Role of ureterocalicostomy in management of giant hydronephrosis in children in contemporary practice: Indications, outcomes and challenges.

INTRODUCTION

Given the rarity of giant hydronephrosis (GH), ideal surgical approach, assessment of drainage after surgery, expected improvement in renal function and morphological changes in the kidney on follow up have not been studied extensively. The aim of this study was to investigate the role of ureterocalicostomy (UC) in unilateral GH with respect to its current indications, outcomes and the challenges associated with it.

MATERIALS AND METHODS

We retrospectively analysed data of 25 children (up to the age of 18 years) who underwent UC between January 2008 and January 2019 using open, laparoscopic or robotic-assisted approach. Preoperative workup included ultrasonography for pelvic anteroposterior diameter (APD) and cortical thickness (CT), and diuretic scan for split renal function (SRF) and drainage. Patients were followed with ultrasonography and diuretic renal scan at 3 months, after further 6 month and then annually.

RESULTS

The median age was 7 years and median follow-up was 22 months. Eight children underwent UC as salvage procedure while 17 children underwent UC as an upfront procedure. APD declined significantly (p < 0.001) and CT improved significantly (p = 0.009) after surgery. The drainage as well as SRF did not change significantly after surgery. Four children developed flank pain after stent removal; one required a redo-ureterocalicostomy for anastomotic stricture while another required balloon dilatation of the anastomosis. Two children responded to prolonged stenting for 2 months.

DISCUSSION

Ultrasonography (APD, CT), Diuretic renal scan (SRF and drainage pattern) are used to monitor HDN. APD is particularly important in GH because the diuretic renogram invariably shows an obstructive drainage owing to the large volume of the pelvicalyceal system. Similar to previous studies in literature, we too reported a decline in APD. CT improved in our study, however, the drainage pattern as well as SRF did not change significantly (Figure). Diuretic scan in isolation was not sufficient to predict failure. A combination of ultrasonographic and diuretic scan parameters were useful for follow up and for detection of failure. The success rate in our study was 92%. Chief limitations of our study were retrospective nature and lack of comparison with pyeloplasty. Moreover, some cases were performed with minimal invasive techniques, so the study group was heterogenous.

CONCLUSIONS

UC offers excellent outcome in children with GH due to primary as well as secondary UPJO. Isolated ultrasonographic or diuretic renogram parameters are not sufficient to predict failure and a combination of them should be used for follow up after UC.