Transpelvic anastomotic stenting: A good option for diversion after pyeloplasty

Le Tan Son, Le Cong Thang, Le Thanh Hung 

Journal of Pediatric Urology, Volume 7, Issue 3 , Pages 363-366, June 2011

Several options are available to drain the renal pelvis after a dysmembered pyeloplasty. The purpose of our study was to review the results of transrenal pelvic transanastomotic stenting following ureteropelvic junction obstruction pyeloplasty (UPJO).

Patients and methods

A retrospective chart review of 238 patients with UPJO (243 renal units) treated in 2004–2007. The patients were divided into 4 groups (1): renal units with very poor function (

Results

Group 1: 13 nephrectomies and 31 pyeloplasties diverted with stents and Foley catheters; 1/31 re-do pyeloplasty. Group 2: 33 pyeloplasties that were performed without diversion or stenting; 2/33 required re-do pyeloplasty. Group 3: 122 pyeloplasties diverted with only stents inserted through renal pelvis with 1 nephrostomy due to urine leakage, 2 prolonged urine leaks that ceased spontaneously, 1 urinary infection, no re-do pyeloplasty needed. Group 4: 44 pyeloplasties that were performed with stents and nephrostomy tubes, 2 delays of removal of Foley catheters, no re-do pyeloplasty needed.

Conclusions

Transrenal pelvis transanastomotic stenting using a feeding tube is a good option for diverting urine following dysmembered pyeloplasty in children.

Introduction 

Since 1949, the Anderson-Hynes pyeloplasty has been the gold standard for the repair of ureteropelvic junction obstruction (UPJO). A debate remains over whether to divert post-operatively or not. Several options are available to drain the renal pelvis after a dismembered pyeloplasty: indwelling stents [1], [2], [3], [4], nephrostostent [5], [6], [7], externalized stent alone, externalized stents consisting of nephrostomy with Foley catheter or other tubes associated with stent [8] or nephrostomy tube alone [9].

If diversion is chosen, debate also continues over the optimal technique. With regard to external drainage, the transparenchymal route for nephrostomy or other stent drainage seems to be favored [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11].

The purpose of our study was to review the results of utilizing a transanastomotic, externalized stent for pyeloplasty which is brought out through the renal pelvis.

Materials and methods 

A retrospective chart review of 238 patients with UPJO (243 renal units) treated with pyeloplasty between April 2004 and December 2007 was carried out. All patients had ultrasound, IVP and 99m DTPA diuretic renal scans carried out pre-operatively. Surgery was indicated in cases of obstruction by renal scan, poor renal function, prolonged pain and urinary infection.

The patients were divided into 4 groups. Group 1: the renal units showing very poor function (Рис.1). Patients were maintained on antibiotics while they had a tube in place. Group 4: pyeloplasties diverted with both stents and nephrostomy catheters. In both Groups 1 and 4, the stents were generally removed on day 5–7 post-op. The nephrostomy tubes were removed 1–2 days after if patients did well with clamping. In all groups, Penrose drains were used and removed 3–5 days post-operatively.

 

 

          stent          

(Рис.1) Transpelvic anastomotic stenting in group 3.

A flank incision with a retroperitoneal approach to the kidney and ureter was made in all cases. The technique included excision of the redundant pelvis if necessary. Spatulation of the proximal ureter for 1.5–2 cm beyond the stenosis of the UPJ was standard. All anastomoses were performed using 6-0 Vicryl. The distal aspect (apex) of the anastomosis to the proximal ureter was made with interrupted sutures while the remaining closure was with running suture. A small opening was made on the portion of the exposed renal pelvis with a needle tip cautery as far from the anastomosis as possible. Insertion of a 5Fr or 6Fr feeding tube (depending on the diameter of the ureter) was made from skin and through the pelvic opening and placed distally through the anastomosis and into the proximal ureter. The stent was secured to the pelvis with Vicryl 6-0. Closure of the pyeloplasty was completed and a Penrose drain was placed in all patients. Before closure, the stent placement was double-checked and it was secured at skin level.

Other than Group 1 patients (all of whom had pre-op nephrostomies), the decision on whether to place a stent or not and which method to utilize was made by the operating surgeon. Generally, the patients in Groups 2 and 3 did not have pre-op urinary infections and the renal pelvis was not as dilated as those in Groups 1 and 4. All three senior surgeons (LTS, LCT, LTH) had roughly the same numbers of patients from the 4 groups. In order to keep surgical technique consistent for all patients and avoid inter-surgeon technical differences, all three senior surgeons were involved from the beginning to the end in every individual operative case, with designated tasks.

Follow-up was carried out from 6 months to 4 years post-op with ultrasound. A nuclear renal scan was only indicated if the ultrasound revealed worsening hydronephrosis post-operatively or other problems raising a suspicion of obstruction, such as pain, nausea or urinary infection.

Results 

There were 243 UPJOs in 238 patients, including 5 bilateral: 183 cases on the left side, 37 cases on the right; 174 boys and 51 girls. The patients were divided into 4 groups. The results of these procedures were: 13 patients in Group 1 underwent nephrectomy for continued poor function, and 1 of 31 pyeloplasties of Group 1 needed to be repeated later because of secondary obstruction. In Group 2, 2 of 33 cases required repeat pyeloplasty for the same reason; 1 case had urine leakage from the Penrose drain for 17 days. In Group 3, none of 122 patients required later re-do pyeloplasty. Among these 122 patients, 1 had a nephrostomy tube placed on the 7th postoperative day because of continuing urinary drainage from the Penrose drain after removing the stent. The nephrostomy tube was withdrawn 1 week later without incident. Two other cases had prolonged urine leakage until day 9 and 10 post-op, but ceased spontaneously. One patient had a urinary infection. In Group 4, there were 2 patients with delays of withdrawal of the nephrostomy tube until the 30th and 35th postoperative day for temporary obstructions of the anastomosis; no pyeloplasty repeat was needed in either case (Табл.1).

(Табл.1)  Results of procedures.

Group

Patients

Diversion

Complications (%)

1

31

Nephrostomy tube + stent

1Redopyeloplasty (3)
2 33 NO 2 Redopyeloplasties (6)

 3

122

Transrenal pelvic stenting

1 Nephrostomy due to urine leakage
2 Urine leakage which stopped spontaneously
1 Urinary infection (3)

4

44

Nephrostomy tube + stent

2 Delays of nephrostomy tube withdrawal [4], [5]

 

Discussion 

The optimal drainage method after dismembered pyeloplasty is still controversial, especially with the relatively small diameter ureters in children [2]. There is general agreement that some form of temporary drainage should be considered in cases of solitary kidneys, poor overall renal function, extreme pyelocaliectasis, pre-existing urinary infection or revision pyeloplasty [12]. There is some support for stenting as a more general strategy as noted by Smith in his literature review, which provided evidence that the re-operative rate was less in stented versus nonstented pyeloplasty [8]; Elmalik also found that complications following surgery itself were significantly higher in unstented patients [10].

The theoretical advantages of drainage following pyeloplasty include: a decrease in urinary extravasation, a decrease in transient obstruction secondary to postoperative anastomotic edema, the ability to confirm the flow of contrast through the anastomosis later via the nephrostomy tube and optimization of alignment of the anastomosis [13].

The commonly stated disadvantages of a nephrostomy tube or an external stent are the risk of damage to the renal parenchyma, bleeding, infection, persistent leakage around the tube, and patient discomfort at the tube site. In the study by Sibley [1], there were four patients with external stents who had significant hemorrhage requiring blood transfusion from tube placement through the kidney. This complication also was noted by Ninan [14] but did not require blood transfusion. Another potential complication with external stents is the problem of persistent leakage (>24 h) from the site where the external stent or nephrostomy is removed. This occurred in 13 of the 67 patients (19%) with a Cummings tube and 3 of the 15 (20%) with other external stents [1].

With regard to the JJ stent, among 58 stented patients, Elmalik [10] noted that 5 stents had migrated. Ahmed: “There is also a risk of damaging the ureter and precipitating ureterovesical obstruction.” Cystoscopy and general anesthesia are also necessary for removal of JJ stents later and the stents themselves are not always available in developing countries. Moreover, as the majority of pyeloplasties are performed in male infants, this makes urethral manipulation more concerning and more difficult [4]. Woo and Farnsworth reported using indwelling JJ stents in 38 pyeloplasties; one stent migrated proximally and one stent fragmented [2]. With Blue stents used in 25 pyeloplasties, 4 cases developed urinary infection and 1 anastomotic leak needed repeat pyeloplasty [5]. Reed and William [3] thought that a urinary infection due to vesicoureteric reflux had been caused by use of a Blue stent.

We did not have a JJ stent available to us for insertion in our first case of urine leakage after pyeloplasty [13]. To learn from this experience, in the next 2 cases we followed up the patients carefully with ultrasound to detect a worse hydronephrosis. We did not place a nephrostomy unless there was concern for reobstruction of the anastomosis. Anyway, according to Dixon Walker, “minor complications” such as urinary infection and urine leakage are more acceptable than placement of a nephrostomy tube or re-operative pyeloplasty [15].

The advantages of using a modified feeding tube as an externalized transpelvic and transanastomotic stent as described in this manuscript are: feeding tubes are inexpensive and available throughout the developing world, the stent is inserted passing through the renal pelvis and not through renal parenchyma which avoids the risk of bleeding and of injuring nephrons, it allows for contrast assessment of the repair and it is simple to remove. The stent functions as a nephrostomy tube and urine is collected into a down drain bag.

Serda reported using 6 Fr and 8 Fr feeding tubes with extra holes created in the distal 5 cm of the tube, and some holes were put in the pelvic portion as well [6]. We used the 5 Fr and 6 Fr tubes with extra holes, but these holes were not necessary in the pelvis because the diameters of the stents were much smaller than that of the ureter; the 6 Fr feeding tubes were used chiefly in patients over 10 years old. We believe that using the small caliber tubes allowed urine to pass down around the walls of the stent and the side holes in the tube or all the way to the bladder. We also feel that smaller tubes can maintain ureteral caliber and maintain anastomotic alignment without causing stricture due to ischemic pressure of the stent on the anastomosis.

We did not find any difficulty in inserting the stent in cases of a small pelvis. VanderBrink has suggested that the stent could actually be left exiting through the suture line of the pelvic anastomosis in the case of a small renal pelvis [7]. Beyond this, we have found little in the literature presenting the outcome when stents are inserted through the renal pelvis following pyeloplasty, except in the case noted above and mentioned by King [16]. Our results in Group 3 patients, in whom we saw no re-operative pyeloplasties in 122 cases with transpelvic stenting, show that the renal pelvis is a safe exit site for external urinary diversion with stent in such patients.

Conclusions 

Transpelvic anastomotic stenting using a modified feeding tube is a good option for diverting the urine following dismembered pyeloplasty in children. In this series, no re-do pyeloplasties were required. The insertion of the stent through the renal pelvis avoids trauma to the renal parenchyma, and therefore the complication of bleeding is excluded.

If urinary drainage or diversion is chosen after pyeloplasty, we believe that utilizing a small caliber externalized stent brought out through the renal pelvis is a very safe and effective alternative.

Acknowledgements 

Special thanks to Pr. Catherine de Vries, Pr Marc Cendron, Pr. Patrick Cartwright, Scott Miller, Joshua Wood.

References 

  1. Sibley GNA, Graham MD, Smith ML. Improving splingtage techniques in pyeloplasty. BJU Int. 1987;60:489–491
  2. Woo HH, Farnsworth RH. Dysmember pyeloplasty in infants under the age of 12 months. BJU Int. 1996;77:449–451
  3. Reed MJ, Williams MPL. Open pyeloplasty in children: experience with an improved stenting technique. Urol Int. 2003;71:201–203
  4. Ahmed S, Crankson S. Non-intubeted pyeloplasty for pelviureteric junction obstruction in children. Pediatr Surg Int. 1997;12:389–392
  5. Zaidi Z, Mouriquand PDE. The use of a multipurpose stent in children. BJU Int. 1997;80:802–805
  6. Serda Arda I, Pelin Oguzkurt, Sinasi Sevmis. Transanastomotic stents for dysmembered pyeloplasty in children. Pediatr Surg Int. 2002;18:115–118
  7. VanderBrink Brian A, Cary Clint, Cain Mark P. Kidney internal splint/stent (KISS) catheter revisited for pediatric pyeloplasty. Urology. 2009;74:894–897
  8. Smith Karen E, Holmes Nicholas, Lieb Jeremy I. Stented versus nonstented pediatric pyeloplasty: a modern series and review of the literature. J Urol. 2002;168:1127–1130
  9. Austin Paul F, Cain Mark P, Rink Richard C. Nephrostomy tube drainage with pyeloplasty: is it necessarily a bad choice?. J. Urol. 2000;163:1528–1530
  10. Elmalik K, Chowdhury MM, Capps SNJ. Ureteric stents in pyeloplasty: a help or a hindrance?. J Pediatr Urol. 2008;4:275–279
  11. Pierre Mouriquand. Congenital anomalies of the pyeloureteral junction and the ureter. In:  O’Neill James,  Rowe Marc I,  Grosfeld Jay L,  Fonkalsrud Eric W,  Coran Arnold G editor. 5th ed.. Pediatric surgery. vol. 2:Mosby; 1998;p. 1591–1608Ch 108
  12. Lim DJ, Dixon Walker R. Management of the failed pyeloplasty. J Urol. 1996;156:738
  13. Yiee Jenny, Duncan T. Wilcox: ureteropelvic junction obstruction in pediatric urology: surgical complications and management. Blackwell Publishing Ltd; 2008;p58–66
  14. Ninan George K, Sinha Chandrasen, Patel Ramnik. Dismembered pyeloplasty using double ‘J’ stent in infants and children. Pediatr Surg Int. 2009;25:191–194
  15. Dixon Walker R, Smith Karen E, Holmes Nicholas, Lieb Jeremy I. Stented versus nonstented pediatric pyeloplasty: a modern series and review of the literature. J Urol. 2002;168:1127–1130Editorial comment in
  16. King Lowell R. Management of neonatal ureteropelvic junction obstruction. Curr Urol Rep. 2001;2:106–112

© 2011 Journal of Pediatric Urology Company. Published by Elsevier Inc. All rights reserved.

 

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