Clinical and radiographic outcomes following salvage intervention for ureteropelvic junction obstruction

Crivelli, Joseph J.; Johnson, Brett A.; Steinberg, Ryan L.; Gahan, Jeffrey C.; Antonelli, Jodi A.; Morey, Allen F.; Pearle, Margaret S.; Cadeddu, Jeffrey A.

doi:10.1590/S1677-5538.IBJU.2021.0303

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Original Article • IBJUInt. braz j urol 47 (6) • Nov-Dec 2021 • https://doi.org/10.1590/S1677-5538.IBJU.2021.0303 copy

Clinical and radiographic outcomes following salvage intervention for ureteropelvic junction obstruction

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose:

We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO).

Materials and Methods:

A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both.

Results:

Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF.

Conclusions:

Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.

Keywords:
Cakut [Supplementary Concept]; Salvage Therapy; Kidney Function Tests

			All patients (n=34)	1° pyeloplasty, 2° endopyelotomy (n=21, 62%)	1° pyeloplasty, 2° pyeloplasty (n=6, 18%)	1° endopyelotomy, 2° pyeloplasty (n=7, 21%)	p value^* * Comparison of primary pyeloplasty/secondary endopyelotomy and primary pyeloplasty/secondary pyeloplasty groups;
Table 1-A) Baseline characteristics
	Median age, years (range)		38 (19-82)	36 (21-79)	43 (19-61)	40 (30-82)	0.5
Gender
	Female		17 (50%)	10 (48%)	2 (33%)	5 (71%)	0.7
	Male		17 (50%)	11 (52%)	4 (67%)	2 (29%)	0.7
Race ^† † p value reflects comparison of non-white and white race; race data available for 32/34 (94%) patients;
	White		26 (81%)	14 (70%)	6 (100%)	6 (100%)	0.3
	Black		4 (13%)	4 (20%)	0 (0%)	0 (0%)
	Asian		2 (6%)	2 (10%)	0 (0%)	0 (0%)
Ethnicity ^‡ ‡ Ethnicity data available for 32/34 (94%) patients;
	Non-Hispanic		29 (91%)	17 (85%)	6 (100%)	6 (100%)	1.0
	Hispanic		3 (9%)	3 (15%)	0 (0%)	0 (0%)	1.0
Side
	Left		17 (50%)	13 (62%)	3 (50%)	1 (14%)	0.7
	Right		17 (50%)	8 (38%)	3 (50%)	6 (86%)
	Median BMI, kg/m² (range)		28 (20-45)	28 (20-36)	28 (22-45)	24 (21-37)	0.8
	Median ASA score (range)		2 (1-3)	2 (1-3)	2 (1-3)	2 (1-3)	0.5
	History of urolithiasis		15 (44%)	9 (43%)	3 (50%)	3 (43%)	1.0
	History of UTIs		13 (38%)	8 (38%)	3 (50%)	2 (29%)	0.7
Table 1-B) Perioperative outcomes^§ § Pertains to the secondary intervention.
	Median OR time, min (range)		109 (50-343)	74 (50-131)	187 (131-279)	270 (137-343)	0.001
	Median LOS, days (range)		1 (0-7)	0 (0-2)	2 (2-7)	2 (2-3)	<0.001
	Median EBL, mL (range)		5 (0-150)	2 (0-50)	25 (10-150)	50 (10-50)	0.01
Table 1-C) Long-term outcomes
	Failure^§ § Pertains to the secondary intervention. ,⁺⁺ ++ Statistical significance defined as p< 0.16 or failure outcomes.
		Symptomatic	14 (41%)	12 (57%)	0 (0%)	2 (29%)	0.020
		Radiographic	12 (35%)	10 (48%)	1 (17%)	1 (14%)	0.3
		Overall	20 (59%)	16 (76%)	1 (17%)	3 (43%)	0.015
	Tertiary intervention		11 (32%)	10 (48%)	1 (17%)	0 (0%)	0.3
	Nephrectomy		5 (15%)	5 (24%)	0 (0%)	0 (0%)	0.6

	All pyeloplasties	^1° 1° primary pyeloplasties	^2° 2° secondary pyeloplasties	^3° 3° tertiary pyeloplasties
Open	13 (28%)	8 (30%)	3 (23%)	2 (33%)
Laparoscopic	15 (33%)	9 (33%)	5 (38%)	1 (17%)
Robotic	18 (39%)	10 (37%)	5 (38%)	3 (50%)
Total	46	27	13	6

Surgical intervention	Complication	Grade
Tertiary ureterocalicostomy	Wound infection	I
Secondary endopyelotomy	Pyelonephritis	II
Tertiary robotic pyeloplasty	Pyelonephritis	II
Tertiary ureterocalicostomy	Pneumonia, parapneumonic effusion requiring drainage	IIIa
Secondary open pyeloplasty	Pulmonary embolism, rhabdomyolysis requiring intensive care	IV

	All secondary endopyelotomies (n=21)	Symptomatic failure		Radiographic failure		Overall failure
		Yes	No	Yes	No	Yes	No
		(n=12, 57%)	(n=9, 43%)	(n=10, 48%)	(n=11, 52%)	(n=16, 76%)	(n=5, 24%)
Stricture present on RGPG^* * RGPG = performed at time of secondary endopyelotomy available for 19/21 (90%) patients.	13 (68%)	5 (50%)	8 (89%)	7 (88%)	6 (55%)	9 (64%)	4 (80%)
	13 (68%)	p=0.14		p=0.2		p=1.0
Median stricture length, cm (range)^* * RGPG = performed at time of secondary endopyelotomy available for 19/21 (90%) patients.	1.0 (0.5-2.0)	1.0 (0.5-2.0)	1.0 (0.5-1.5)	1.0 (0.5-1.5)	1.0 (0.5-2.0)	1.0 (0.5-2.0)	1.0 (0.5-1.0)
	1.0 (0.5-2.0)	p=0.8		p=0.3		p=0.9
Median SKF, % (range)^† † SKF values prior to secondary endopyelotomy available for 20/21 (95%) patients.	44 (26-63)	46 (30-63)	43 (26-54)	42 (26-63)	45 (29-54)	44 (26-63)	44 (29-54)
	44 (26-63)	p=0.6		p=0.7		p=0.7

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[1] Correspondence address: Jeffrey A. Cadeddu, MD, Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9110, USA. Phone: 214-648-4765. Fax: 214 648-8786. E-mail jeffrey.cadeddu@utsouthwestern.edu