Impact of drainage technique on pediatric pyeloplasty: Comparative analysis of externalized uretero-pyelostomy versus double-J internal stents

Abstract

Introduction: Pediatric pyeloplasty with double J (DJ) stent drainage requires manipulation of the uretero-vesical junction (UVJ) and a second anesthetic for removal. Externalized uretero-pyelostomy (EUP) stents avoid these issues. We report outcomes of laparoscopic and open pyeloplasty with EUP compared to DJ stents in children. Methods: We retrospectively reviewed 76 consecutive children who underwent pyeloplasty for ureteropelvic junction (UPJ) obstruction over a 1-year period by 5 pediatric urologists at a single institution. The exclusion criteria included patients with concomitant urological procedures, other urinary drainage strategies, "stentless" pyeloplasty or patients without follow-up data. Based on surgeon preference, 24 patients had a EUP stent and 38 had a DJ stent placed. Results: The mean follow-up was 23.8 ± 10.9 months and 21.1 ± 11.1 months for the EUP and DJ stent groups, respectively (p = 0.32). The mean age was 40 ± 54 months and 80 ± 78 months for the EUP and DJ groups, respectively (p = 0.04). The EUP group had a greater proportion of open pyeloplasties (n = 17, 71%) versus the DJ group (n = 16, 42%; p = 0.04). There were no statistically significant differences in operative time, length of stay, and overall complication rate between groups. Complications were divided by timing of complication (intraoperative, before and after 3 months) and according to the Clavien Classification system. There were no statistically significant differences between these subgroups. The limitations of this study include small sample size, potential selection bias, and heterogeneity between both study groups. Conclusions: Pyeloplasty using EUP stents does not incur prolonged operative time, longer length of stay or higher complication rate when compared to DJ stents. Within the limitations of this study, EUP stents may be a safe alternative to DJ stents.

The BULT Method for Pediatric Minilaparoscopic Pyeloplasty in Infants: Technique and Results

“…One report suggested that there were fewer complications with the use of a percutaneous transanastomotic stent ( 13 ), but in others, the results were similar or better compared with JJ stent ( 16 ). In our series with retrograde placement of the JJ stent after a retrograde pyelogram, there have been no stent-related postoperative complications.…”

Does a small stent size increase the risk of post-operative complications following reconstructive robotic surgery in the pediatric population?

“…It has been suggested, that DJS use during robotic reconstructive surgery, might lower the rate of post-operative leaks and obstruction by maintaining an appropriate ureteral diameter and prevent adhesions or kinking of the suture line. Furthermore, stenting may prevent transient obstruction by blood clots or edema at the anastomotic site [3,6,8,16,20]. One might believe that a smaller stent, with narrower lumen such as the 3Fr DJS, would be more prone to obstruction and thus to anastomotic leak or hydronephrosis aggravation.…”

“…In the past few decades, less invasive laparoscopic and robot-assisted laparoscopic approaches have become more widely used in reconstructive ureteral procedures among the pediatric population [1]. Placement of an indwelling ureteral DJS at the time of the procedure has both its advocates and detractors, with different outcomes reported in several studies, ranging from lowered morbidity and shortened hospital stay to stent failure and the need for a redo operation [2][3][4][5][6][7][8]. The diameter of DJS as a predicament to its failure or success, has not been addressed in most studies.…”

Clinical profile of infantile pelviureteric junction obstruction

“…18 Cost of stent, second anesthesia, early discharge, urinary leak, infections and anastomotic stricture will determine use of the stent. 11,12,19 However prospective double blind random study of pyeloplasty on stent or stent less may be needed. Post pyeloplasty EC scan showed 5-10% renal function recovery.…”