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Objective: To perform a critical analysis of the management of the pediatric failed pyeloplasty in a large tertiary center. The ideal approach to this rare entity is not well established., Methods: Retrospective record review of children undergoing pyeloplasty from 2000 to 2010. All cases that required any type of reintervention, excluding stent removal, were analyzed. Data collected included: demographics, indication for and modality of the initial surgery, presence of crossing vessels, mode of diagnosis of failure, and type(s) of reintervention with the correspondent success rate(s)., Results: Overall, pyeloplasty failure rate was 27 per 455 patients (5.9%). Age, initial indication for pyeloplasty, and modality of surgery (open vs laparoscopic) yielded similar failure rates. Indications for reintervention were as follows: worsening asymptomatic hydronephrosis 16 of 27 (59%), pain 7 of 27 (26%), urosepsis 2 of 27 (7.5%), and others 2 of 27 (7.5%). Eight of 27 (30%) improved with 1, 14 of 27 (52%) had 2, and 5 of 27 (18%) required 3 reinterventions, respectively. Mean interval between the first operation and subsequent interventions was 19.3, 24.9, and 27 months for the first, second, and third reinterventions, respectively. Modalities of reintervention with respective success rates were as follows: double J stent insertion 16% (6%), endopyelotomy 18% (50%), redo pyeloplasty 12% (92%), and ureterocalicostomy 4% (100%). Only 1 patient (7%) was documented to have a missed crossing vessel. All patients were stable and doing well after a mean follow-up of 56 months after the first operation., Conclusion: According to this series, more invasive and definitive techniques, such as redo pyeloplasty and ureterocalicostomy, are more successful than minimally invasive ones to treat failed pyeloplasty and should probably be offered sooner rather than later., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Ureteropelvic junction obstruction with concomitant ureterovesical junction obstruction is a rare condition whose treatment remains challenging [1-3]. Renal ultrasonography and diuretic renogram are universally utilized to assess a patient prior to pyeloplasty; however, the role of retrograde pyelography at the time of pyeloplasty is still debatable [5-7]. Herein, we describe two cases where the use of retrograde pyelography preoperatively helped to avoid pyeloplasty failure by allowing the surgeon to visualize a concurrent ureterovesical junction obstruction, which would not have been visible in the surgical field had the procedure been carried out without intraoperative imaging., (Copyright © 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Despite the widespread use of ureteral stents for pyeloplasty by pediatric urologists there is ongoing controversy regarding the most advantageous type of transanastomotic drainage. We compared patients who underwent placement of an externalized pyeloureteral Salle intraoperative pyeloplasty stent (Cook Urological, Spencer, Indiana) to those who had a standard Double-J ureteral stent placed to assess the benefits, drawbacks and costs of each modality during open pyeloplasty., Materials and Methods: Our study sample comprised 470 age matched children who underwent primary open pyeloplasty in an 11-year period. A total of 242 patients (51.5%) underwent Double-J ureteral stent insertion and 228 (48.5%) underwent placement of a Salle intraoperative pyeloplasty stent at surgery. Operative time, hospital stay, overall complication and success rates, type of complications and hospital costs were compared between the 2 groups., Results: Median age was 18 months and median followup was 39 months. Mean hospital stay was 3.0 and 3.1 days in children with a Double-J ureteral and a Salle intraoperative pyeloplasty stent, respectively (p = 0.7). The overall complication rate was 9.9% (24 of 242 patients) for the Double-J ureteral stent vs 8.3% (19 of 228) for the Salle intraoperative pyeloplasty stent (p = 0.6). Complications in patients with a Double-J ureteral stent consisted of urinoma in 3, return visits due to bladder spasms in 7 or catheter obstruction in 6 and readmission due to pyelonephritis in 5. Complications in children with a Salle intraoperative pyeloplasty stent involved urinoma in 1, prolonged drainage through the Penrose drain in 5 and readmission due to pyelonephritis in 1. Recurrent ureteropelvic junction obstruction developed in 12 cases per group. The success rate was 95.0% (230 of 242 cases) and 94.7% (216 of 228) for the Double-J ureteral and the Salle intraoperative pyeloplasty stent, respectively (p = 0.2). Hospital charges, including the surgical procedure, postoperative hospitalization and cystoscopy or a clinical visit for catheter removal, in patients with a Double-J ureteral and a Salle intraoperative pyeloplasty stent were $9,825 and $9,260, respectively., Conclusions: The 2 ureteral stents are equivalent in regard to overall complication and success rates after pyeloplasty. However, Salle intraoperative pyeloplasty stent insertion was associated with a Canadian $565 cost decrease per patient and most importantly the preclusion of a second general anesthesia for catheter removal.

Purpose: We compared retrograde endopyelotomy to redo pyeloplasty for the treatment of failed pyeloplasty in children., Materials and Methods: Of 32 patients with recurrent ureteropelvic junction obstruction retrograde endopyelotomy was performed in 18 and redo pyeloplasty was performed in 14. Patient age, gender, side, stent placement at initial pyeloplasty, presentation of secondary ureteropelvic junction obstruction, hospital stay, complications and success rates were compared. Success was defined as radiographic relief of obstruction as determined by ultrasound or diuretic renography at latest followup., Results: Median patient age was 6 years (range 2 to 14) at retrograde endopyelotomy and 7.2 years (1 to 17) at redo pyeloplasty. Retrograde endopyelotomy technique consisted of holmium laser in 10 patients and cautery/balloon dilation in 8. Redo pyeloplasty was performed through a flank incision in 12 patients and by laparoscopy in 2. Retrograde endopyelotomy was successful in 39% of the patients, while redo pyeloplasty had a 100% success rate (p = 0.002). Of the patients with failed retrograde endopyelotomy 5 had a stricture greater than 1 cm and 7 were younger than 4 years. Mean length of the narrowed ureteral segment was 10.1 mm in the failed retrograde endopyelotomy group vs 5.8 mm in the successful group (p <0.01). Only 1 of 8 children (13%) had a successful retrograde endopyelotomy using cautery followed by balloon dilation. Hospital stay was 1.3 days for the retrograde endopyelotomy group and 2.9 days for the redo pyeloplasty group (p <0.01). Mean followup was 47 months (range 15 to 132) after retrograde endopyelotomy and 33.1 months (12 to 78) after redo pyeloplasty., Conclusions: Retrograde endopyelotomy had a significantly lower success rate than redo pyeloplasty for correction of recurrent ureteropelvic junction obstruction after failed pyeloplasty in children. Patient age less than 4 years and narrowed ureteral segment greater than 10 mm were associated with a poor outcome after retrograde endopyelotomy.

We report the case of a neonate who underwent bladder exstrophy repair on the second day of life. Bilateral ureteral stents were placed intra-operatively. Postoperatively azotemia developed secondary to kinking of the proximal ureter bilaterally. Issues in diagnosis and management are discussed.

Urinary tract obstruction (UTO) is a frequent cause of renal failure in the pediatric population. We report a patient with type I/I cystinuria, followed prospectively from birth with yearly ultrasonography, who developed acute UTO due to a cystine stone at 10 years of age. In animal models of UTO, acute obstruction produces rapid loss of renal parenchyma secondary to apoptosis of tubular cells. Since we had prospectively obtained serial ultrasonographic measurements of renal growth, we were able to document sudden decrease in kidney size and function following UTO, suggesting that programmed cell death may similarly have caused the rapid irreversible loss of renal parenchyma in our patient. Despite surgical relief of the obstruction, kidney size decreased for at least 3-4 months. We speculate that anti-apoptotic drugs might be considered as a therapeutic strategy to protect ongoing renal parenchyma loss in UTO.