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Antegrade Ballon Dilatation of Pelvi-Ureteric Junction Obstruction in Infants and Children

Hilal Matta¹, Aymen Saleh², Ahmed H. Al-Salem³

¹Department of Pediatric Surgery, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates

²Department of Radiology, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates

³Department of Pediatric Surgery, Qatif Central Hospital, Qatif , Saudi Arabia

 

Correspondence:

Ahmed H. Al-Salem

Department of Pediatric Surgery

Qatif Central Hospital

P. O. Box 61015

Qatif 31911 Saudi Arabia

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Background: Pelviureteric junction (PUJ) obstruction is the commonest cause of urinary tract obstruction in children. The majority of prenatally diagnosed PUJ resolve spontaneously but 20-25% will worsen and require intervention. The treatment options include: open pyeloplasty, laparoscopic or robot assisted pyeloplasty and endoluminal balloon dilatation. This is a report of our experience with antegrade balloon dilatation for PUJ obstruction in children. The aim of this study was to evaluate the effectiveness of balloon dilatation with double J stenting in the management of infants and children with PUJ obstruction.

Patients and methods: A total of 24 children (14 males and 10 females) with a mean age of 4.2 months (1.5 months-13 years) who had antegrade balloon dilatation for PUJ obstruction were reviewed. All had increasing dilatation of the renal pelvis on ultrasound and obstructive curve on MAG3 isotope scan with minimal or no response to diuretics.

Results: There were 3 technical failures. All three had nephrostomy followed by pyeloplasty, 21 had successful dilatation and 20 of them were discharged home the next day. One developed fever. All had a double J stent which was removed 6-8 weeks later. On follow-up (mean 26 months), 16 had excellent outcome while in 5, there was recurrence of hydronephrosis. Four of them underwent pyeoplasty and 1 was lost for follow-up. The overall success rate was 66.7% and if we exclude the technical failures and the one lost for follow-up, it is 74%.

Conclusion: Balloon dilatation of PUJ obstruction in infants and children is technically feasible, safe and viable alternative to open or laparoscopic pyeloplasty. This is especially true in infants where surgery is technically difficult and in experienced hands its efficacy is comparable to open or laparoscopic pyeloplasty.

Keywords: pelvi-ureteric junction obstruction, balloon dilatation, double J-stent

 

Introduction

Pelviureteric junction (PUJ) obstruction is the commonest cause of urinary tract obstruction in children. The incidence of PUJ obstruction in infants is increasing due to increased use of antenatal ultrasound. The majority of prenatally diagnosed PUJ obstruction resolve with follow-up (75-80%). A minority (20-25%) will worsen and require surgical intervention [1-6]. The criteria for surgical intervention is controversial but the following aspects are considered indications for surgical intervention: progressive increase in the diameter of renal pelvis (2.5-3 cm), reduction of differential renal function and scarring on renal isotope scan, symptoms of pain, colic, hypertension, recurrent urinary tract infection and obstructive curve on MAG3 with no response to diuretics. The treatment options include open surgery (Anderson-Hynes dismembered pyeloplasty), laparoscopic or robot-assisted pyeloplasty and endoluminal balloon dilatation the PUJ obstruction [7-10]. Balloon dilatation of PUJ obstruction was first done by Kadir et al. in 1982 [11].

Balloon dilatation can be done antegrade, retrograde or combined and the success rate is variable [7, 11-17]. This manuscript reports our experience with antegrade balloon dilatation for PUJ obstruction in infants and children. The literature on the subject is also reviewed.

Patients and methods

The medical records of all infants and children who had antegrade balloon dilatation for PUJ obstruction were reviewed and the following information was recorded: age at diagnosis, sex, indication for surgical intervention and outcome. Their radiological investigations were also reviewed including isotope scans and follow-up ultrasounds.

All dilatations are done under general anesthesia in the angio-suite and under fluoroscopy. 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) were passes over the guide wire and used to dilate the PUJ obstruction. The flow through the PUJ was checked after dilatation and a double J-sent was inserted (Fig. 1). All patients received one dose of prophylactic broad spectrum antibiotics. We use a cutting balloon to widen the area of stenosis and it is important during the process of dilatation to abolish the area of balloon wasting which is confirmed radiological under fluoroscopy (Fig. 2).

Figure 1: Steps of antegrade balloon dilatation supported by radiological images.

Fig 5-1

Figure 2: Radiological images showing abolishing the wasting at the PUJ which is an important prognostic sign.

Fig 5-2

Results

A total of 24 infants and children with PUJ obstructions underwent antegrade balloon dilatation of PUJ obstruction. Their mean age was 4.2 months (1.5 months -13 years). Fifteen (62.5%) of them were below 2 years of age. There were 14 males and 10 females. Seventeen (70.8%) of them had an antenatal diagnosis. All had increasing dilatation of renal pelvis on ultrasound and all had obstructive curve on MAG 3 isotope scan with no or poor response to diuretics. Fourteen (58.3%) had proven urinary tract infection.

There were three technical failures. In 2, we failed to pass the guide wire via the PUJ and in 1 the double J-stent slipped into the urinary bladder. In all three, we inserted a nephrostomy tube and subsequently had open pyeloplasty. In 4, there was contrast extravasation. Three of them had no detrimental effect and 1 was hospitalized for 8 days because of pain and fever. Twenty of those who had successful dilatation (from total 21) were discharged home the second day and one required hospitalization because of fever and pain.

All patients continued to receive prophylactic antibiotics and the double J-stent was removed 6-8 weeks later under general anesthesia as a day case. On follow-up, all had serial ultrasounds to measure the antero-posterior diameter of the renal pelvis and MAG3 isotope scan. The mean follow-up was 29 months (9 - 61 months). On follow-up, out of 24 patients, 21 had successful balloon dilatation (2 of them have less than 6 months follow-up – so they are not included in the results) and of these 19, 14 (74%) had successful outcome while 5 had recurrence of hydronephrosis. Four of them had open pyeloplasty and 1 was lost for follow-up. The mean age of those who had successful outcome was 18 months (1.5 months - 7 years) while the mean age of those who were not successful was 5.1 years (1.1 - 13 years). Fourteen patients were less than 2 years of age and in this group there was only one failure (92%).

Discussion

PUJ obstruction is the most common cause of neonatal and antenatal hydronephrosis, with an estimated incidence of 1 per 1500 live births. With the recent advances and availability of prenatal ultrasonography, most patients with PUJ obstruction are being diagnosed prenatally. More than fifty percent of patients with antenatal hydronephrosis are eventually diagnosed to have PUJ obstruction. The natural course of PUJ obstruction is however variable. The majority of prenatally diagnosed PUJ obstruction resolve spontaneously but 20-25% will worsen and require intervention [1-6]. The treatment options of PUJ obstruction include: open pyeloplasty, laparoscopic or robot assisted pyeloplasty and endoluminal balloon dilatation [7-10]. Open pyeloplasty (Anderson-Hynes dismembered pyeloplasty) is still considered the standard treatment for PUJ obstruction in infants and children and laparoscopic pyeloplasty, with or without robotic assistance, is increasingly being used in older children and adults [18]. The success rate of open dismembered pyeloplasty for treating PUJ obstruction exceeds 95%. The success rates of laparoscopic pyeloplasty are comparable with those of open pyeloplasty, and some studies have shown that laparoscopy offers additional advantages of decreased morbidity, shorter hospital stay, and faster recovery [18, 19]. This is even after failed open pyeloplasty [20]. Robotic-assisted laparoscopic pyeloplasty has become increasingly popular and the results of it are similar to those of conventional laparoscopic pyeloplasty [21]. Laparoscopic pyeloplasty however, is a technically demanding procedure that generally requires significant laparoscopic experience. In many cases, laparoscopic pyeloplasty is technically unfeasible in very small children and infants because of space constraints.

With the recent advances in minimal invasive techniques, balloon dilatation and stenting is a feasible, safe and effective alternative to treat PUJ obstruction. The success rates of this technique are however variable [7, 11-17] (Table 1).

Table 1 - Literature review of balloon dilatation in infants and children including the success rate of the procedure

Reference No. of Patients Route Success rate
Kadir et al (1982) 9 Combined 44%
McClinton et al (1993) 49 Retrograde 80%
Snow et al (1994) 26 Retrograde 64%
Doraiswamy (1994) 12 Retrograde 90%
Tan HL (1995) 10 Retrograde 70%
Sugita et al (1997) 17 Retrograde 55%
MacKenzie et al (2002) 10 Retrograde 70%
Wilkinson et al (2005) 14 Retrograde 100%
Hernandez A (2006) 7 Retrograde 100%
Parente et al (2013) 50 Retrograde 90%
Matta et al 24 Antegrade 74%

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 become comparable to those of open or laparoscopic pyeloplasty. Balloon dilatation however, has a low morbidity and no mortality, less cost, no scars and a short hospital stay. It 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 difficult. The more invasive open or laparoscopic pyeloplasties can be reserved for those who fail balloon dilatation. All our patients underwent antegrade balloon dilatation and the main difficulty we encountered was the inability to pass the catheter through the PUJ. It is difficult to speculate whether the retrograde technique is more successful in this regard. During dilatation, it is essential to abolish the wasting at the PUJ which is an important prognostic sign [12]. Excessive dilatation on the other hand can traumatizes the PUJ and causes subsequent scarring which leads to recurrence of stenosis.

In conclusion, balloon dilatation and stenting is a useful alternative to open or laparoscopic pyeloplasty, but has a lower success rate. Balloon dilatation is especially useful in infants with pelvi-ureteric junction obstruction where open and laparoscopic pyeloplasties are known to be difficult due to the small size of the ureter and space constraints. It has a low morbidity and no mortality, a short hospital stay and the success rate increases in experienced hands.

 

 

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