Research Article
Austin J Urol. 2022; 8(1): 1073.
Efficacy of Open Anderson-Hynes Pyleloplasty in Congenital Unilateral Uretero-Pelvic Junction Obstruction in Terms of GFR in Children
Ur Rehman F, Ud Din S, Izhar M*, Ali Shah SI, Khan RA and Khan N
Institute of Kidney Diseases, Peshawar, Pakistan
*Corresponding author: Muhammad Izhar, Institute of Kidney Diseases, Peshawar, Pakistan
Received: January 11, 2022; Accepted: February 04, 2021; Published: February 11, 2022
Abstract
Background: Ureteropelvic junction obstruction” is defined as an anatomical abnormality that results in a functionally significant impairment of urinary transport from the renal pelvis to the ureter. Congenital UPJ obstruction results due to the presence of an aperistaltic segment of the ureter.
Objective: To determine the efficacy of Open Anderson-Hynes pyeloplasty in unilateral congenital UPJO in terms of GFR
Materials and Methods: This descriptive study of 139 patients of paediatric age group was conducted in the department of urology, Institute of Kidney Diseases, Peshawar from 24 July, 2019 to 24 July 2020. Patients with UPJO were operated. Efficacy of the procedure noted in term of GFR. Follow up ultrasound followed by nuclear scan was done after 2 months.
Results: Out of 139 patients, 60(43.16%) were of age 5-10yrs and 79(56.83%) i.e. the majority were 11-15 yrs with mean and SDs of 11±2.37. The overall complication rate was 36.69%. The efficacy in terms of GFR improvement OR at least prevention of deterioration of renal function was recorded in 115 (82.73%) patients while 24 (17.26%) showed no efficacy
Conclusion: Anderson-Hynes pyeloplasty is an effective procedure in terms of renal function improvement or to prevent GFR deterioration at the preoperative level in comparison to those not operated with gradual reduction in GFR.
Keywords: Pyeloplasty; Anderson-Hynes; Pediatric Pyeloplasty; Uretero-Pelvic Junction Obstruction
Introduction
Ureteropelvic junction obstruction is an anatomical abnormality that causes physiologically significant resistance to the flow of urine from the renal pelvis to the ureter [1]. The condition is more common in males and on the left side and may present with flank pain and hematuria [2]. UPJ obstruction is diagnosed prenatally by maternal ultrasonography. In younger children it is commonly diagnosed by ultrasonography, intravenous urography and DTPA/MAG3 scan. VCUG can also be considered to exclude vesico-uretero reflux which is present in up to 10% patients [3].
For the first time in the history Kuster did UPJO repair in 1891, later the dismembered pyeloplasty was described by the British plastic and urologic surgeons J.C Anderson and Wilfred Hynes [4]. Anderson-Hynes dismembered pyeloplasty is effective in almost every case and improves function in more than 90% cases following the procedure [5]. The follow up is usually done with post- operative USG, followed by IVU and further elaborated by DTPA/MAG3 after three months of surgery [6]. Another technique of flap instead of dismembered one was introduced by Foley in 1936 and was named as YV-plasty [7]. In 1946, Anderson and Hynes presented the details of their procedure mentioning the dismembering, spatulation as well as resection of the redundant tissue of the renal pelvis [8]. Östling folds and incomplete re-canalization are considered the main causes of UPJ obstruction [9]. In Obstructed kidneys there is an increase in cyclooxygenase activity and also increased level of thromboxane synthetase is observed [10,11].
In the obstructed kidney, renin-angiotensin activation leads to sclerosis and ACE inhibitors arrest this process [12]. The obstruction also indirectly induces spasm of the renal vasculature leading to decrease in GFR [13]. Once the obstruction becomes chronic, there is collagen deposition paving way to renal fibrosis [14]. As the renal obstruction is hostile to the kidney and spontaneous resolution of hydro nephrosis is not always positive so early intervention is indicated [15,16]. The internal drainage via DJS as recommended for six (6) weeks [17]. In paediatric patients external drainage via a feeding tube is preferred as this can be removed as a day case without anesthesia [18]. The association of horse-shoe kidney with UPJ obstruction is well known but other anomalies can also occur in combination [19]. The purpose of this study is to judge the efficacy of open Anderson- Hyne pyleoplasty. The efficacy measured by improvement in GFR or preservation of the renal function and preventing deterioration of function, resulting from no or physiologically insignificant resistance to urine move from renal pelvis into the ureter.
Objective
To determine the efficacy of Open Anderson-Hynes pyeloplasty in unilateral congenital UPJO in terms of GFR.
Materials and Methods
This descriptive study of 139 patients of paediatric age group was conducted in the department of urology, Institute of Kidney Diseases, Peshawar from 24 July, 2019 to 24 July 2020.
Patients meeting inclusion criteria i.e having primary unilateral UPJO, with split renal function >15% and age 5 to 15 years admitted in Urology Department of Institute of Kidney Diseases, Peshawar for surgery were included in study. The disease and the surgical procedure was explained to parents and written permission was obtained. The detailed history and clinical examination were recorded. Diagnosis of UPJO were made on sonogram, supported by contrast study like IVU/CTU and confirmed by MAG3/DTPA renal scan and further supported and outlined by retrograde ureteropyelography. Operations were done through flank incision. Dismembered pyeloplasty performed using 4/0 polyglycol running or initial two interrupted sutures. In majority DJS put antegradely and also a drain in all cases. Postoperative complications were recorded and efficacy of the procedure noted in term of GFR improvement, free drainage of contrast from the pelvis to the ureter and abolishment of the symptoms. Post operatively DJS was removed after six weeks and follow up ultrasound followed by nuclear scan was done after 2 months to see improvement/arrest of deterioration in renal function and smooth flow of urine without resistant at UPJ.
Results
Out of 139 patients, 60 (43.16%) were of age 5-10yrs and 79 (56.83%) i.e. the majority were 11-15 yrs with mean and SDs of 11±2.37. Amongst 139, 89 (64.02%) were males and 50 (35.97%) were females. The post- operative complications were early and delayed. The early complications were fever in 33 (23.74%) patients, visible hematuria in 6 (4.31%) patients, leakage of urine in 7 (5.03%) patients. The urine leakage settled in the majority of the patients within 2 to 3 days without intervention. Delayed complications as re-stenosis occurred in 5 (3.5%) and required surgical intervention as endo-pyelotomy or redo peloplasty. The overall complication rate was 36.69%. The efficacy in terms of GFR improvement OR at least prevention of deterioration of renal function was recorded in 115 (82.73%) patients while 24 (17.26%) showed no efficacy. The efficacy of the pyeloplasty was predicted by the duration of the hospital stay. In 115 patients with less than 3days hospital stay 96 (69.01%) gained improved renal functions while 19 (13.66%) did not. A total of 24 patients stayed for more than 3 days, 19 (13.66%) patients benefited from the surgery while 05 (3.59%) showed no efficacy (Table 1-7).
Numerical Variables
Mean
SDs
Age
11
2.37
Duration of hospital stay
3
0.84
Table 1: Laboratory values at hospital admission.
Age Groups
Frequencies
Percentages
5-10 Years
60
43.16%
11-15 Years
79
56.83%
Total
139
100%
Table 2: Frequency and Percentages for Age (n=139).
Gender Groups
Frequencies
Percentages
Male
89
64.02%
Female
50
35.97%
Total
139
100%
Table 3: Frequency and Percentages for Gender (n=139).
Efficacy
Frequencies
Percentages
Yes
115
82.73%
No
24
17.26%
Total
139
100%
Table 4: Frequency and Percentages for Efficacy (n=139).
Age Groups
Efficacy
Frequencies
Percentages
P Value
5-10 Years
Yes
50
35.97%
No
10
7.19%
11-15 Years
Yes
65
46.76%
0.87
No
14
10.07%
Table 5: Stratification of Efficacy WTH Age (n=139).
Gender Groups
Efficacy
Frequencies
Percentages
P Value
Male
Yes
72
51.79%
0.445
No
17
12.23%
Female
Yes
43
30.93%
No
7
5.03%
Table 6: Stratification of Efficacy WTH Gender (n=139).
Duration of Hospital stay
Efficacy
Frequencies
Percentages
P Value
< 3 Days
Yes
96
69.01%
0.611
No
19
13.66%
> 3 Days
Yes
19
13.66%
No
5
3.59%
Table 7: Stratification of Efficacy WTH Duration of Hospital Stay (n=139).
Discussion
The study provided the evidence that open Anderson-Hyne pyeloplasty is the very much reasonable and most successful option to treat UPJO [20]. In dismembered pyeloplasty we remove the diseased abnormal UPJ and restore the continuity of the renal pelvis to the ureter [21]. Though the dismembered pyelo-plasty has its roots back in thehistory in1891 by Kuster and 1949 by Anderson-Hynes but the outcome is very much comparable to the newer laparoscopic technique [22,23]. Majority of our patients (n=79, 56.83%) were in the age group of 11-15 years which in contrast to the age spectrum cited by Mughal and Soomro in their study where the majority (60%) were 1-5 years [24].
The male patients were more in number (n=89, 64.02%) than female patients (n=50, 35.97%) showing male to female ratio 2:1, which is more like mentioned in the literature [25].
In our study we noticed some minor complications as fever (n=33, 23.74%), self limiting visible hematuria (n=6, 4.3%), and urine extra- vasation (n=7, 5.03%). In comparison the local study by Rafique Ahmed Sahito and Bshir Ahmed Soomro, fever rate (23.74%) was high in our patients while they recorded in 16.67% patients, while hematuria was 4.31% in ours and 3.33% in their study, much more comparable. We recorded 5.03% leakage of urine as compared to 3.33% by them. The re-stenosis which is the late complication of the procedure after three months was 3.5% in our observations while it was 11.1% in the study conducted by Marcin Polok and Wojciech Apoznanski [26].
The efficiency as determined by improvement in GFR, prevention of further deterioration and symptomatic relief was 82.7% in our set up while reported 95% in literature for pyelo plasty and is considered as the gold standard [27].
Conclusion
Anderson-Hynes pyeloplasty is an effective procedure in terms of renal function improvement or to prevent GFR deterioration at the pre-operative level in comparison to those not operated with gradual reduction in GFR.
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