3.9 Post-operative Complications and Follow-Up	97

the least invasive approach and are associated with the lowest risk of hemorrhage.

–Balloon dilatation of PUJ obstruction in infants and children is technically feasible, safe and viable alternative to open or laparoscopic pyeloplasty.

–Ante grade (percutaneous) balloon dilatation:

•All dilatations are done under general anesthesia.

•Under ultrasound guidance, a puncture is made in the renal pelvis, followed by insertion of a Teflon coated (0.014– 0.035) guide wires into the renal pelvis and through the PUJ.

•Balloon catheters (2, 3, or 4 mm in diameter) are passed over the guide wire and used to dilate the PUJ obstruction.

•The flow through the PUJ is checked after dilatation and a double J-sent is inserted.

•A cutting balloon is used to widen the area of stenosis and it is important during the process of dilatation to abolish the area of wasting which is confirmed radiologically under fluoroscopy.

–This is especially so in infants where surgery is technically difficult and in experienced hands its efficacy is comparable to open or laparoscopic pyeloplasty.

–Generally, balloon dilatation and stenting has a lower success rate than the open or laparoscopic pyeloplasty but this increases in experienced hands where the results Balloon dilatation however, has a low morbidity and no mortality, less cost, no scars and a short hospital stay.

–Balloon dilatation is an attractive alternative to open or laparoscopic pyeloplasty as first-line treatment for PUJ obstruction. This is specially so in infants where open and laparoscopic pyeloplasties are known to be technically difficultbecome comparable to those of open or laparoscopic pyeloplasty.

3.9Post-operative Complications and Follow-Up

•Open surgical pyeloplasty is known to be associated with complications which include:

–Urinary tract infection and pyelonephritis

–Anastomotic leakage and urinary extravasation

–Recurrent pelviureteric junction obstruction

–Stenosis and stricture at the anastomosis site

•The treatment of postoperative urinary leakage:

–Some surgeons advocate placing a drain adjacent to the anastomosis to provide drainage in case of a leak.

–The drain can be removed 48–72 h postoperatively if there is no leak.

–Others advocate insertion of a transanastomotic stent to keep the anastomosis open and drain the renal pelvis.

–Some surgeons place a double J stent which is removed after few weeks.

–Postoperative leak without a drain can be treated by placing a perianastomotic drain percutaneously under ultrasound guidance.

–Other methods to control the leak include:

•Placement of percutaneous nephrostomy

•Placement of a ureteral stent

•Postoperative complications following endopyelotomy include:

–Significant intraoperative bleeding if the endoscopic incision is made inadvertently into a major polar vessel.

–Those with significant bleeding can be treated with emergency angiography and embolization of the bleeding vessel.

–Postoperative urinary tract infection

–Recurrence of PUJ obstruction.

•A follow-up ultrasound should be obtained approximately 4–12 weeks postoperatively to monitor the outcome.

•Over time, nearly all patients (up to 95 %) have radiographic improvement and resolution of their symptoms.

•Renal ultrasound is the main investigation for postoperative follow-up of patients with PUJ obstruction.

98	3 Pelviureteric Junction (PUJ) Obstruction

• The first renal ultrasound is performed 4–6 weeks postoperatively.

–If the follow-up ultrasound shows improvement where there is decrease in the severity of hydronephrosis, the patient can then be

followed by repeat ultrasound initially 1 year postoperatively and then every 2–3 years.

–If the follow-up ultrasound does not show improvement in the degree of hydronephrosis, diuretic renography is performed to detect persistent obstruction, which may require an additional surgical procedure.

Further Reading

1. Baek M, Park K, Choi H. Long-term outcomes of dismembered pyeloplasty for midline-crossing giant hydronephrosis caused by ureteropelvic junction obstruction in children. Urology. 2010;76:1463.

2. Blanc T, Muller C, Abdoul H, et al. Retroperitoneal laparoscopic pyeloplasty in children: long-term outcome and critical analysis of 10-year experience in a teaching center. Eur Urol. 2013;63:565.

3. Chertin B, Pollack A, Koulikov D, et al. Conservative treatment of ureteropelvic junction obstruction in children with antenatal diagnosis of hydronephrosis: lessons learned after 16 years of follow-up. Eur Urol. 2006;49:734.

4. Dangle PP, Kearns J, Anderson B, Gundeti MS. Outcomes of infants undergoing robot-assisted laparoscopic pyeloplasty compared to open repair. J Urol. 2013;190:2221.

5. de Waard D, Dik P, Lilien MR, et al. Hypertension is an indication for surgery in children with ureteropelvic junction obstruction. J Urol. 2008;179:1976.

6. Duong HP, Piepsz A, Collier F, et al. Predicting the clinical outcome of antenatally detected unilateral pelviureteric junction stenosis. Urology. 2013;82:691.

7. Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol. 1993;23(6):478–80.

8. Gill IS, Desai MM, Kaouk JH, Wani K, Desai MR. Percutaneous endopyeloplasty: description of new technique. J Urol. 2002;168(5):2097–102.

9.González R, Schimke CM. Ureteropelvic junction obstruction in infants and children. Pediatr Clin N Am. 2001;48:1505.

10.Heinlen JE, Manatt CS, Bright BC, et al. Operative versus nonoperative management of ureteropelvic junction obstruction in children. Urology. 2009;73:521.

11. Heyman S, Duckett JW. The extraction factor: an estimate of single kidney function in children during

routine radionuclide renography with 99mtechnetium diethylenetriaminepentaacetic acid. J Urol. 1988;140(4):780–3.

12.Islek A, Güven AG, Koyun M, et al. Probability of urinary tract infection in infants with ureteropelvic junction obstruction: is antibacterial prophylaxis really needed? Pediatr Nephrol. 2011;26:1837.

13.Josephson S. Antenatally detected pelvi-ureteric junction obstruction: concerns about conservative management. BJU Int. 2000;85:973.

14. Kim HJ, Jung HJ, Lee HY, et al. Diagnostic value of anteroposterior diameter of fetal renal pelvis during second and third trimesters in predicting postnatal surgery among Korean population: useful information for antenatal counseling. Urology. 2012;79(5):1132–7.

15.Koff SA. Postnatal management of antenatal hydronephrosis using an observational approach. Urology. 2000;55:609.

16. Kojima Y, Sasaki S, Mizuno K, Tozawa K, Hayashi Y, Kohri K. Laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction in children. Int J Urol. 2009;16(5):472–6.

17. Liang CC, Cheng PJ, Lin CJ, et al. Outcome of prenatally diagnosed fetal hydronephrosis. J Reprod Med. 2002;47:27.

18. McMann LP, Kirsch AJ, Scherz HC, et al. Magnetic resonance urography in the evaluation of prenatally diagnosed hydronephrosis and renal dysgenesis. J Urol. 2006;176:1786.

19. Mearini L, Rosi P, Zucchi A, et al. Color Doppler ultrasonography in the diagnosis of vascular abnormalities associated with ureteropelvic junction obstruction. J Endourol. 2003;17(9):745–50.

20. Monn MF, Bahler CD, Schneider EB, et al. Trends in robot-assisted laparoscopic pyeloplasty in pediatric patients. Urology. 2013;81:1336.

21. Parente A, Angulo JM, Romero RM, et al. Management of ureteropelvic junction obstruction with high-pressure balloon dilatation: long-term outcome in 50 children under 18 months of age. Urology. 2013;82:1138.

22. Penn HA, Gatti JM, Hoestje SM, et al. Laparoscopic versus open pyeloplasty in children: preliminary report of a prospective randomized trial. J Urol. 2010;184:690.

23. Piaggio LA, Franc-Guimond J, Noh PH, et al. Transperitoneal laparoscopic pyeloplasty for primary repair of ureteropelvic junction obstruction in infants and children: comparison with open surgery. J Urol. 2007;178:1579.

24. Riachy E, Cost NG, Defoor WR, et al. Pediatric standard and robot-assisted laparoscopic pyeloplasty: a comparative single institution study. J Urol.

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25. Roarke MC, Sandler CM. Provocative	imag-
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26. Romao RL, Koyle MA, Pippi Salle JL, et al. Failed pyeloplasty in children: revisiting the unknown. Urology. 2013;82:1145.

Further Reading	99

27. Sampaio FJ, Favorito LA. Ureteropelvic junction stenosis: vascular anatomical background for endopyelotomy. J Urol. 1993;150(6):1787–91.

28. Seideman CA, Tan YK, Faddegon S, Park SK, Best SL, Cadeddu JA, et al. Robot-assisted laparoendoscopic single-site pyeloplasty: technique using the da Vinci Si robotic platform. J Endourol. 2012;26(8):971–4.

29. Song SH, Lee SB, Park YS, Kim KS. Is antibiotic prophylaxis necessary in infants with obstructive hydronephrosis? J Urol. 2007;177(3):1098–101.

30.Stein RJ, Berger AK, Brandina R, et al. Laparoendoscopic single-site pyeloplasty: a compari-

son with the standard laparoscopic technique. BJU Int. 2011;107(5):811–5.

31. Sukumar S, Djahangirian O, Sood A, et al. Minimally invasive vs open pyeloplasty in children: the differential effect of procedure volume on operative outcomes. Urology. 2014;84:180.

32. Symons SJ, Bhirud PS, Jain V, Shetty AS, Desai MR. Laparoscopic pyeloplasty: our new gold standard. J Endourol. 2009;23(3):463–7.

33. Tan HL, Najmaldin A, Webb DR. Endopyelotomy for pelvi-ureteric junction obstruction in children. Eur Urol. 1993;24:84.

34.Tasian GE, Casale P. The Robotic-Assisted Laparoscopic Pyeloplasty: Gateway to Advanced Reconstruction. Urol Clin N Am. 2015;42(1):89–97.

35. Turner 2nd RM, Fox JA, Tomaszewski JJ, et al. Laparoscopic pyeloplasty for ureteropelvic junction obstruction in infants. J Urol. 2013;189:1503.

36. Ulman I, Jayanthi VR, Koff SA. The long-term followup of newborns with severe unilateral hydronephrosis initially treated nonoperatively. J Urol. 2000;164:1101.

37. Varda BK, Johnson EK, Clark C, et al. National trends of perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty. J Urol. 2014;191:1090.

38. Yeung CK, Tam YH, Sihoe JD, et al. Retroperitoneoscopic dismembered pyeloplasty for pelvi-ureteric junction obstruction in infants and children. BJU Int. 2001;87:509.