Отдаленные результаты пиелопластики в плохо функционирующей почке у детей

Journal of Pediatric Urology, Volume 8, Issue 1 , Pages 25-28, February 2012

Long-term results of pyeloplasty in poorly

functioning kidneys in the pediatric age group.

Rajesh Bansal, M.S. Ansari, Rakesh Kapoor

Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Urological Society of India, Lucknow 226014, India 

Abstract

Цель исследования: определение эффективности и долгосрочных результатов в пиелопластика, при  плохо функционирующей почки у детей. Проведен ретроспективный анализ данных больных, перенесших пиелопластику в 2000-2008 гг. Были проанализированы послеоперационные результаты, которые оценивались на основе либо улучшения симптомов или улучшения эвакуации по данным ренографии  с Tc-99m ДТПА  через 3 месяца и ежегодно.В общей сложности 39 пациентов (средний возраст 8,6лет,  от 4 месяцев до 13 лет), и соотношение мальчиков и девочек  3:1, с плохой функцией по данным  нефрограмм. Заключение: пиелопластика дает хорошие среднесрочные результаты при плохо функционирующей почки в детской возрасте. 

Introduction 

Uretero-pelvic junction obstruction (UPJO) is the most common form of obstruction in the upper urinary tract. It is reported to occur in 1:500 to 1:1250 live births [1], [2]. Surgical repair is indicated by significantly impaired renal drainage or progressive deterioration of renal function. Other indications for active intervention are to relieve pain, or treat pathologies secondary to obstruction like calculi and infections [3], [4].

The treatment of UPJO in poorly functioning kidneys remains controversial. Some authors have recommended nephrectomy (when split renal function

Materials and methods 

A retrospective analysis of 39 patients, who underwent pyeloplasty in poorly functioning kidneys (

Success was defined on the basis of either improvement in symptoms (based on the subjective feeling of the patient), improvement in drainage on postoperative Tc-99m DTPA renography, and/or improvement in renal function (>10% over baseline) on renal scan done at 3 and 6 months postoperatively and yearly thereafter. Renal scan done at last follow up was included for analysis.

Results 

A total of 39 patients with a mean age of 8.6 years (4 months to 15 years), and male to female ratio of 3:1, with poor function on isotope renogram (

 

 

Table 1. Data for patients in Group II.

No.

Preop. function (%)

Postop. function (%)

Intervention

1

0

25

PCN → Open pyeloplasty

2

5

20

Open pyeloplasty

3

8

23

Open pyeloplasty

4

4

22

Laparoscopic pyeloplasty

5

4

24

Laparoscopic pyeloplasty

6

10

0

Lost to follow up

 After pyeloplasty, the mean postoperative function increased to 38.9% in group I (mean increase 14.2%) and 19% in group II (mean increase 13.9%). Of the patients who remained obstructed, two had significant deterioration in split function and the other two underwent redo pyeloplasty by open technique.

None of the patients in the present study have had any postoperative complications such as hypertension. All are under regular follow up to record any such event. At a mean follow up of 41.6 months (8–75), the overall success rate was 90%.

Discussion 

UPJO is defined as an obstruction to the flow of urine from the renal pelvis to the proximal ureter. As a result of back pressure within the renal pelvis, progressive renal damage and deterioration sets in. Widespread use of ultrasonography and the advent of modern imaging techniques have resulted in earlier diagnosis of UPJO. The condition is frequently encountered by both adult and pediatric urologists, and is more common in males and on the left side, as noted in the present study. Bilateral obstruction has been reported in 10%–40% of patients [6], [7], [8].

There is tremendous variability in the natural history of UPJO; while some cases undergo progressive or irreversible renal damage, others remain stable for long periods or even improve with growth. When the number of functioning nephrons decreases, there is an increase in the single nephron filtration rate. This adaptive response, called glomerular hyperfiltration, contributes to the maintenance of homeostasis. This represents the ability of the kidney to increase the glomerular filtration rate (GFR). Jindal et al. studied this functional reserve in patients with UPJO by measurement of baseline GFR and stimulated GFR after protein load. The renal function reserve was the difference between the two GFR measurements. They revealed that this reserve is preserved in children with hydronephrosis, which ultimately contributes to the improvement in renal function after surgery [9], [10], [11].

The goals of management of UPJO are to improve urine flow, to prevent further parenchymal damage and to alleviate symptoms. If a renogram shows UPJO, with 15–40% split function, an operative pyeloplasty is performed; where the renal function is less than 15–20%, it is common to give these kidneys a chance to recover function after temporary relief of the obstruction with a percutaneous nephrostomy (PCN).

In the literature there are a number of studies both in favor and against preservation of poorly functioning kidneys. Stock et al. studied the relationship between split renal function and renal histology and outcome after pyelolasty. Renal biopsy was abnormal in patients with a differential function of less than 35%. None showed postoperative improvement on follow-up scans. Patients with preoperative function greater than 44% had normal biopsies. They concluded that for UPJO patients with a differential function of less than 35%, there is a high probability of significant histological changes on biopsy and a low probability of postoperative improvement in differential function [12].

In the present study there was an average increase of 14.2% above baseline in the patients with moderately impaired split renal function (group I). Similar results have also been observed by Castagnetti et al., where improvement in renal function was greater in patients with moderately rather than severely impaired preoperative function [13].

In renal units that are poorly functioning (split function  40%, II 10–40%, III 

In another similar study, Gupta et al. performed PCN in all patients with split renal function of less than 10%. Twelve of the 17 kidneys with unilateral UPJO improved after PCN drainage and split function increased to 29.2% ± 12.6%, thus emphasizing that all such kidneys should not be removed without a trial of PCN [5].

Aziz et al. also placed a PCN in hydronephrotic kidneys with

Vihma et al. studied the effect of pyeloplasty in 23 children and followed them with a postoperative renal scan. They observed that hydronephrotic kidneys that had reduced glomerular function preoperatively improved after pyeloplasty. The improvement was more pronounced in the group of kidneys with severely reduced preoperative glomerular function [16].

Laparoscopic pyeloplasty is now the procedure of choice for UPJO. The principles are the same as for open pyeloplasty: the diseased segment is excised and reduction of the pelvis is done; hence the degree of hydronephrosis, length of stenotic segment and presence of crossing vessel do not have an effect on the success rate. Although technically more difficult, it shares the same success rate as its open counterpart. There are a number of studies on laparoscopic pyeloplasty in pediatric patients available to date [17], [18], [19], [20].

In the present study, renal units with

Conclusion 

Pyeloplasty gives good intermediate-term results in poorly functioning kidneys in the pediatric age group, and in most cases the sacrifice of such kidneys can be avoided.

References 

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  2. Grignon A, Filiatrault D, Homsy Y, Robitaille P, Filion R, Boutin H, et al.Radiology. 1986;160:649–651
  3. Joyner BD, Mitchell ME. Ureteropelvic junction obstruction. In: Pediatric surgery. 6th ed.. Mosby; 2006;
  4. Mouriquand P. Congenital anomalies of the pyeloureteral junction. In: Pediatric surgery. 5th ed.. Mosby Year Book; 1996;
  5. Gupta DK, Chandrasekharam VV, Srinivas M, Bajpai M. Percutaneous nephrostomy in children with ureteropelvic junction obstruction and poor renal function. Urology. 2001;57:547–550
  6. Lebowitz RL, Griscom NT. Neonatal hydronephrosis: 146 cases. Radiol Clin North Am. 1977;15:49
  7. Uson AC, Cox LA, Lattimer JK. Hydronephrosis in infants and children. JAMA. 1968;205:323
  8. Haq A, Khan I. Tubeless and stentless pyeloplasty. J Pak Med Assoc. 2003;17:124–127
  9. Brenner BM, Meyer W, Hostetter TH. Dietary protein intake and the progressive nature of kidney disease, the role of hemodynamically mediated glomerular injury and pathogenesis of progressive glomerular sclerosis in ageing, renal ablation, and intrinsic renal disease. N Engl J Med. 1982;307:652–659
  10. Pascual L, Oliva J, Vega PJ, Principal I, Valles P. Renal histology in uretero pelvic junction obstruction: are histological changes consequence of hyperfiltration?. J Urol. 1998;160:976–979
  11. Jindal B, Bal CS, Bhatnagar V. The role of renal function reserve estimation in children with hydronephrosis. J Indian Assoc Paediatr Surg. 2007;12:196–201
  12. Stock JA, Krous HF, Heffernan J, Packer M, Kaplan GW. Correlation of renal biopsy and radionuclide renal scan differential function in patients with unilateral ureteropelvic junction obstruction. J Urol. 1995;154:716–718
  13. Castagnetti M, Novara G, Beniamin F, Vezzú B, Rigamonti W, Artibani W. Scintigraphic renal function after unilateral pyeloplasty in children: a systematic review. BJU Int. 2008;102:862–868
  14. Wagner M, Mayr J, Häcker FM. Improvement of renal split function in hydronephrosis with less than 10% function. Eur J Pediatr Surg. 2008;18:156–159
  15. Aziz MA, Hossain AZ, Banu T, Karim MS, Islam N, Sultana H, et al.In hydronephrosis less than 10% kidney function is not an indication for nephrectomy in children. Eur J Pediatr Surg. 2002;12:304–307
  16. Vihma Y, Korppi-Tommola T, Parkkulainen KV. Pelviureteric obstruction in children: the effect of pyeloplasty on 99mTc-DTPA uptake and washout. Z Kinderchir. 1984;39:358–363
  17. Ansari MS, Mandhani A, Singh P, Srivastava A, Kumar A, Kapoor R. Laparoscopic pyeloplasty in children: long-term outcome. Int J Urol. 2008;15:881–884
  18. Maheshwari R, Ansari MS, Mandhani A, Srivastva A, Kapoor R. Laparoscopic pyeloplasty in pediatric patients: the SGPGI experience. Indian J Urol. 2010;26:36–40
  19. Lopez M, Guye E, Varlet F. Laparoscopic pyeloplasty for repair of pelvi-ureteric junction obstruction in children. J Pediatr Urol. 2009;5:25–29
  20. Inagaki T, Rha KH, Ong AM, Kavoussi LR, Jarrett TW. Laparoscopic pyeloplasty: current status. BJU Int. 2005;95:102–105

Journal of Pediatric Urology, Volume 8, Issue 1 , Pages 25-28, February 2012

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