Percutaneous Antegrade Endoscopic Pyelotomy: Review of 50 Consecutive Cases

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Val. 153, 701-703, March 1995 Printed in U.S.A.

PERCUTANEOUS ANTEGRADE ENDOSCOPIC PYELOTOMY: REVIEW OF 50 CONSECUTIVE CASES BRUCE A. KLETSCHER, JOSEPH W. SEGURA,* ANDREW J. LEROY AND DAVID E. PATTERSON From the Departments of Urology and Radiology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

ABSTRACT

Between 1988 and 1993, 50 percutaneous antegrade endoscopic pyelotomies were performed for ureteropelvic junction obstruction at this institution. The success of the procedure was based on radiological parameters as well as patient symptomatology. The overall success r a t e of the procedure was 88%. Endoscopic pyelotomy was successful in 9 of 11patients (82%)who presented after failing previous renal procedures. When endoscopic pyelotomy was used as the initial treatment modality the success rate was 90%. These results support the argument that endoscopic pyelotomy should be considered as first line therapy for most adults with ureteropelvic junction obstructions. KEY WORDS: endoscopy, kidney diseases, urination disorders, kidney calculi

The use of percutaneous endoscopic pyelotomy as a treatment modality for obstruction of the ureteropelvicjunction is not a new concept. Indeed, the current operative technique of percutaneous endoscopic pyelotomy has its roots dating back to the performance of intubated ureterotomies by Davis et al.'f2 Not until the work of Wickham and Kellet did the idea of performing an intubated ureterotomy via a percutaneous nephrostomy tract become a viable alternative to open pyelop l a ~ t y .Later, ~ the technique was further refined and the term endo-pyelotomy was coined by Badlani et al.4 Since that time, further refinements in surgical instrumentation have allowed endoscopic pyelotomy to gain more popularity gradually. We analyze retrospectively the results of 50 consecutive percutaneous antegrade endoscopic pyelotomies performed at our clinic. The starting date and number of cases presented are not arbitrary since the date approximates the point at which surgical equipment and general surgical technique became standardized a t this institution. All patients referred to us (J.W. S. and D. E. P.) for management of ureteropelvic junction obstruction were offered endoscopic pyelotomy or open surgery. Three patients elected open surgery and in 1the distortion of the collecting system was judged too great for endoscopic pyelotomy. METHODS

raphy is usually reserved for patients with equivocal findings on Ivp.Retrograde pyelography typically was performed as the initial test of choice in those with allergies to contrast medium or renal insufficiency, or as a confirmatory test before treatment. Postoperative IVPs were obtained at 3 and 6 months, and then at 12 to 18-month intervals (part B of figure). Subsequent IVPs were not obtained routinely. Diuretic renography in the postoperative period was only used in the same fashion as it had been during the preoperative period. Pressure-flow studies as described by Whitaker were not routinely performed as part of either the diagnostic evaluation or postoperative followup. Endoscopic pyelotomy was considered successful only when the patient was completely free of any symptomatology and had improved radiological findings, such as significantly increased emptying of the renal pelvis on IVP.Followup ranged from 3 months to 4 years (mean 12 months). Endoscopic pyelotomy was initiated by performing a percutaneous nephrostomy through an upper or middle pole calk with the patient in the prone position. The tract was then dilated to 24F and nephroscopic examination of the renal pelvis was performed. After the stenotic area was identifled, a guide wire was placed across the area and well into the ureter. The cold-cut knife was passed over the guide wire with the endo-pyelotomy being performed in the posterolatera1 position, making a full thickness cut into the peri-

Between January 1988 and May 1993, 50 percutaneous antegrade endoscopic pyelotomies were performed at our institution as the treatment for patients with ureteropelvic junction obstruction. Mean age of the 29 female and 2 1 male patients was 42 years (range 4 to 87 years). Of the patients 33 (66%) presented with chronic episodic flank pain and 10 (20%) with single incapacitating bouts of flank pain. An incidental finding was noted in an asymptomatic patient (2%). One patient (2%) had an iatrogenic injury and the condition was noted during medical evaluation of pyelonephritis in 2% or recurrent nephrolithiasis in 8%. Indeed, 16 patients (32%) had a medical history that included nephrolithiasis. Ureteropelvic junction obstruction was noted on the right side in 27 patients and on the left side in 23. The diagnosis of ureteropelvic junction obstruction was based upon patient symptomatology and radiological findings. Excretory urography (IVP)was the initial test of choice in the majority of patients (part A of figure). Diuretic renogA, preoperative NP in patient with long history of intermittent left Accepted for publication August 19, 1994. * Requests for reprints: Department of Urology, Mayo Clinic, 200 ureteropelvic junction obstruction. B, NP in same patient approximately 5 months &r endoscopic pyelotomy. First St., S.W.,Rochester, Minnesota 55905. 701

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ureteral fat. The incision was extended inferiorly down the ureter or up to 2.0 an.in most patients. As a practical matter, it is difficult to incise a greater distance and we would not select for this procedure patients with obstructed ureters longer than 2.0 cm. Balloon dilation was not used after the endoscopic pyelotomy, although occasionally a balloon was used to dilate the ureteropelvic junction to expose the upper ureter and facilitate the procedure. In 26 patients a 7F to 14F 22 cm. endoscopic pyelotomy stent was placed under fluoroscopic guidance and left indwelling for approximately 6 weeks. These stents can be difficult to insert, although preparation of the ureter for 1week or so with a Double-J* stent would clearly be helpful. This was generally not practical in the majority of our patients. All stents were passed over guide wires as a standard procedure. Any renal calculi evident at nephroscopy were removed. RESULTS

Overall, endoscopic pyelotomy was successful in 44 patients (88%, table l).There were ll patients who presented for endoscopic pyelotomy after previous procedures failed, including open pyeloplasty in 7, open pyelolithotomy in 2 and balloon dilation in 2. Of the 11 patients 9 (82%) had a successful outcome after endoscopic pyelotomy. Of the 39 patients who underwent the procedure as the initial treatment modality 35 (90%)had a successful outcome. Followup in this series ranged from 4 to 74 months (mean 12). Among the 6 patients in whom endoscopic pyelotomy failed 4 (67%) presented with recurrent pain and radiological evidence of obstruction, while 2 (33%) were pain-free at presentation. However, radiological evaluation demonstrated persistent obstruction (table 1). Of note, the mean interval between endoscopic pyelotomy and failure was only 1.8 months, with no failures occurring after 3 months. During the last few years the 14F to 7F 22 cm. endoscopic pyelotomy stent has been used as the stent of choice for the majority of procedures (table 2). This stent was used in 27 patients with a successful outcome in 23 (85%),while 21 received either an 8.0 or 8.5F ureteral stent. There did not seem to be any correlation between the type of stent used and ultimate surgical success or failure. The failures included a 4-year-old boy with intermittent right flank pain secondary to right ureteropelvic junction obstruction in whom a prior dismembered pyeloplasty and balloon dilation elsewhere had failed. After endoscopic pyelotomy the flank pain persisted and a retrograde pyelogram

* Medical Engineering Corp., New York, New York. TABLE1. Success and failure rates in 50 consecutive endoscopic pyelotomies NoSTotal(%) success:* 44/50 (88) Overall success rate F’ts. undergoing endoscopic pyelotomy after failing 11/50 (22) other pmcedures Other pmcedures included: Open pyeloplasty 7 (14) Pyelolithotomy 2 (4) Balloon dilation 2 (4) Success in this group 9/11 (82) Success rate in pts. undergoing primary endoscopic 35/39 (90) pyelotomy Fai1ure:t Overall failure rate 6/50 (12) Recurrent pain and radiological evidence of 4 (67) obstruction Pain-free with radiological evidence of obstruction 2 (33) * Success based on radiological parameters and patient symptomatology. t Mean interval to failure 1.8 months (range 1 to 3).

TABLE2. Stents used in 50 consecutive endoscopic pyelotomies Stent Type Total No. NO.Failures ~

14F to 7F (Clavman) 8.OF to 8.5F Universal* 7F 6F

26 21 1 1 1 Totals 50 * Cook Urological, Inc., Spencer, Indiana.

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3

1 1 0 1 6

at 2 months demonstrated persistent ureteropelvic junction obstruction. Subsequently, the patient underwent successful right uretero-calicostomy and lower pole nephrectomy. Likewise, endoscopic pyelotomy failed in a 25-year-old man with intermittent left flank pain who had previously undergone dismembered pyeloplasty, since the flank pain continued and the obstruction persisted. This man was treated successfully by uretero-calicostomy. Endoscopic pyelotomy also failed to relieve the symptoms in a 24-year-old woman with a 12-year history of intermittent flank pain. Despite mild improvement on the IVP, this patient experienced 2 episodes of renal colic within 3 months of endoscopic pyelotomy and was then treated by open pyeloplasty. A similar presentation also occurred in a 34-year-old woman who was treated successfully by the open procedure. Dismembered pyeloplasty was performed subsequent to an endoscopic pyelotomy failure in a 33-year-old woman with a long history of renal colic and nephrolithiasis. Despite resolution of the symptoms, the postoperative furosemide IVP continued to show ureteropelvic junction obstruction. Finally, a 48-year-old woman failed endoscopic pyelotomy after presenting with a 10-month history of chronic flank pain that remained refractory to ureteral stenting. Postoperative rVP and retrograde pyelography performed at 6 weeks demonstrated persistent narrowing of the ureteropelvic junction. Balloon dilation was performed at that time and followup radiological studies to 15 months have shown the ureteropelvic junction to be widely patent. The patient remains free of symptoms. Mean operative time for endoscopic pyelotomy, including 14 patients who required percutaneous ultrasonic lithotripsy, was 70 minutes (range 15 to 184). The mean hospital stay was 3.8 days (range 1to 10, with the day of procedure as day 1). There were 3 operative complications (6%) that occurred in 2 patients (4%), including 2 cases of hemorrhage requiring transfusion (4%) and 1case of urosepsis (2%). One complication occurred in a 42-year-old woman with an anomalous renal vein that was transected as the incision was performed in the posterolateral aspect of the ureteropelvic junction. The bleeding was controlled by allowing clot to form in the renal pelvis causing tamponade. The patient received 3 units of whole blood. Convalescence was uneventful and she was discharged from the hospital on postoperative day 6. The other complications occurred in an 86-year-old man in whom significant bleeding was encountered at the incision site. The bleeding was again treated by allowing clot formation in the renal pelvis resulting in compression. The patient received a total of 6 units of whole blood. Additionally, Klebsiella urosepsis developed, which responded to appropriate antibiotic therapy. He was discharged from the hospital on postoperative day 10. Also of note, 2 patients with a large solitary kidney and 1 with a horseshoe kidney successfully underwent endoscopic pyelotomy with uneventful operative and postoperative courses. Operative time in these 3 patients ranged from 20 to 88 minutes. DISCUSSION

The unequivocal diagnosis of ureteropelvic junction obstruction, or even a standard definition of what represents such a clinical entity, has been a point of contention among

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urologists for years. The practice at our institution has been 1 month, 3 at 2 months and 1 at 3 months). Likewise, in 17 to minimize the number of radiological tests performed to patients undergoing endoscopic pyelotomy Perez et a1 rediagnose ureteropelvic junction obstruction, particularly in ported that both of their failed cases were evident by 6 the symptomatic patient. The IVP continues to be the initial weeks." Of the 27 endoscopicpyelotomy failures reported by test of choice and, if positive in a symptomatic patient, is the Motola et al, the mean interval to failure was 4.8 months, only test obtained before percutaneous nephrostomy tube with 24 failures occurring within 6 months and only 2 occurplacement at which time an antegrade nephrostogram is ring after 1year." obtained. Retrograde pyelography is the initial test of choice All of our patients who underwent an open procedure to in patients with allergies to contrast medium or renal insuf- correct the ureteropelvic junction obstruction after failed enficiency. Diuretic renography is usually reserved for patients doscopic pyelotomy have done well and remain asymptomatic with equivocal findings on IVP or retrograde pyelography. on followup. Motola et a1 reported similar findings." Also, Pressure perfusion studies as described by Whitaker are not when comparing open pyeloplasty after failed endoscopicpyeroutinely performed because, in the experience at our insti- lotomy to de novo pyeloplasty, they found that the former tution, a combination of these tests along with patient his- procedure was no more technically difficult than the latter. tory is enough to establish the diagnosis. Whitaker studies Mean operative time, blood loss and hospital stay between certainly have a role when the diagnosis cannot be firmly the 2 groups were remarkably similar. Thus, endoscopic pyeestablished. Again, IVP remains the mainstay of postopera- lotomy failure does not preclude nor technically impede tive followup with the other tests performed only if the en- the use of a subsequent open procedure. We conclude that the doscopic pyelotomy results are in question after the IVP. data presented support the argument that endoscopic pyeAlthough endoscopicpyelotomy is a less invasive procedure lotomy should be considered as first line therapy for the than dismembered pyeloplasty, it is not without risks since 2 majority of ureteropelvic junction obstructions in the adult. patients (4%) required transfusion for intraoperative bleeding. In 1 patient the bleeding episode was related to access REFERENCES while in the other it was due to an aberrant vessel. There is a certain learning curve with this procedure but the long1. Davis, D. M.: Intubated ureterotomy: a new operation for ureterm success rate approaches that of the dismembered pyeloteral and ureteropelvic strictures. Surg., Gynec. & Obst., 7 6 plasty. In a series of 95 patients with documented uretero513, 1943. pelvic junction obstruction treated initially by dismembered 2. Davis, D. M., Strong, G. H. and Drake, W. M.: Intubated ureterotomy: experimental work and clinical results. J. Urol., 5 9 pyeloplasty at our institution the long-term success rate was 851,1948. 95%.5 In comparison, the 90% success rate for endoscopic 3. Wickham. J. E. and Kellet. M. J.: Percutaneous -Dvelolvsis. _ - Eur. pyelotomy when used as the initial procedure in the treatUrol., 9: 122, 1983. ment of ureteropelvic junction obstruction seems acceptable. G.. Eshghi. M. and Smith, A. D.: Percutaneous surgery Additionally, the decreased hospitalization and convalescent 4. Badlani. for ureteropel& junction obstn&ion (endopyelotomy):techtimes should be particularly attractive to the patient and nique and early results. J. Urol., 136 26, 1986. surgeon. Karlin et a1 compared the results of 32 consecutive 5. Clark, W. R. and Malek, R. S.: Ureteropelvic junction obstrucopen pyeloplasties against 56 consecutive endoscopicpyelototion. I. Observations on the classic type in adults.J.Urol., 138 mies and found that, while the success rate of the open 276, 1987. 6. Karlin, G. S., Badlani, G. H. and Smith, A. D.: Endopyelotomy procedure was higher (100% versus 87.5%), endoscopic pyeversus open pyeloplasty: comparison in 88 patients. J. Urol., lotomy offered several distinct advantages.6 The average 140: 476, 1988. operative time, blood loss, postoperative analgesic require7. Horgan, J. D., Maidenberg, M. J. and Smith, A. D.: Endopyements, hospital stay and interval to normal activities all lotomy in the elderly. J. Urol., 150: 1107, 1993. favored endoscopic pyelotomy over the open technique. 8. Kavoussi, L. R., Meretyk, S., Dierks, S. M., Bigg, S. W., Gup, The indications for endoscopic pyelotomy do not appear D. I., Manley, C. B., Shapiro, E. and Clayman, R. V.: Endopyeto be restricted to any age groups. In this series 6 patients lotomy for secondary ureteropelvicjunctionobstruction in chilwho presented for the procedure were 65 years or older and dren. J. Urol., 146: 345, 1991. 9. Tan, H. L., Najmaldin, A. and Webb, D. R.: Endopyelotomy for all had a successful outcome. Similarly,in a series of 18patients pelviureteric junction obstruction in children. Eur. Urol., 2 4 older than 65 years treated with endoscopic pyelotomy Horgan 84, 1993. et al reported only 2 failures? Although in this series endoscopic pyelotomy was attempted in only 1child and failed, other 10. Perez, L. M., Friedman, R. M. and Carson, C. C., 111: Endoureteropyelotomyin adults. Review of procedure and results. Urolchildren have had successful outcomes before and after this ogy, 3 9 71, 1992. report. Others have also reported successful results using en- 11. Motola, J. A., Badlani, G. H. and Smith, A. D.: Results of 212 doscopic pyelotomy to treat primary and secondary ureteropelconsecutiveendopyelotomies: an 8-year followup. J. Urol., 149 vic junction obstructions in children?.' 453, 1993. In our series, if endoscopic pyelotomy failed it did SO early 12. Motola, J. A., Fried, R., Badlani, G. H. and Smith, A. D.: Failed endopyelotomy:implicationsfor future surgery on the ureteroin the postoperative course (mean interval to failure 1.8 pelvic junction. J. Urol., 150 821, 1993. months, with no failures after 3 months-2 patients failed at