Anderson-Hines Open Pyeloplasty in the Treatment of Pyelo-Ureteral Junction Syndrome: Results from 36 Cases ()
1. Introduction
The syndrome of pyelo-ureteral junction (SJPU) or hydronephrosis is the most frequent malformations of the urinary tract system. The incidence of congenital hydronephrosis is about 5 per 100,000 births [1] .
SJPU corresponds to a dilation of the pyelocalicielles cavities upstream of an obstacle situated at the level of the pyelo-ureteral junction [2] . The etiology is often congenital. It is either an aperistaltic junction segment, or aberrant vessels or a high insertion ureter [1] [3] .
The standard treatment for SJPU remains open pyeloplasty according to the Anderson-Hynes technique [4] . This technique has a success rate greater than 90% [1] [3] .
Nowadays, the management of SJPU is marked by the development of so-called mini-invasive techniques which are laparoscopic pyeloplasty and endopyelotomies.
In Congo, an earlier study on the diagnosis and treatment of pyelo-ureteral junction syndrome in 13 cases was published in 2004 by Bouya, et al. [5] . Our work proposed to study the Anderson-Hynestechnic [4] in order to evaluate the results obtained and the short, medium and long term complications.
2. Patients and Methods
2.1. Framework and Methods of Study
This was a retrospective study on the medical records of patients operated for an anomaly of the pyeloureteral junction, in the urology-andrology department of University Hospital, Brazzaville, from 2000 to 2014. Diagnostic of pyelo-ureteral junction syndrome was based on ultrasonography, urography and tomography result.
We included in the study any patient with pyelo-ureteral junction syndrome, operated by Anderson-Hynes [4] open pyeloplasty, who had a complete medical record. Operated patients whose records were incomplete were not included. We classified hydronephrosis into 4 types as proposed by CendrenMoulard and Valeyer. Type1: localized dilatation with pelvis; Type 2: dilation of the pelvis and calices, but rapid impregnation of the cavities and good thickness of the parenchyma; Type 3: Large pelvic-calyx dilation with a fuzzy and incomplete image within normal delays, very clear thinning of the cortex; Type 4: silent kidney [6] . In total, 36 files were the subject of this study.
The variables studied were: whether preoperative nephrostomy was performed, the approach used for pyeloplasty, intraoperative exploration, associated procedures, intraoperative drainage (transnephro-anastomotic or transpyelo-anastomotic drain), intraoperative incidents, duration of interventions, average duration of drains and bladder catheter, average length of hospital stay, short-term complications, medium and long-term complications, follow-up (clinical intravenous urography and tomograhy) after average of 12 months.
After the discharge of the service, the patients were reviewed at 1 month for a clinical control. During this check, the presence of residual pain and the condition of the wound was assessed. At three months, clinical and ultrasound control was performed. At 6 months, antomograhy was performed to assess the permeability of the anastomosis and ureter. Clinical and ultrasound control was performed at 1 year and every year up to 3 years. The result of the surgery was considered a “success” when there was both the disappearance of clinical signs and the permeability of the ureteropulmonary anastomosis to intravenous urography, that is to say the passage of the contrast product throughout the ureter in normal time and without hydronephrosis.
2.2. Characteristics of the Population
During the study period, 36 patients met our inclusion criteria.
The average age of our patients was 29.4 years, extreme (7 and 53 years). There was male predominance in 63.9% (23 cases) with a 2/1 sex ratio. The patients came from Brazzaville in the majority of cases (32 cases) Pointe-Noire (3 cases) and Kinkala (1 case).
Clinically, the circumstances of discovery were multiple. Flank or lumbar pain was the most common form of discovery (28 cases). The other circumstances were repeated urinary tract infection (5 cases), hematuria (2 cases) and abdominal mass (1 case).
Physical examination was normal in 29 cases. He had noted a large kidney in 1 case; a sensitivity of the lumbar fossa in 6 cases.
Paraclinically, cytobacteriological examination of urine (ECBU) was performed in all patients. It had allowed isolating a germ in 6 cases. It was an Escherichia coli (4 cases) and Klebsiella pneumoniae (2 cases). These urinary tract infections had been treated by antibiotic therapy in relation to the results of the antibiogram. This examination is performed systematically in all our patients preoperatively to sterilize the urine before any intervention.
3. Results
Preoperative nephrostomy was performed in 11 patients. The surgical approach was the lombotomy in the 11th intercostal space in all cases.
Intraoperative exploration revealed pyelo-ureteral junction stenosis in all cases, peripelitis in two patients (5.5%) with pyeliclithiasis. In three patients (8.3%), there was evidence of an inferior polar vessel crossing the pyelo-ureteral junction.
Resection of the pyelo-ureteric junction, sometimes associated with remodeling of the renal pelvis, followed by pyelo-ureteral anastomosis using the Anderson Hynes technique. The pyelo-ureteral anastomosis was made by two suture contin. The suture material used was vicryl® Absorbable Yarn 4/0.
Two patients (5.5%) underwent pyelolithotomy for pyeliclithiasis associated with the treatment of pyelo-ureteral junction syndrome.
Three patients (8.3%) had an aberrant lower polar vessel decay (Figure 1) associated with treatment.
The drainage was transpyeloanastomotic in 56% of the cases, transurethral in 17% of the cases, and in 28% of the cases, it did not have drainage. The drainage of the renal lodge by a Redon drain was systematic in all cases (36 cases).
Peroperatively, we noted as incident: a case of peritoneal breccia (2.8%) and a case (2.8%) of pleural breccia.
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Figure 1. Left giant hydronephrosis in a 45-year-old patient.
The average duration of interventions was 119 ± 15 min, extreme (94 - 237 min). The postoperative monitoring parameters are shown in Table 1.
Patients were followed for an average of 12 months with extremes of 6 and 24 months.
The 35 patients (97.2%) had an improvement in symptomatology with disappearance of lumbar or flank pain and other functional signs. One patient (2.8%) had persistent low back pain.
The results of intravenous urography at 6 months of postoperative follow-up are shown in Table 2.
In the short term, seven patients had complications. It was a parietal suppuration in 3 cases, treated by antibiotic adapted to the isolated germ, and a urinary leakage by the operative wound in 4 cases supported by drainage of the urine.
In the medium and long term, one patient (2.8%) had pyelo-ureteral stenosis. The success rate of pyeloplasty was 97.2% (n = 35).
Renal function was explored in all patients by the determination of blood creatinine. No cases of renal failure had been revealed. The radiological assessment makes it possible to establish the diagnosis of hydroneplorosis. Ultrasound was performed in all patients. It revealed a dilatation of the renal cavities in all cases. In addition, she had diagnosed 2 cases of pyelic calculus.
Intravenous urography was performed in all patients. It allowed making the diagnosis in all cases. It is the same as for urography performed in 7 cases (Figure 2). The attack was unilateral in 34 cases; right in 21 cases and left in 13 cases. Urography was performed in 13 patients in our study. He confirmed the diagnosis in all these cases (Figure 2). Two cases of pyelic computation had been diagnosed by urography, three cases of inferior polar aberrations had been found. The syndrome of the pyelo-ureteral junction was bilateral in 2 cases. Only the symptomatic side was operated. Taking into account the classification of CENDREN MOULARD and VALAYER, pyelo-ureteral junction syndrome was type 1 (0 cases); type 2 in 14 cases (38.9%), type 3 in 21 cases (58.3%) and type 4 in 1 case (2.8%).
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Figure 2. Intraoperative image of a polar vessel crossing the pyelo-ureteral junction.
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Table 1. Result postoperative monitoring parameters.
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Table 2. Results of intravenous urography at 6 months according to the grade of hydronephrosis.
4. Discussion
Open pyeloplasty according to the Anderson-Hynes technique associates the resection of the stenosedpyelo-ureteric junction with a pyelo-ureteral anastomosis. The open surgical approach was the standard treatment for SJPU since1949, its description by Anderson-Hynes [4] . This technic had been improved by René Kuss. It makes to treat SJPU as well as associated pathologies (removal of pyeliclithiasis, uncrossing of the inferior polar pedicle) [1] [3] .
Other techniques exist, Fenger’s plasty, Foley’s Y-V plasty which have the distinction of not removing the non-functional area, but repair the stenotic portion by increasing functional area with pyelic’s flap.
Lombotomy was the first route used in all our patients. Extraperitoneal and extrapleural is the most commonly used approach in open pyeloplasty [1] [3] [5] . Diao et al. [7] performed lombotomy in 83.4% of cases. It has the advantage of combining a good exposure on the pyelo-ureteral junction, to allow an excellent section of the pelvis and to realize an impervious anastomosis [3] . However, it has the disadvantage of causing non-esthetic scars, causing significant postoperative pain and causing parietal weakness and evenenation [2] [8] [9] . To avoid these complications of lombotomy, other minimally invasive surgical techniques have been developed (laparoscopy, endopyelotomy) giving functional results comparable to open surgery [10] [11] [12] .
In our study, two patients (5.56%) underwent pyelotithomy with pyeloplasty for pyelic computation. Bentani et al. [13] found a renal calculus associated with SJPU in 17.8% of cases.
We have considered the pyelo-ureteral junction syndrome as the factor favoring the occurrence of pyelic calculus. However, several authors believe that the stasis of urine alone is not enough to explain the occurrence of lithiasis: the urinary metabolic factors (hypercalciuria) of lithogenesis are necessarily associated [14] . In addition, in three patients (8.3%), there was evidence of an inferior polar vessel crossing the pyelo-ureteral junction. These patients had undergone a decrease in the inferior polar vessel associated with pyeloplasty. These results are comparable to those observed by Kirakoya et al. [15] , who found rates of 11.4%. These vessels have been demonstrated in 30% to 70% of cases of pyelouretral junction syndrome [16] . The implementation of transpyelo-ureteral drainage associated with drainage of the renal lodge is recommended [3] , but there is no consensus regarding drainage. Excretory drainage seems to be an immediate safety factor, limiting the risk of fistula and urinoma. It does not affect the long-term prognosis and the occurrence of recurrence. In our study, one case of peritoneal breccia and 1 case (2.78%) of pleural breccia were observed. The peritoneal gap had been treated peroperatively by suture. The pleural breccia had been repaired immediately. The frontal chest x-ray performed on day 1 postoperative had not revealed a pneumothorax. These incidents are also reported in the literature in similar proportions [7] . The haemorrhagic incidents have been described [16] .
The mean duration of the intervention in our study was 119 ± 15 min. This operating time is comparable to those reported in the literature (90 - 120 min) [1] [3] [7] . The operative time in open surgery is generally lower than that of laparoscopic pyeloplasty. This operating time in laparoscopic pyeloplasty varies from 180 to 480 min in the literature [1] . The mastery of laparoscopic techniques by the different teams has improved the operating time. Thus Bentani et al. in Morocco [13] find an average operative time of 175.5 min. Soulie et al. [18] , in France, an average time of 150 min. The average hospital stay in our study was 11.2 days with extreme 7 - 30 days. This stay is comparable to those reported in the literature: between 10 to 12 days [1] [2] [14] [16] .
However, the average stay was significantly reduced by laparoscopic surgery between 3 and 5 days [1] [13] [17] [18] . This laparoscopic pyeloplasty allows a rapid recovery of activity. In our study, seven patients had short-term complications. Diao et al. [7] had 20% short-term complications, including 3 cases (10%) parietal suppuration and 3 cases of urohematoma (10%). Short-term complications of pyeloplasty are usually urinary leakage in the anastomosis, urinary fistulas and urinomas [1] [3] . These complications are found both during the PCO and laparoscopically [19] .
Open pyeloplasty gives very good results (disappearance of clinical signs, normalization of urographic images) with a long-term success rate of 90% to 100% [1] [3] [5] . In our series, a case of failure (pyelo-ureteral stenosis) was noted. This stenosis is due to periuretal fibrosis. Percutaneous nephrostomy was performed while waiting for pyeloplasty to be resumed. The failures most often correspond to persistent stenosis, either by insufficient resection, periuretal fibrosis, non-sloping anastomosis or neglect of a lower polar pedicle, and sometimes an error of indication (retention kidney very deficient) [3] .
The results of PCO are currently comparable to those of laparoscopic pyeloplasty [13] [18] [20] .
5. Conclusion
Anderson-Hynes open pyeloplasty remains the treatment of choice for SJPU in our context with excellent results. But its indications tend to decrease in favor of laparoscopic pyeloplasty, which reproduces the Anderson-Hynes technique with comparable functional results and less morbidity. Thus, the arrival of laparoscopic and endoscopic surgery in our therapeutic arsenal is necessary because it will contribute to the reduction of the length of hospitalization of patients.
Ethical Clearance
This paper obtained the ethical clearance of the ethical comity of health sciences number 00000077/MRS/DGRST/CERSSA.