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Objective: To determine the efficacy of retrograde endopyelotomy for the treatment of pelvi-ureteric junction (PUJ) obstruction using the Acucise ureteric balloon cutting catheter., Patients and Methods: Between February 1995 and July 1997, 13 consecutive patients with primary PUJ obstruction underwent Acucise endopyelotomy at our institution. The mean follow-up was 17.7 months (range 7-33). The success of the procedure was based on objective patency on follow-up diuretic isotopic renography and the subjective resolution of symptoms., Results: The treatment was successful by objective criteria in eight of 13 patients and by subjective criteria in nine. The mean operative duration was 33 min (range 25-45) and all 13 patients were discharged within 24 h of the procedure. There were no major complications, such as vascular injury requiring transfusion. There were no delayed failures, as all failures occurred within 3 months of the procedure. Of the four total failures, two patients have successfully undergone open pyeloplasty and one other was found to have a crossing vessel at the lower pole at the time of the operation., Conclusion: In this small series. Acucise endopyelotomy was a safe procedure that offered effective, expeditious first-line treatment for PUJ obstruction. All failures occurred soon after treatment and did not hinder subsequent open pyeloplasty. Further studies with additional patients and a longer follow-up are warranted to determine the long-term efficacy of this promising new treatment.

Objective: To evaluate the efficacy of retrograde balloon dilatation for primary pelvi-ureteric junction (PUJ) stenosis (RBDP) in children., Patients and Methods: Sixteen children (12 boys, four girls; mean age 29 months) with primary PUJ stenosis initially underwent RBDP. A double-pigtail catheter was left in the ureter for 6 weeks to provide drainage. The initial diagnosis of PUJ stenosis and the subsequent post-operative assessment were both made by diuretic renography in almost all patients. All children were followed up for between 9 and 38 months (mean 25) after the procedure., Results: RBDP was unsuccessful in nine of 17 renal units. In three of these, failure was caused by inability to pass the catheter through the PUJ or vesico-ureteric junction (VUJ). In six cases, failure was caused by recurrent or persistent stenosis. In eight of 17 renal units, RBDP was successful in relieving the stenosis. The morbidity from the procedure was minimal., Conclusions: Long-term follow-up revealed a significant failure rate for RBDP, caused by the inability to pass the catheter through the VUJ or PUJ, or persistent and/or recurrent stenosis. Recurrent stenosis may result from excessive dilatation which traumatizes the PUJ and causes subsequent scarring. Failure to overcome the stenosis is thought to be caused by a large redundant renal pelvis, producing 'kinking' of the upper ureter. In these cases, only reduction pyeloplasty may be successful in relieving the obstruction.

Objective: To conduct a prospective study of patients with malignant obstructive uropathy treated actively by percutaneous nephrostomy and J-J ureteric stents., Patients and Methods: Forty-two patients (27 men, 15 women, median age 62 years, range 29-83) with obstructive nephropathy secondary to malignancy underwent urinary diversion followed, where appropriate, by active treatment of the underlying cancer., Results: The median survival of all patients was 133 (range 7-712) days. Seventeen patients (40%) survived for > 6 months and five (12%) for < 1 month. Patients who had received no prior therapy and for whom further therapeutic options were available were more likely to benefit from urinary diversion. In nine patients (21%) nephrostomy insertion failed to relieve renal failure. In 20 patients (48%) obstructive nephropathy recurred. The procedure was complicated by urinary tract or nephrostomy site infection in 16 patients, by septicaemia in six patients, by percutaneous urine leak in 13 patients and by pelvi-calyceal perforation in two patients, but not by haemorrhage or death. The median percentage of the patients' remaining life which was spent in hospital was 23.6% (range 2.2-100)., Conclusions: Patients likely to benefit from nephrostomy were those for whom there were therapeutic options available for the treatment of their malignancy. Prolonged survival is possible in obstructive nephropathy secondary to malignancy, which should no longer be cited as an absolute contra-indication to urinary diversion. Patients unlikely to benefit from urinary diversion can also be identified and they should not routinely undergo this intervention.

Objective: To determine what effect the presence of a nephrostomy, left on free drainage, might have on the rate of occurrence of ureteric strictures after ureteric instrumentation., Patients and Methods: Eighteen patients were identified in this unit who had had ureteric instrumentation while a nephrostomy was in place., Results: Eight of 11 patients in whom the nephrostomy was left open developed ureteric strictures. None of seven patients in whom the lumen was maintained by stenting and/or clamping of the nephrostomy developed strictures. The strictures needed dilatation and stenting in seven patients and the ureter had to be reimplanted in the other., Conclusion: In patients in whom a nephrostomy is in place, the opening should be occluded after ureteric instrumentation or a stent should be inserted if it is to be left on free drainage.

Over the last 8 years, 30 patients with ureteric injuries underwent endoscopic treatment. There were 14 failures, 5 because of blockage or diversion of the catheter in the fistulous gap and 9 because it was impossible to penetrate the stenotic tract. All failures occurred when treatment was attempted more than 3 weeks after the trauma. Sixteen lesions were successfully treated by placing a 6 to 10 F double pigtail catheter in the damaged ureter and leaving it for at least 3 months. Patients were followed up for 24 months. No recurrences were seen and good long-term results were achieved in all cases. In our experience, endourological treatment can be recommended for recent strictures < 2 cm in length, or for small fistulas in which continuity of the ureteric wall is still partially preserved. Despite the risk of failure, especially following late treatment of an injury, it should be considered a safe and effective procedure that is accepted well by the patients and that avoids the need for open surgery and its possible complications.

A review of 1288 patients with previously untreated prostatic cancer revealed 209 patients (16%) with ureteric obstruction; the obstruction was bilateral in 36%. The effect of hormonal treatment was assessed in 88 patients with 120 obstructed kidneys: 77 patients had androgen deprivation or hormonal medication alone and 11 patients needed percutaneous nephrostomy or ureteric catheters in addition. Drainage improved in 58% of the kidneys. The diverting catheter was withdrawn in 9 of the 11 patients after a median of 4 weeks. In all, 95% of patients were discharged. The patients with hormonal therapy alone survived for a median of 26 months (range 1-111), while the patients who also needed diversion survived for a median of 13 months (range 1-28). The median time spent at home was 24 months (0-102) and 10 months (0-23) respectively, presumably reflecting the worse general condition of the patients who required diversion.

A total of 49 retrograde balloon dilatations for pelviureteric junction (PUJ) obstruction were carried out on 43 pelviureteric junctions in 42 patients from 1986 to 1991. The majority (34/43) were performed as primary treatment for PUJ obstruction, with 9 patients having a history of previous open pyeloplasty. Follow-up ranged from 3 months to 4 years (mean 18 months). Clinical improvement, as assessed by absence of symptoms, was seen in 34 cases (80%). There was either no change or an improvement in renographic findings (t1/2 time and/or split function) in 40 patients (93%). Of the 9 patients who were undergoing secondary treatment, 5 showed clinical improvement and 8 showed no change or renographic improvement. Nine patients required 12 further procedures, of which 5 were interval nephrectomy. Balloon pyelolysis is a simple procedure with good results over a 4-year follow-up period. It is less effective for the treatment of secondary pelviureteric junction obstruction. It has a low morbidity and no mortality, involves a short hospital stay and allows an immediate return to full activity. It is therefore an attractive alternative to open pyeloplasty as first-line treatment for PUJ obstruction.

We report follow-up data (minimum of 1 year) on 63 kidneys with antenatally detected pelviureteric junction obstruction, as defined by renographic criteria. The condition was bilateral in 10 patients (i.e. 20 kidneys), 2 patients had unilateral obstruction with contralateral multicystic dysplastic kidneys, and 41 patients had unilateral obstruction with a normal contralateral kidney. In the latter group, 29 (71%) had good function (greater than 40%) at initial assessment. Of the 63 kidneys, 24 (38%) were operated upon following initial assessment, mainly for impaired function. Of 39 patients, initially managed non-operatively, 8 (21%) were operated upon subsequently: 3 for deteriorating function (2 of whom have been reassessed and both have regained their lost function) and 5 for other renographic or ultrasonic indications). Of the original 63 kidneys, 31 (49%) continue to be managed non-operatively; 16 of these (52%) show improving ultrasound appearances, 8 of 17 studied show improved drainage, and all unilateral cases have stable good function. It is concluded that non-operative management of selected cases of antenatally detected pelviureteric junction obstruction is safe.

Serum atrial natriuretic peptide (ANP), plasma renin activity (PRA), angiotensin II (AII) and aldosterone levels have been studied in patients with chronic bilateral ureteric obstruction resulting from high pressure chronic retention of urine (HPCR), both in the obstructed state and during the post-obstructed period. Increased ANP levels observed during chronic obstruction fell rapidly following urinary tract decompression by urethral catheterisation. Serum ANP resurged briefly within 24 h but stabilised thereafter at a lower level. PRA was initially suppressed but rose after catheterisation, the increase lagging behind the changes seen for ANP. Rising levels of AII and aldosterone followed this trend but, unlike PRA, levels were not completely suppressed in the obstructed state. The observed hormonal changes probably reflect homeostatic mechanisms directed to the maintenance of sodium and water balance during obstruction and to limitation of the diuresis following its relief.

The presentation and management of 153 patients with ureteric calculi requiring active treatment over a 12-month period were reviewed; 74% of patients had primary ureteric calculi and 26% had ureteric calculi composed of fragments resulting from extracorporeal piezoelectric shockwave lithotripsy (EPL) to renal calculi; 32 patients (21%) had more than 1 calculus or a steinstrasse. The primary procedures included were in situ EPL (n = 54), push-bang (44), retrograde ureteroscopy (40), Dormia basket extraction (6), push-pull (1), antegrade ureteroscopy (1) and combinations of these (7). The success of the primary procedure could not be predicted from stone size, site or duration in the ureter, but upper tract dilatation was significantly less (p less than 0.01) in the successful group. The overall success rate for complete stone extraction was 97%, but 54 patients (35%) required more than 1 procedure to achieve this. In situ EPL and push-bang, as either primary or secondary procedures, were successful in treating 79 patients (52%); 2 patients required ureterolithotomy (1.3%). The overall complication rate was 18%. Since EPL is only successful in treating approximately half of ureteric calculi, a range of other treatments should be available to maintain a low rate of open surgery.

Since 1982, we have used internal indwelling ureteric stents for the management and prevention of ureteric reconstruction complications in 28 renal allograft recipients. A total of 30 stents were placed in 18 patients either diagnostically or therapeutically in the management of allograft ureteric obstruction. In 16 patients internal stents were placed at the time of reconstruction for primary ureteropyelostomy (3), secondary ureteropyelostomy (8), repeat reimplant (3) and repair of ureteric or pelviureteric junction injury (2). Complications included 3 episodes of transplant pyelonephritis, proximal stent migration (1), persistent bacteriuria (1) and prolonged healing of a ureteropyelostomy (1). Internalised ureteric stenting is a safe and effective means of managing or preventing ureteric reconstruction complications in renal transplant recipients.

Extracorporeal shockwave lithotripsy (ESWL) and retrograde ureterorenoscopy (RU) have transformed the management of ureteric calculi. Nevertheless, patients with obstructing proximal ureteric calculi are not suitable for ESWL or RU. From January 1986 to September 1988, 17 patients with fixed upper ureteric stones underwent antegrade renoureteroscopy and percutaneous surgery. The technique was effective in removing incarcerated proximal ureteric calculi: all patients were stone-free at follow-up 3 months later.

Twenty patients found to have unilateral radiologically non-functioning obstructed kidneys on excretory urography (IVU), and who had normal contralateral kidneys, were further evaluated. Ultrasonography, radionuclide imaging and CT scan were carried out pre-operatively to try to predict which of the kidneys were potentially recoverable after relief of obstruction. Percutaneous nephrostomy was also performed on the last consecutive 7 patients 4 weeks before definitive treatment and the function of the kidneys determined daily. The patients were re-evaluated 2 months after the relief of obstruction. Ultrasonography, radionuclide imaging and CT scan were not found to be reliable in predicting whether these kidneys were potentially recoverable. We consider percutaneous nephrostomy a good procedure for obtaining prognostic information prior to definitive surgery.

A prospective study of apparent obstruction of the ureter by Bilharzia was undertaken. Over a 2-year period, 130 patients with active Bilharzia and 58 patients with inactive or chronic Bilharzia, all of whom had apparently obstructive lesions of the ureter, were studied. Ureteric lesions were examined for true mechanical obstruction by post-micturition erect radiography, erect diuresis renography and, in selected cases, by perfusion pressure flow studies. Of the 130 patients with active Bilharzia, 32 ureters were found to be mechanically obstructed and in each case the obstruction resolved with anti-bilharzial medication. Of the 58 patients with chronic or inactive lesions, only 5 ureters were found to be truly obstructed and required surgery. It is concluded that surgery is unnecessary for ureters obstructed by active Bilharzia within 2 months of starting treatment because the obstruction will resolve in most patients. In the so-called chronic bilharzial stricture, obstruction is more apparent than real and thorough investigation will save many patients from unnecessary surgery.

Twenty-one patients with chronic obstructive uropathy due to high pressure chronic retention of urine underwent renal functional assessment both during the period of obstruction and repeatedly up to 3 months following its relief. Glomerular filtration rate (GFR) was determined using clearance of 99mTc-DTPA and iohexol. Creatinine, water, urea and electrolyte excretion was assessed from timed urine collections. Excretion of water, urea and electrolyte was normal during obstruction but increased dramatically immediately following relief (e.g. sodium 110 to 234 mmol/24 h). Values returned to normal by 2 weeks (sodium excretion 148 mmol/24 h). No further significant changes occurred up to 3 months. Mean 99mTc-DTPA and iohexol clearances during obstruction were 59.0 and 50.5 ml/min respectively. Following relief of obstruction, no significant improvement occurred at 2 weeks but did at 3 months (mean = 68.4 and 55.7 ml/min). Mean creatinine clearance during obstruction was 32.5 ml/min. This improved 2 days following relief to 46 ml/min. No further improvement was seen until 3 months (mean = 57.3 ml/min). It was concluded that recovery of renal function from obstructive injury occurs in two phases, an early tubular phase lasting up to 2 weeks and a later, predominantly glomerular phase, between 2 weeks and 3 months. There is some disparity between creatinine clearance and more accurate measurements of GFR which may be explained by tubular excretion of creatinine in the early phase of recovery.

The clinical presentation and management of 57 primary obstructed megaureters in 46 patients, 35 of whom were children, are reported. Indications for operation include pain, infection, progressive pyelo-ureteric dilatation and reduction in the glomerular filtration rate. We have found that affected children cannot be managed successfully without operation. Conservative treatment may be employed effectively in adults in whom the condition is often stable and complications are less frequent. The preferred surgical technique is ureteric narrowing with reimplantation to the bladder by the Politano-Leadbetter method. The results of surgery are less satisfactory in adults than in children. This may be related to the reduced quantity of elastic tissue in the ureteric wall in adult cases.

Balloon dilatation was performed in nine patients with bilharzial ureteric strictures. In six patients a percutaneous, antegrade approach was used and in three a balloon catheter was introduced into the ureter via a cystoscope. In another four patients, negotiation of the strictured area with a guide wire failed. In all dilated patients, symptomatic and urographic relief of the obstruction was obtained during follow-up periods of 3 to 38 months (mean 19). One patient was re-dilated after 24 months and has remained symptom-free for a further 18 months. Balloon dilatation seems to be a promising method of treating this condition.

Endoballoon rupture and stenting was performed on 31 patients with pelviureteric junction obstruction. A percutaneous antegrade approach was used in 20 patients, a retrograde technique in 11. Clinical and renographic improvement was seen in 21 patients. Four patients later underwent nephrectomy, all of whom had a GFR of less than 20% in the affected kidney. Endoballoon rupture is technically undemanding, easier and less invasive than endopyelotomy. In patients with adequate renal function it provides a suitable alternative to pyeloplasty.

Pelviureteric obstruction was treated by dilatation with a Fogarty balloon catheter in 2 children. The catheter was introduced through the cystoscope without any percutaneous procedure, ureteric stents or drainage. Follow-up for 18 months indicated improved drainage and renal function. The merits and demerits of this technique are discussed.