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Approach to the Failed Pyeloplasty In Children: Revisiting the Unknown

Sunday, October 21, 2012: 1:03 PM
Grand Ballroom B (Hilton Riverside)
Rodrigo LP Romao, Martin Koyle, Joao L Pippi Salle, Abdulhakim Alotay, Victor Figueroa, Armando J Lorenzo, Darius Bagli and Walid Farhat, Division of Urology, The Hospital for Sick Children, Toronto, ON, Canada

Purpose: Pediatric pyeloplasty has a high success rate. However, reasons for failure and the ideal approach to the management of the failed pyeloplasty (FP) are poorly understood. We sought to identify risk factors as well as perform a critical analysis of the management of FP in a large tertiary care center.

Methods: Retrospective chart review of children undergoing pyeloplasty from 2000-2010. All cases that required any type of reintervention, excluding stent removal, were reviewed. Data collected included: demographics, indication for and modality of the initial surgery, presence of crossing vessels, mode of diagnosis of failure, type(s) and success rate of the re-intervention(s).

Results: 455 patients underwent pyeloplasty in the study period and 27 failed (5.9%). Open (20/330) and laparoscopic (7/115) pyeloplasty yielded identical failure rates (6%); likewise, age and initial indication for pyeloplasty did not have an impact on failure (age: 17/287, 5.9% 0-5 years; 10/168, 5.9% >5 years; 15/230, 6.5%; indication: worsening antenatal hydronephrosis, 9/128, 7% pain and 3/38, 7.9% incidental finding). Indications for reintervention were: worsening asymptomatic hydronephrosis 16/27 (59%), pain 7/27 (26%), urosepsis 2/27 (7.5%) and other 2/27 (7.5%). 7/21 (33%) patients had a postoperative nuclear scan with documented decrease in differential renal function by at least 5%. Eight of the 27 patients (30%) improved with one intervention, 14 (52%) required 2 interventions and 5 (18%) had 3 interventions (see figure 1 for details). Mean interval between the first operation and subsequent interventions was 19.3, 24.9 and 27 months for the 1st, 2nd and 3rd reinterventions, respectively. All 7 patients with documented decrease in renal function had at least 2 interventions. Success rates for each modality of re-intervention were as follows: double –J stenting alone: 1/16 (6%); endopyelotomy: 9/18 (50%);  redo pyeloplasty: 12/13 (92%); uretero-calycostomy: 4/4 (100%). Only one patient (7%) had a documented missed crossing vessel. All patients eventually improved after a mean follow-up of 56 months following the initial pyeloplasty.

Conclusions: Pyeloplasty is a highly successful procedure. Age and initial indication for pyeloplasty do not influence the risk for failure. More invasive and definitive techniques, such as redo pyeloplasty and uretero-calicostomy are more successful than minimally invasive ones to treat FP and should probably be offered sooner rather than later.