obstructive hydronephrosis? J Urol. 2007;177:1098-101; discussion 1101.) found that the incidence of urinary tract infections (UTI) in children with primary ureteral strictures was 36.2%. Children with failed pyeloplasties may have a higher urinary tract infection rate because of the series of iatrogenic operations. In our study, the rate of positive urine culture was 61.5% (8 of 13). Therefore, we should pay more attention to diagnosis and treatment of UTI.

There are several potential limitations to our study. First, we only assessed renal function by renal dynamic imaging in several patients who had severe hydronephrosis before surgery. Due to the cost and radiation, the examination of renal dynamic imaging was not accepted by most parents. Second, the length of the strictured segment that was considered an adverse factor for prognosis was not recorded. Finally, the number of cases was insufficient.

CONCLUSIONS

Balloon dilation has the advantages of fast recovery, few complications and lack of incision; nevertheless, it is not recommended for children with failed pyeloplasties because of the low success rate.

ABBREVIATIONS

  • UPJO  Ureteropelvic Junction Obstruction
  • APD  anteroposterior diameter of the pelvis
  • DJ stent  double J stent
  • Atm  atmosphere
  • UTI  urinary tract infection

ACKNOWLEDGMENTS

This work was financed by grants from the National Natural Science Foundation of China (NO. 81670643), the Collaborative Innovation Project of Guangzhou Education Bureau (NO. 1201620011) the Guangzhou Science Technology and Innovation Commission (No. 201604020001 and No. 201704020193), and the Science and Technology Planning Project of Guangdong Province (No. 2017B030314108).

REFERENCES

  • 1
    Lebowitz RL, Griscom NT. Neonatal hydronephrosis: 146 cases. Radiol Clin North Am. 1977;15:49-59.
  • 2
    Eden CG. Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results. Eur Urol. 2007;52:983-9.
  • 3
    Dy GW, Hsi RS, Holt SK, Lendvay TS, Gore JL, Harper JD. National Trends in Secondary Procedures Following Pediatric Pyeloplasty. J Urol. 2016;195(4 Pt 2):1209-14.
  • 4
    Osther PJ, Geertsen U, Nielsen HV. Ureteropelvic junction obstruction and ureteral strictures treated by simple high-pressure balloon dilation. J Endourol. 1998;12:429-31.
  • 5
    Parente A, Angulo JM, Romero RM, Rivas S, Burgos L, Tardáguila A. Management of ureteropelvic junction obstruction with high-pressure balloon dilatation: long-term outcome in 50 children under 18 months of age. Urology. 2013;82:1138-43.
  • 6
    Autorino R, Eden C, El-Ghoneimi A, Guazzoni G, Buffi N, Peters CA, et al. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis. Eur Urol. 2014;65:430-52.
  • 7
    Riachy E, Cost NG, Defoor WR, Reddy PP, Minevich EA, Noh PH. Pediatric standard and robot-assisted laparoscopic pyeloplasty: a comparative single institution study. J Urol. 2013;189:283-7.
  • 8
    Braga LH, Pace K, DeMaria J, Lorenzo AJ. Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate. Eur Urol. 2009;56:848-57.
  • 9
    Lucas SM, Sundaram CP, Wolf JS Jr, Leveillee RJ, Bird VG, Aziz M, et al. Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group. J Urol. 2012;187:522-7.
  • 10
    Niver BE, Agalliu I, Bareket R, Mufarrij P, Shah O, Stifelman MD. Analysis of robotic-assisted laparoscopic pyleloplasty for primary versus secondary repair in 119 consecutive cases. Urology. 2012;79:689-94.
  • 11
    Brooks JD, Kavoussi LR, Preminger GM, Schuessler WW, Moore RG. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology. 1995;46:791-5.
  • 12
    Gerber GS, Kim JC. Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction. Urology. 2000;55:198-202;discussion 202-3.
  • 13
    Lewis-Russell JM, Natale S, Hammonds JC, Wells IP, Dickinson AJ. Ten years'experience of retrograde balloon dilatation of pelvi-ureteric junction obstruction. BJU Int. 2004;93:360-3.7
  • 14
    Lin DW, Bush WH, Mayo ME. Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy. J Urol. 1999 Sep;162(3 Pt 1):696-8.
  • 15
    Cohen TD, Gross MB, Preminger GM. Long-term follow-up of Acucise incision of ureteropelvic junction obstruction and ureteral strictures. Urology. 1996;47:317-23.
  • 16
    Osther PJ, Geertsen U, Nielsen HV. Ureteropelvic junction obstruction and ureteral strictures treated by simple high-pressure balloon dilation. J Endourol. 1998;12:429-31.
  • 17
    Van Cangh PJ, Nesa S, Galeon M, Tombal B, Wese FX, Dardenne AN, et al. Vessels around the ureteropelvic junction: significance and imaging by conventional radiology. J Endourol. 1996;10:111-9.
  • 18
    Braga LH, Lorenzo AJ, Skeldon S, Dave S, Bagli DJ, Khoury AE, et al. Failed pyeloplasty in children: comparative analysis of retrograde endopyelotomy versus redo pyeloplasty. J Urol. 2007;178:2571-5; discussion 2575.
  • 19
    Park K, Baek M, Cho SY, Choi H. Time course of hydronephrotic changes following unilateral pyeloplasty. J Pediatr Urol. 2013;9(6 Pt A):779-83.
  • 20
    Kurtz MP, Chow JS, Johnson EK, Rosoklija I, Logvinenko T, Nelson CP Imaging after urinary tract infection in older children and adolescents. J Urol. 2015;193(5 Suppl):1778-82.
  • 21
    Song SH, Lee SB, Park YS, Kim KS. Is antibiotic prophylaxis necessary in infants with obstructive hydronephrosis? J Urol. 2007;177:1098-101; discussion 1101.

Publication Dates

  • Publication in this collection
    27 June 2019
  • Date of issue
    May-Jun 2019

History

  • Received
    21 June 2018
  • Accepted
    05 Oct 2018
  • Published
    04 Jan 2019
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