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Single session endoscopic management of intrinsic ureteropelvic junction obstruction and concomitant renal stone disease in a child: a case report
© Ugras et al; licensee BioMed Central Ltd. 2002
Received: 20 April 2002
Accepted: 24 September 2002
Published: 24 September 2002
Percutaneous nephrolithotomy is a well known therapeutic modality for stone diseases of childhood. Antegrade and retrograde endopyelotomies are also well defined options of treatment for secondary ureteropelvic junction obstruction. Yet there are few reports regarding endoscopic therapy of intrinsic ureteropelvic junction obstruction. To our knowledge, there exist only a few reports of endosurgical treatment of children with stone disease and with concomitant intrinsic ureteropelvic junction obstruction, in the literature.
We present the endoscopic management of stone disease and concomitant intrinsic ureteropelvic junction obstruction of a child in one session.
Percutaneous nephrolithotomy and antegrade endopyelotomy is combined safely with successful outcome in a child.
Renal calculi of children may be divided into two categories according to the cause: those with an underlying urologic cause and those without. Among the anatomic causes, ureteropelvic junction obstruction (UPJO) is the most common lesion, paralleling that seen in adults .
Since renal stone disease of childhood is a recurrent situation, the patient is a candidate for multiple interventions for stone clearance during lifetime. For this reason, care must be taken to be as minimally invasive as possible in the initial therapy without sacrificing the treatment outcomes, and open surgery should be considered as the last choice . Stone disease in childhood is managed with success rates of 83% to 100% by percutaneous nephrolithotomy (PNL) [3, 4].
Open pyeloplasty remains as the gold standart for treatment of both intrinsic and secondary UPJO . With the advent of equipment and experience, endoscopic procedures are gaining popularity as a treatment option of intrinsic UPJO in children with success rates of 70 % to 88% [5–8]. Cold knife is thought to be the preferred method of incision because of the risk of secondary scarring due to electrocautery .
In a MEDLINE search for a combination of PNL and endopyelotomy in a single session, the authors realised one report of PNL, endopyelotomy and nephropexy in a single session of a 47-year-old man, and another report of endopyelotomy and PNL of an 8-year-old child [8, 9]. To our knowledge, the presented case is one of the few pediatric cases with intrinsic UPJO that has undergone PNL for stone disease and antegrade endopyelotomy in the same session.
After informing her parents on stone disease of childhood, UPJO, current treatment modalities and complications, surgical team and family decided on performing PNL and endopyelotomy. Written consent was obtained for both the operation and publishing of the outcomes.
She was followed up monthly with ultrasonography and urine cultures and has undergone metabolic evaluation which has failed to determine any significant cause for the renal stone disease. Analysis with x-ray diffraction showed that the stones were consisted of calcium oxalate dihydrate.
On the fourth postoperative month, DTPA and DMSA scintigraphy and diuretic renogram was obtained revealing slightly elongated but better elimination of the tracer without any evidence of further scarring of the renal tissue with total and right GFRs of 59.5 ml/min and 21.2 ml/min, respectively (Figure 2).
The patient is taken to our routine control programme for recurrent stone disease and is undergoing ultrasound, urine culture and urinalysis in every six months.
Despite a silent residual stone, patient benefit in terms of stone removal and functional correction was satisfactory. Today, there is agreement that a renal pelvis with stones and a suspicion of UPJO should first be freed of stones, as the obstruction may be reactive (that is secondary to the stone) and then re-evaluated for true anatomical UPJO [10, 11]. Usually six to eight weeks of time is recommended for assesing the UPJ again. We have considered this during the surgery, but since that the stones were no larger than seven mm in diameter, moving freely inside the pelvis without obstructing the UPJ; since a 6 Fr ureteral catheter could not be passed through the narrow part of the ureter and since there was no evidence of renal pelvic edema with visual control, we decided to go on with endopyeletomy. In our opinion, endoscopical approach seems to be a rational choice in pediatric cases with intrinsic UPJO and concomitant renal stone disease.
MU diagnosed the disease, performed the operation, conceived of the study and drafted the manuscript. AG discussed treatment options, guided in the operation. UY participated in drafting of the manuscript. CB participated in manuscript design and coordination.
Written consent was obtained from the patients' family for publication of the study.
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2490/2/11/prepub
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