|Year : 2006 | Volume
| Issue : 1 | Page : 35-38
Pediatric pyeloplasty: Intubated vs nonintubated
YK Sarin, R Gupta, N Nagdeve
Department of Paediatric Surgery, M.A.M.C. and Lok Nayak Hospital, New Delhi, India
Y K Sarin
Department of Paediatric Surgery, Maulana Azad Medical College, New Delhi-110002
| Abstract|| |
Objectives: Despite continued controversy regarding the optimal method of urinary diversion after pyeloplasty, we have treated majority of our patients without any tubes or stents. The present study is done to assess the benefits of performing nonintubated pyeloplasty in children. Materials and Methods: Thirty consecutive cases of pelviureteric junction obstruction were enrolled in the study from 1998 to 2004 (5.6 years). Six patients underwent nephrectomy and were excluded from the study. Twenty-four patients underwent pyeloplasty performed by a single surgeon; 20 were nonintubated pyeloplasties, other four were intubated. Postoperative complications and length of hospital stay were assessed. Results: The intubated group had higher incidence of UTI and persistence of partial mechanical obstruction postoperatively on radio-nucleotide scans. They also had a significantly longer hospital stay as compared with the nonintubated group. Conclusions: Nonintubated pyeloplasty in children is safe, cost effective and associated with fewer complications. A stent and a nephrostomy tube appear to be unnecessary in the routine pyeloplasty.
Keywords: Children, nonintubated, pyeloplasty
|How to cite this article:|
Sarin Y K, Gupta R, Nagdeve N. Pediatric pyeloplasty: Intubated vs nonintubated. Indian J Urol 2006;22:35-8
Intrinsic pelviureteric junction obstruction (PUJO) is the commonest cause of hydronephrosis in infants and children. Some form of pyeloplasty is always required to correct this anomaly, the most common procedure being Andersen-Hynes dismembered pyeloplasty. As with all surgical procedures, there are lots of variations in the technique. Similarly, there is controversy regarding the diversion of urine after surgery by using stents or nephrostomy tubes. Many pediatric surgeons recommend drainage of kidney with a nephrostomy tube and a trans-anastomotic stent, while others believe that they are unnecessary for routine pyeloplasty.
We present a series of 24 consecutive patients of PUJO undergoing pyeloplasties, which were operated by a single surgeon over a period of 6 years.
| Materials and Methods|| |
Thirty patients of intrinsic PUJO were treated by a single surgeon in the Department during the period of November 1998 to April 2004. Of these 30 children, 24 were males and six were females. In 21 instances, left kidney was involved and in six instances, the right kidney was involved; three patients had bilateral disease. The age ranged from 2 months to 11 years with a mean of 5.25 years.
Predominant clinical presentations that led these patients seek medical attention included pain ( n = 12), urinary tract infection(s) ( n = 9), abdominal mass ( n = 8) and hematuria ( n = 1). Eight cases were diagnosed antenatally. Investigations used to confirm PUJO included ultrasonography (USG), Tc-99m DTPA scan and occasionally intravenous pyelography. Intravenous pyelography was done in three patients in the early part of study when radioisotope scan was not readily available.
Surgery was advised in all symptomatic patients. The decision to operate was also guided by the imaging results, the aim being to avoid loss of renal function. Significant pelvicalyceal dilatation and thinned out renal parenchyma on USG, supported by DTPA scan findings of an obstructive pattern and/or compromise of split renal function below 40% were important indicators.
During the same period, six patients had to undergo nephrectomy because of poorly functioning kidneys (DTPA scan showing split renal function less than 15%) and were thus excluded from the study. A total of 24 patients underwent a dismembered Andersen-Hynes pyeloplasty through an anterior extraperitoneal approach. After excising the redundant pelvis and 1-1.5 cm of ureter, the pelvi-ureteric anastomosis was made using 5-0/6-0 catgut, polyglactin or polydioxanone randomly. Urethral catheter drainage of urinary bladder was not done in any case.
The decision upon the form of drainage was a reflection of the date. Early on, the pyeloplasties were performed predominantly with upper tract drainage tubes and trans-ureteral stents, while later most of them were performed in a nonintubated fashion. Both the groups, however, had peri-renal tube drain, which was removed once there was no significant drainage.
The first four patients in the series had a routine insertion of nephrostomy tube (no.14 Malecot's catheter) and a feeding tube stent (6 Fr.). The stent was removed on seventh postoperative day. A nephrostogram was done on 10th postoperative day and the nephrostomy tube was removed if the nephrostogram was found to be normal.
In the second group of 20 consecutive patients, a nonintubated pyeloplasty was performed where a small retroperitoneal tube drain was left. In this nonintubated group, one patient had undergone a stented pyeloplasty elsewhere and presented to us with decreasing split renal function on DTPA scan (from 30 to 13% in 1 year). Redo-pyeloplasty (nonintubated) was performed on this patient and on follow-up, the split renal function improved to 24% and there was no evidence of any mechanical block on DTPA scan postoperatively.
One-third patients (8/24) underwent pyeloplasty with in first year of life, with a mean age of 5.87 months. Of these, seven had nonintubated and one intubated pyeloplasty. Presence of an abdominal mass was the presentation in all these infants.
| Results|| |
The outcome analysis was based on clinical follow-up, serial renal biochemical tests, urine cultures, USG and DTPA scan. DTPA scan was performed between 3 and 12 months postoperatively.
In the intubated group, urinary tract infection (defined as greater than 10 bacteria per milliliter) related to surgery was seen in three (75%) patients. Two of these patients (50%) showed evidence of partial mechanical obstruction also and significant pelvicalyceal dilatation on USG, though the split renal function in these patients was preserved on serial DTPA scans. Both these patients had an episode of UTI postoperatively. One child eventually underwent re-exploration. A nephrostomy was done followed by re-exploration of renal fossa, which showed presence of peri-ureteral and peri-pelvic adhesions that were removed.
In the nonintubated group, 18/20 patients (90%) showed improved function and drainage. The only patient in nonintubated group who did not show improvement in DTPA scan was the child in whom a preoperative percutaneous nephrostomy had been done 2 months prior to surgery because of gross hydronephrosis. He showed partial mechanical block postoperatively, although the function was preserved. This outcome was very similar to that of the two patients who had intubated pyeloplasty and developed partial mechanical obstruction later on. He was the only child in the nonintubated group to have an episode of UTI postoperatively. This child is on regular follow up.
In the nonintubated group, minimal or no leakage was seen from the flank drain that could be removed after 2-4 days postoperatively. Overall, the patients in this group could be discharged between 3 and 6 days postoperatively with a mean of 4.43 days. However, in intubated pyeloplasties the patients could be discharged only after 10 days with a mean of 11.5 days. No patient in either group was discharged on an indwelling tube.
Of these 24 children, eight patients underwent pyeloplasty with in first year of life, with a mean age of 5.87 months, of which seven were nonintubated and one intubated. The child with intubated pyeloplasty developed UTI and partial mechanical obstruction. Of the seven infants having undergone nonintubated pyeloplasties, one child died and rest six are doing well on follow-up.
The child who died was a 3-month-old boy with bilateral PUJO and had presented to us with bilateral cystic abdominal masses. A left sided percutaneous nephrostomy and a right sided nonintubated pyeloplasty was done in the same sitting. Postoperatively, the child had massive diuresis and lost lot of fluids and electrolytes from the nephrostomized kidney. These losses were not replaced in time, which led the patient to succumb to resultant hypovolemic shock, metabolic derangements, dyselectrolytemia and acute renal failure.
| Discussion|| |
Dismembered Andersen-Hynes pyeloplasty is the surgical procedure of choice for the treatment of intrinsic pelvi-ureteric junction obstruction in pediatric population.,,, The procedure eliminates the diseased segment and re-establishes the continuity of urinary tract.
Significant improvements in surgical techniques, refinements of surgical materials and sutures enables us to obtain a nearly water tight anastomoses and reduce any peri-anastomotic leak to minimum., Wainstein et al in their study on rabbits have shown that polyglactic acid suture is the best for performing pyeloplasties because of its mild inflammatory response and rapid tissue absorption. However, we did not find any significant statistical difference as regard the outcome of surgery is concerned. Most important aspect of the successful outcome of this surgery is to avoid un-necessary dissection around the upper ureter. This probably aids in early resumption of pelvic and ureteral peristalsis postoperatively, avoiding hold up of urine and possible leak.
Urinary diversion during pyeloplasty is a matter of individual preference based upon the belief and experience of the pediatric surgeon. Many authorities recommend nephrostomy tube and stent drainage with all pyeloplasties for fear that even little edema at the anastomotic site would completely occlude the ureteral lumen. Others have enumerated numerous advantages by using nephrostomy tubes viz. it provides temporary diversion, allowing early postoperative edema to subside, it allows the radiographic assessment of repair and avoidance of extravasation and theoretically, it provides endoscopic access should further evaluation and treatment be required. Others believe that the patency of the uretero-pelvic anastomoses is best ensured by encouraging the urine to pass through the anastomoses as early as possible.,,, One study comprising of 32 children indicated that nephrostomy and stent were un-necessary if a watertight closure of uretero-pelvic junction could be achieved. It cited decreased infection rates, decreased hospitalization and early patient mobilization as improvements relative to the experience with drained pyeloplasties. This is what we have observed in our series too.
Another study reported that a number of unstented pyeloplasties had prolonged postoperative urinary flank drainage that necessitated increase hospitalization and further instrumentation. Thus the debate concerning optimal drainage continues!
The duration of hospitalization has become an increasingly important issue in hospitals which have limited resources and lot of patient load.,,,, In our study, in intubated pyeloplasties, the duration of hospital stay ranged from 10 to 13 days, while in nonintubated group, all patients were discharged in 3-6 days. There are few studies, which have shown that even the children with stents and nephrostomies can also be discharged after 3-4 days and the tubes managed at home or on OPD basis. But in our clinical practice, where we are dealing with not so literate section of the society, outpatient management of drainage tubes is virtually impossible.
A higher incidence of UTI in intubated pyeloplasties has been observed in many studies.,,, This was also the case in the present study. Additional risks of intubated pyeloplasties include wound infection, haemorrhage and mechanical block., Contrary to this, few studies have shown that nephrostomy tubes could not be held responsible for an increased incidence of UTI. In fact, few authors have mentioned the specific indications where stented pyeloplasties need to be performed. These include redo-pyeloplasties, solitary kidney, inflamed renal pelvis and hugely distended and atonic renal pelvis.
Andersen in his original article had reported that splinting of any anastomoses is not only un-necessary but it is against all the principles of plastic procedure, as it leads to infection and fibrosis at the suture line and subsequent stricture. In fact, the pyeloplasty described originally by Andersen was a nonintubated one.
A large number of cases presented to us in infancy. Many authors have advocated early pyeloplasty with the belief that the rapidly maturing infant kidney has the greatest potential to improve. It has also been observed by few authors that the only infant kidney without prior infection demonstrates significant improvement in renal function after pyeloplasty. One study has even shown that in most human kidneys with congenital obstructive hydronephroses, a steady state is reached by 1 year of age after which relief of obstruction is unlikely to result in maximum recovery of lost function. Once the hydronephroses has been identified and PUJO confirmed and other anomalies have been ruled out, early surgical intervention is advisable. It should be performed if collecting systems deteriorate, or are obstructed, or severe hydronephroses has been documented. Nonintervention in such cases may compromise renal function. A successful surgery, on the other hand, is followed by an improved renal function and somatic growth. Surgery in infancy, with the advent of modern anesthesia is absolutely safe and should be encouraged so as to get best possible results.,,
To conclude, nonintubated pyeloplasty if performed meticulously and delicately by gentle handling of tissues and by minimal mobilization of ureter is a much better option than an intubated pyeloplasty in terms of UTI, shorter hospital stay and later on mechanical obstruction. The choice of suture really does not matter much. Lastly pyeloplasty should be performed in first year of life to get maximum beneficial results.
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