Discussion
1
an open procedure, and it may influence port placement for the laparoscopic approach. In years past I agreed with Rush- ton et al that preoperative imaging was sufficient to avoid RPG (reference 11 in article). However, I have had several instances in which ultrasound failed to demonstrate a di- lated distal ureter and renal scans that showed no nuclide below the UPJ but was found on RPG to have a large megau- reter that extended up to the UPJ. Finally, several times I have found extensive ureteral strictures that dictated a com- pletely different incision then what I was planning. From an incision standpoint I find that the younger the child, the easier it is to approach UPJO via the dorsal lum- botomy approach. I would challenge the comment made re- garding an increased risk of missing a crossing vessel when using the posterior lumbotomy approach. My preferential inci- sion when possible is posterior lumbotomy. I mobilize the renal pelvis and proximal ureter sufficiently, so that I can easily recognize any aberrant vessels. To my knowledge I have not missed a crossing vessel to date in more than 23 years of practice. With that said, posterior lumbotomy is the wrong incision to use for a lengthy stricture, which may have led to some of the failures in this series when RPG was not performed. Having spent the last 2 decades alternating between the use of internal drainage stents vs no stents, I find that the greatest benefit for using stents are in patients with a capa- cious pelvis and/or in those with a tight anastomosis. Finally, discerning between the normal and abnormal ureter during spatulation is an important component for preventing surgical failures. There is usually a clear demar- cation zone where the distal ureter opens up and calibrates well. In cases in which that demarcation is not recognizable, it is possible that one is dealing with an abnormal or hypo- plastic ureter that would increase the risk of surgical failure. Mark R. Zaontz Temple University School of Medicine Philadelphia, Pennsylvania These authors offer us a review of their experience with pediatric pyeloplasty. Our experience, of which some is reported (reference 11 in article), differs somewhat since we do not use the posterior approach, do not do retrograde pyelograms, do not use Foley catheter drainage in patients without ipsilateral VUR and do not insert stents or nephrostomy tubes other than under exceptional circumstances. The report by Rushton et al (reference 11 in arti- cle) documented our experience in the early 1990s with 106 of 108 patients who underwent pyeloplasty and were followed with post- operative renal scans. Our methods have not changed since then. Retrograde pyeloureterograms were done in none and all kidneys were approached through the flank. Drainage was noted to be improved in 104 of 106 patents and only 1 required reoperation (2 were lost to followup). The conclusion reached was that the com- bination of imaging with high quality renal/bladder sonograms and diuretic renograms can reliably exclude distal obstruction. Care must be taken to visualize the ureter beyond the UPJ on sonography, particularly in the true pelvis. Delayed nuclear scan images should be carefully inspected for isotope held up in the ureter. Unless there is total proximal obstruction at the time of the study some isotope will enter the ureter and demonstrate distal ureteral ectasia. Intraoperatively careful attention must be given to the point of obstruction and the ureter distal to that. I have found that one can be suspicious of a crossing vessel by pulling on the ureter. If the kidney cannot be brought inferior by this maneu- ver, one can assume a crossing vessel, which should be vigor- ously pursued. The ureter should be calibrated from above through a pyelotomy before making an extensive incision in the pelvis. The area of narrowing should be incised or excised and the ureter then should also be calibrated distal to that to ensure normal patency. If there is a long area of narrowing or the obstruction is distal, flap pyeloplasty or distal ureterouret- erostomy should be done. None of this can be achieved through the posterior approach and it is evident by the results reported that RPG does not guarantee avoiding these problems. Finally, if a stent must be used because of unusual cir- cumstances, such as recent pyelonephritis or concern about the anastomosis, it makes no sense to me to use an internal stent that requires repeat anesthesia for removal in a child. They should be brought out the kidney. A. Barry Belman Children’s National Medical Center Washington, D. C. DISCUSSION Dr. Max Maizels. Would it be fair to say this is not recurrent obstruction? It is persistent obstruction that was not appreciated. Dr. Luis H. Braga. Yes but some cases were recurrence. Doctor Maizels. If you do a dorsal lumbotomy, while it is a nice incision, your visualization may be less and mobilization of the ureter is restricted. If you do not have a roadmap ahead of you, then you may not know to go a little extra further down the ureter looking for that other kink that the retrograde showed. Doctor Braga. I totally agree. That is the idea behind the retrograde to try to provide better planning for the operation. Although some people use just ultrasound and renal scan, and they get good delineation. If the patient has reflux, of course, you have the anatomy up the ureter with which to contend. Dr. Tim Bukowski. Did any of your data with regard to the retrograde pyelogram include percutaneous antegrade nephrostogram? Doctor Braga. No. Doctor Bukowski. That is a nice way to visualize the urinary tract and upper tract when using the lumbotomy approach. Doctor Braga. Yes. Doctor Bukowski. And it may help with exposure, particularly if you have a more distal obstruction for which you need to change the patient to a flank position. Doctor Braga. I agree. RISK FACTORS FOR RECURRENT OBSTRUCTION AFTER PYELOPLASTY 1688
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Transcript of Discussion
an open procedure, and it may influence port placement forthe laparoscopic approach. In years past I agreed with Rush-ton et al that preoperative imaging was sufficient to avoidRPG (reference 11 in article). However, I have had severalinstances in which ultrasound failed to demonstrate a di-lated distal ureter and renal scans that showed no nuclidebelow the UPJ but was found on RPG to have a large megau-reter that extended up to the UPJ. Finally, several times Ihave found extensive ureteral strictures that dictated a com-pletely different incision then what I was planning.
From an incision standpoint I find that the younger thechild, the easier it is to approach UPJO via the dorsal lum-botomy approach. I would challenge the comment made re-garding an increased risk of missing a crossing vessel whenusing the posterior lumbotomy approach. My preferential inci-sion when possible is posterior lumbotomy. I mobilize the renalpelvis and proximal ureter sufficiently, so that I can easilyrecognize any aberrant vessels. To my knowledge I have notmissed a crossing vessel to date in more than 23 years of practice.
With that said, posterior lumbotomy is the wrong incisionto use for a lengthy stricture, which may have led to some ofthe failures in this series when RPG was not performed.
Having spent the last 2 decades alternating between theuse of internal drainage stents vs no stents, I find that thegreatest benefit for using stents are in patients with a capa-cious pelvis and/or in those with a tight anastomosis.
Finally, discerning between the normal and abnormalureter during spatulation is an important component forpreventing surgical failures. There is usually a clear demar-cation zone where the distal ureter opens up and calibrateswell. In cases in which that demarcation is not recognizable,it is possible that one is dealing with an abnormal or hypo-plastic ureter that would increase the risk of surgical failure.
Mark R. ZaontzTemple University School of Medicine
Philadelphia, Pennsylvania
These authors offer us a review of their experience with pediatricpyeloplasty. Our experience, of which some is reported (reference11 in article), differs somewhat since we do not use the posteriorapproach, do not do retrograde pyelograms, do not use Foley
catheter drainage in patients without ipsilateral VUR and do notinsert stents or nephrostomy tubes other than under exceptionalcircumstances. The report by Rushton et al (reference 11 in arti-cle) documented our experience in the early 1990s with 106 of 108patients who underwent pyeloplasty and were followed with post-operative renal scans. Our methods have not changed since then.Retrograde pyeloureterograms were done in none and all kidneyswere approached through the flank. Drainage was noted to beimproved in 104 of 106 patents and only 1 required reoperation (2were lost to followup). The conclusion reached was that the com-bination of imaging with high quality renal/bladder sonogramsand diuretic renograms can reliably exclude distal obstruction.Care must be taken to visualize the ureter beyond the UPJ onsonography, particularly in the true pelvis. Delayed nuclear scanimages should be carefully inspected for isotope held up in theureter. Unless there is total proximal obstruction at the time ofthe study some isotope will enter the ureter and demonstratedistal ureteral ectasia.
Intraoperatively careful attention must be given to thepoint of obstruction and the ureter distal to that. I have foundthat one can be suspicious of a crossing vessel by pulling on theureter. If the kidney cannot be brought inferior by this maneu-ver, one can assume a crossing vessel, which should be vigor-ously pursued. The ureter should be calibrated from abovethrough a pyelotomy before making an extensive incision inthe pelvis. The area of narrowing should be incised or excisedand the ureter then should also be calibrated distal to that toensure normal patency. If there is a long area of narrowing orthe obstruction is distal, flap pyeloplasty or distal ureterouret-erostomy should be done. None of this can be achieved throughthe posterior approach and it is evident by the results reportedthat RPG does not guarantee avoiding these problems.
Finally, if a stent must be used because of unusual cir-cumstances, such as recent pyelonephritis or concern aboutthe anastomosis, it makes no sense to me to use an internalstent that requires repeat anesthesia for removal in a child.They should be brought out the kidney.
A. Barry BelmanChildren’s National Medical Center
Washington, D. C.
DISCUSSION
Dr. Max Maizels. Would it be fair to say this is not recurrent obstruction? It is persistent obstruction that was not appreciated.Dr. Luis H. Braga. Yes but some cases were recurrence.Doctor Maizels. If you do a dorsal lumbotomy, while it is a nice incision, your visualization may be less and mobilization
of the ureter is restricted. If you do not have a roadmap ahead of you, then you may not know to go a little extra further downthe ureter looking for that other kink that the retrograde showed.
Doctor Braga. I totally agree. That is the idea behind the retrograde to try to provide better planning for the operation.Although some people use just ultrasound and renal scan, and they get good delineation. If the patient has reflux, of course,you have the anatomy up the ureter with which to contend.
Dr. Tim Bukowski. Did any of your data with regard to the retrograde pyelogram include percutaneous antegrade nephrostogram?Doctor Braga. No.Doctor Bukowski. That is a nice way to visualize the urinary tract and upper tract when using the lumbotomy approach.Doctor Braga. Yes.Doctor Bukowski. And it may help with exposure, particularly if you have a more distal obstruction for which you need to
change the patient to a flank position.Doctor Braga. I agree.
RISK FACTORS FOR RECURRENT OBSTRUCTION AFTER PYELOPLASTY1688
