MINISTRY OF EDUCATION MINISTRY OF DEFENCE AND TRAININGMILITARY MEDICAL UNIVERSITY NGUYEN DUC MINH THE ROLE OF 64-SLIDES COMPUTED TOMOGRAPHY AND ASSESSMENT OF RETROPERITONEAL LAPAROSCOPIC
Trang 1MINISTRY OF EDUCATION MINISTRY OF DEFENCE AND TRAINING
MILITARY MEDICAL UNIVERSITY
NGUYEN DUC MINH
THE ROLE OF 64-SLIDES COMPUTED TOMOGRAPHY AND ASSESSMENT OF RETROPERITONEAL LAPAROSCOPIC SURGERY FOR THE TREATMENT OF URETEOPELVIC JUNCTION OBSTRUCTION
Major : SurgeryCode : 9720104
SUMMARY OF PhD IN MEDICINE THESIS
HANOI - 2020
Trang 2THE THESIS ARE COMPLETED AT:
MILITARY MEDICAL UNIVERSITY
Scientific supervisors:
1 Associated Professor Vu Nguyen Khai Ca, PhD
2. Associated Professor Hoàng Long, PhD
Reviewer 1: Associated Professor Nguyen Cong Binh, PhD
Reviewer 2: Associated Professor Tran Cong Hoan, PhD
Reviewer 3: Associated Professor Tran Duc
The thesis will be defended in front of the Scientific Committee at Military Medical Academy, on date month 2020
The thesis can be found at the following library:
+ Vietnam National Library
+ Military Medical Academy Library
Trang 3of success rate, compared to 93% of open surgery, and have fewercomplications than open surgery.
Imaging diagnostics play an important role not only in diagnosis andtreatment orientation, but also in the monitoring and evaluation of UJPOtreatment In particular, the 64-slides computer tomography (CT) is amodern diagnostic method with high sensitivity and specificity rate, hasbeen widely used in diagnosis, orientation, monitoring and evaluation ofeffectiveness treatment of UJPO
In recent years, the application of 64-slides CT, as well as laparoscopicsurgery in the diagnosis and treatment of UJPO has been implemented inVietnam The retroperitoneal laparoscopic technique for the treatment ofUJPO has been performed at the Urology Department of Viet DucUniversity Hospital since 2007, and achieved encouraging initial successresults Assessing the effectiveness of these methods is important to ensurethe best treatment outcomes for patients In addition, research evidences tosuggest appropriate apparoach for different type of UJPO injuries stilllimited in Vietnam This is the issue that our thesis aims to resolve
Based on the purpose has been mentioned above, we conducted thisstudy with two objectives:
1 Assessed the role of 64-slides CT in the diagnose of ureteropelvic junction obstruction at Viet Duc University Hospital.
2 Evaluated the outcomes of retroperitoneal laparoscopic surgery for the treatment of UJPO at Viet Duc University Hospital.
2 Thesis rationale
The ureteropelvic junction obstruction is a common urology disease.Endoscopic surgery, especially retroperitoneal laparoscopy, is graduallygoing to replace the open surgery In addition, with the contribution ofmodern imaging equipment, the 64-slides computer tomography hasincreasingly asserted a role for itself on the replacement of traditionalimaging methods in diagnosis, orientation and monitoring for treatment
of UJPO 64-slides CT has a significant contributed to the success of the
Trang 42treatment The use of 64-slides CT, as well as laparoscopic surgery inthe diagnosis and treatment of UJPO has been applied in Vietnamduring the recent years Assessing the effectiveness of these methods isimportant to ensure the best treatment outcomes for patients Inaddition, there have been several domestic studies in Vietnam that focus
on surgery outcomes of UJPO, but evidences to suggest to suggestappropriate apparoach for different type of UJPO injuries still limited Weaim to answer this question by conducted a longitudinal study amongUJPO patients under treatment with retroperitoneal laparoscopy surgery
at Viet Duc University Hospital
3 New contributions of the thesis
- The role of multi-slides computer tomography in the diagnose of
ureteropelvic junction obstruction at Viet Duc University Hospital
- Evaluated the outcomes of retroperitoneal laparoscopic surgery forthe treatment of UJPO at Viet Duc University Hospital
4 Thesis structure
The thesis consists of 117 pages, including 2 parts and 4 chapters: 2pages of research rantional and objectives, 31 pages of literature review, 21page of materials and methods, 27 pages of results, 33 pages of discussion,
2 pages of conclusion and 1 page of recommendations There are 24 tables,
11 figures, 27 pictures and photos; 127 references (15 in Vietnamese, and
112 in English, including 40% of references in the last 5 years)
CHAPTER 1: LITERATURE REVIEW
1.1 INTRODUCTION TO URETEOPELVIC JUNCTION OBSTRUCTION
1.1.1 Embryo, anatomy of ureteropelvic junction
1.1.1.1 Embryology on the development of ureteropelvic junction
The ureteropelvic junction is formed at 5 weeks of pregnancy.Abnormal development of kidney and ureter may causes the congenitalurinary malformations in children
1.1.1.2 Related anatomy of the kidneys, ureters: The kidney and ureter
located behind the peritoneum in Gerota's fascia, associated with abdominalorgans and with anterior and posterior abdominal wall muscles
1.1.2 Causes and pathogenetic mechanisms of ureteropelvic junction obstruction
1.1.2.1 The development of renal physiological function: After being
formed, urine will be excreted from the renal calyx, renal pelvis, the junction ofthe ureteral ureter, the ureter, and down to the bladder in one direction by theregular contraction of the renal pelvis, the junction, the ureter
1.1.2.2 The circulation of urine when there is a narrowing of the renal pelvis - ureter: urine flows through the junction following Koff's
Trang 53principle, causing the stretch of renal pelvis.
1.1.2.3 Causes of ureteropelvic junction obstruction: Internal causes
of the ureter: oliguria, splenic hypertrophy, mucosal folds; externalcauses: inferior artery or fibrous strip
1.1.3 Pathology
- Renal parenchyma: The thickness of the renal parenchyma depends
on the level of obstruction and the dilatation of renal calyx In cases ofcomplete obstruction when the renal pelvis has been widen stretched,
the renal parenchyma almost ceases to exist.
- Renal calyx and renal pelvis: stretching from mild to severe
depending on the time and level of blockage of the junction, the pelvicwall may have the clinical manifestation of chronic fibrosis
- Ureteropelvic junction: Small and narrow.
- Ureters: The ureter can connect to the renal pelvis in a normal or high
position The lower urethra is usually smaller than normal An abnormalblood vessel in the lower extremity is crossed across the junction
1.1.4 Clinical manifestations of ureteropelvic junction obstruction
Symptoms are often non-specific, depending on many factors such
as the level of obstruction, duration of infection, the status of infection,the status of comorbidities that may cause different clinicalmanifestations, including: upper urinary tract infection, symptoms ofdigestive disorders such as vomiting, diarrhea, hematuria, abdominalpain in the lower abdomen, renal colic, palpation of the kidneys, etc.Particularly in adults, the clinical symptoms may ambiguous and mild
or sudden even severe
1.1.5 Diagnostic imaging techniques
Imaging techniques play an important role in diagnose and furtherapparoach for treatment of ureteropelvic junction obstruction
1.1.5.1 Ultrasound: is the first screening tool to diagnose of renalhydronephrosis due to the ureteropelvic junction obstruction, renalhydronephrosis grading according to American Society of FetalUrology (SFU), and to monitor disease progression
1.1.5.2 Ultrasound imaging velocimetry (UIV): Formerly common
methods for diagnosing UJPO, help to assess the kidney function andseverity of fluid retention and the narrowing location
1.1.5.3 Radioisotope renography: It is valuable to diagnose the level of
obstruction However, the cost is high, as well as the risk of radiation exposure
1.1.5.4 Doppler Ultrasound: could be assess the blood supply status of
the kidneys, and the blood vessels inside the kidneys
1.1.5.5 Retrograde pyelography: The risk of infection is high, some
surgery doctors only perform on the operating table
Trang 61.1.5.6 Magnetic resonance imaging (MRI): It provides a very details
picture of the kidney It is valuable in evaluating kidney function andlevel of obstruction, however, much more expensive
1.1.5.7 Computerized tomography (CT): is a modern, easy-to-perform
diagnostic method, using small amounts of radiation, short executiontime, high value in assessing the function, location of obstruction of theurinary tract and the nature of obstruction to help surgery planning.1.2 THE ROLE OF 64-SLIDES CT IN THE ASSESSMENT OFURETEROPELVIC JUNCTION OBSTRUCTION
The multi-slides CT is a modern, easy-to-perform diagnosticmethod, using small amounts of radiation, short execution time, highvalue in assessing the function, location of obstruction of the urinarytract and the nature of obstruction to help surgery planning
64-slides CT with angiography and vascular model construction hasbeen made the diagnosis of UJPO much more accurate and convenient.64-slides CT are just as valuable as conventional angiography;however, this is a non-intervention method that much less risky than anangiogram
Based on the size of the renal parenchyma, the kidney function could
be assessed by 64-slides This technique has been evaluated that can beused to replace MAG3 radiography in the evaluation and functionalprediction of kidney postoperative
Nowadays, multi-slides CT scan has been proved to be a highlyeffective and cheaper method than other modern diagnostic methods inevaluating of UJPO pathology
1.3 TREATMENT OF URETEROPELVIC JUNCTION OBSTRUCTION
1.3.1 Medical indication
- UJPO with clinical symptoms
- UJPO causes kidney failured
- UJPO causes progressive deterioration of kidney function
- UJPO causes urinary tract infection or stones
- UJPO causes hypertension
With the following methods: Endoscopic junction cutting throughthe skin or through retrograde ureter; open or laparoscopic surgery toreconstruct the junction; Renal resection (indicated whenhydronephrosis and kidney function failured)
1.3.2 Sơ A brief history of development, advantages and disadvantages
of plastic surgical methods to reconstruct ureteropelvic junction
obstruction
1.3.2.1 Plastic surgery methods before the 20th century:
Trendelenburg was the first in history to have a junction surgery at
Trang 75Leizig in 1872 KUSTER (1881) was the first to successfully create asurgery in 3-year-old boys by removing the ureter from the narrowjunction and plug back into renal pelvis at a lower position During theperiod from the nineteenth century to the twentieth century, scientistshave created many methods to help expand the sutures and urinarysystem However, these methods do not have a scientific basis ofphysiology and pathophysiology of the junction So these surgeries nolonger exist.
1.3.1.2 Non-cutting plastic method: Y-V plasty (Foley), using the
rotating flap of the renal pelvis (Culp and De Weerd), plasting thestraight puzzle piece (Vertical flap), method of enlarging the diameter
of the ureter by catheterization (Davis)
1.3.1.3 Cut-off plastic method: Anderson-Hynes surgery, cut off the
damaged junction, reconstruct new junction
1.3.1.4 Laparoscopic resection of the urinary tract
- General principles
+ The cut line at the narrow segment must pass through the entire thickness
of the ureter, from the ureter to the fat layer around the renal pelvis
+ A ureter catheter is placed in place for 6-8 weeks as the bore for theregenerating renal pelvis junction around the tube, according to Davis'sprinciple
- Method of dissecting the joint through endoscopic reverse ureter;Method of creating endoscopic junction through the skin; Method to cutacucise ball joint; Method of connecting with balloon
1.3.1.5 Retroperitoneal laparoscopic surgery of renal pelvis
Endoscopic surgery has gradually been an alternative to opensurgery The success rate in laparoscopic surgery is 96% compared withopen surgery is 93%; help to reduce the number of days in hospital,shorter incision length, improve pain symptoms and analgesic time, lesscomplications than open surgery
Includes retroperitoneal and peritoneal endoscopic surgery Thechoice depends on the surgeon's preference and experience
1.3.1.6 Robotic retroperitoneal laparoscopic surgery: High success
rate, easy to use and has been widely applied around the world
1.3.2 Monitoring and evaluation after surgery So far there has been
no consensus on postoperative evaluation But overall, the evaluationcriteria includes clinical improvement, improvement of circulation,reduction of renal fluid retention, renal function Each study relied ondifferent materials to evaluate the above parameters
Trang 861.4 RESEARCHES RELATED TO THE TOPIC
1.4.1 Domestic studies
There have been many domestic studies reporting the results of applyinglaparoscopic surgery in the treatment of UJPO, such as Ngo Dai Hai(2010), Nguyen Thanh Liem (2011), Nguyen Mai Thuy (2015), NguyenDuc Duy (2015), Truong Thanh Tung (2017) However, the evaluationstudy with the aims to determine which types of lesions will indicate theappropriate surgery methods still limited And very few published reports
on the role of 64-slides CT in the diagnosis and treatment of UJPO
1.4.2 International studies
- Rivas compared laparoscopy and open surgery Evaluation criteria:clinical signs, affected kidney function (monitored by UIV), length ofhospital stay, complications of surgery Results: Laparoscopy resulted
in higher success and fewer complications than open surgery
- Yuanshan et al used CT scan to evaluate the effectiveness oflaboratory analysis of UJPO through assessment of renal morphology(renal fluid retention) Results: fluid retention of kidneys was improvedafter 3 and 12 months of surgery
CHAPTER 2: MATERIALS AND METHODS
2.1 Objectives: Patients diagnosed with UJPO and treated with
retroperitoneal laparoscopic surgery from May 2020 to October 2017 atDepartment of Urology Surgery - Viet Duc University Hospital
2.1.1 Inclusion criteria
- Age > 16 years old
- Having full-clinical data, imaging diagnostic and laboratory results
- Diagnosed with hydronephrosis caused by UJPO and indicated forretroperitoneal laparoscopic surgery at Viet Duc University Hospital:+ Ultrasound: Hydronephrosis level I - IV, the diameter before and afterthe renal pelvis > 15 mm
+ 64-slides CT: confirmation of hydronephrosis due to UJPO, renalparenchyma stilled has absorbed dye
- Patients or their caregivers agreed to partcipate
2.1.2 Exclusion criteria
- Not having full-data of medical records and imaging, laboratoryresults
- Patients with UJPO after surgery
- UJPO treated with other methods
- Patients with enal parenchyma did not absorbe dye on 64-slides CT
2.2 Methods
2.2.1 Design: prospective longitudinal study.
Trang 9n: Minimum sample size (numbers of objectives in the study).
α: Statistical significance level = 0,05 (95% confidence interval)
Z1-α/2: The critical value of the Normal distribution at α/2 → Z1-α/2 = 1,96.p: Endoscopic surgery rates of success (estimated 0,98) [19]
- Step 3: Monitor and evaluate surgical outcomes
+ During surgery and postoperative period
+ Evaluation of long-term outcomes after 3 months: Examination ofclinical and subclinical (blood tests, urine tests, 64-slides CT)
+ Evaluation of long-term outcomes after 12 months: Examination ofclinical and subclinical (blood tests, urine tests, ultrasound)
Trang 108low), the characteristics of renal vascular distribution, the level ofobstruction of the renal pelvis, and cormobidities.
2.3.2.2 In-surgery: Surgery time; characteristics in surgery (with or
without abnormally low renal artery; high or normal origin of the kidney, anterior or posterior diameter of the renal pelvis, external causes of narrowing of the junction if any, blood loss, complications in surgery, sich
as peritoneal tearing, bleeding during surgery, nearby organ damage, subcutaneous emphysema)
2.3.2.3 Post-surgery
- In hospitalization: Monitoring and care after surgery (Overall
condition, the duration of intestinal motility, the duration to drain the abdominal cavity, the duration to take pain medicine, the duration of postoperative treatment, the postoperative complications related to surgery.
- After hospitalizationAfter 1 month, all patients were examined again
to have JJ tube removed In case of the kidney is still hydrated, thesonde will be withdrawn later All patients were scheduled for follow-
up examinations after 3 months and 12 months
2.3.3 Criteria for evaluating surgical outcomes based on the
improvement of clinical signs, improvement of indicators on ultrasound and 64-slides CT.
Ranking of outcomes.
- After 3 months: Based on clinical symptoms and 64-slides CT:
* Good: Normal of renal pelvis.
- Clinical symptoms: No functional symptoms, no palpable kidney
- 64-slides CT: Improvement of 3/4 or all 4 factors (Renal function is recovered, improve the circulation of contrast dye through renal pelvis; size of renal pelvis is smaller than before surgery; water retention of kidney decreases compared to before surgery at least 1 level, kidney dilatation below grade II; thickness of renal parenchyma increased compared to before surgery)
* Moderate: Not completely obstruction.
- Clinical symptoms: Sometimes there are symptoms of urinaryinfections or low back pain
- 64-slides CT: Only improvement of 1/4 or 2/4 factors.
* Bad
- Clinical symptoms: Recurrent urinary infections or frequent lower back pain,palpable kidney
- 64-slides CT: No improvement or worse than before surgery
- After 12 months: Based on clinical symptoms and ultrasound.
* Tốt: No obstruction.
Trang 11- Clinical symptoms: No functional symptoms, no palpable kidney
- Ultrasound: Improvement compared to before surgery: renal pelvis issmaller; the dilatation of the kidney decreases compared to beforesurgery ≥ 1 level, the kidney dilates below the grade III
* Moderate: Not completely obstruction.
- Clinical symptoms: Sometimes there are symptoms of urinaryinfections or low back pain
- Ultrasound: The level of hydronephrosis did not decrease compared tobefore the surgery or decreased but the kidney was still at grade III Nosignificantly decrese of size of renal pelvis
2.4 Statistical analysis and ethical consideration: Data analyze using
3.1 General characteristics
3.1.1 Age and gender: Mean age was 29,1 ± 11,1, min: 16 years old,
max: 68 years old Mostly at age of 18 – 59, there was 2 patients ≥ 60years old (3,23%) Male is the majority with 61.29%
3.1.2 Clinical characteristics: Low back pain is the most common
functional symptom (95.16%) and is also the main cause ofhospitalization (91.94%) Clinical examination showed that palpablekidney only found in 11.29% of cases About 4.84% of patients were
accidentally diagnosed of UJPO during other treatment
3.1.3 Subclinical: The rate of abnormal kidney function is low (3.2%
having urea> 7.5 mmol/l), 1 patient (1.6%) has an increase in creatininebut not significant (121 µmol/l)
3.1.3.1 Ultrasound: 100% of patients had an ultrasound before surgery.
The mean kidney size: 36,2 ± 14,1 mm The 2nd grade of renaldilatation accounted for the highest percentage (43.55%) There was29.03% of patients had grade 3 kidney dilatation, 25.81% of patientshad grade 4 kidney dilatation
Trang 12plastic surgery Total p-
Non-value
n = 39 (%) n = 23 (%) n = 62 (%) The level of
The rate of patients who did not have plastic surgery with abnormalarteries on CT images (60.9%) was higher than the plastic surgerygroup (15.4%), p <0.01
The rate of high origin of ureter comes from the renal pelvis in thegroup of patients having plastic surgery was 38.5% (p <0.05); Nopatients were found in the non-plasnic surgery group
Ureter circulation in the non-plastic surgery group was also better
with the poor circulation only accounted for 13% compared to 59% inthe plastic surgery group (p <0.05)
3.2 Surgery outcomes of retroperitoneal laparoscopic surgery
Out of 62 patients, 39% (63%) underwent plastic surgery, the remaining
23 patients (37%) under non-plastic method In non-plastic surgery: themethod of ureteral displacement accounted for the highest proportion with19% (12 patients), followed by adhesive removal of 16% (10 patients) and
Trang 13112% (1 patient) was cross-cutting of blood vessels to pin down the renalpelvis junction (genital vein cutting in details).
There were 34/62 patients who performed Lasix test during surgery.The positive rate was 14 patients (100%) in the plastic group
The rate of patients with vascular anomalies in the plastic group was10.26%, lower than the non-plastic group with 56.52% (p <0.05)
3.2.1 In and post surgery assessment
3.2.1.1 Comparison of surgical characteristics
Table 3.12 Comparison of surgical characteristics
Characteristics
Plastic surgery
Non-plastic surgery Total p-value
n = 39 n = 23 (%) n = 62 (%) Surgical times
(Mean/SD) 116,02 ± 24,01 91,3 ± 6,59 106,8 ± 29,40 0,005Amount of blood lost
during surgery (ml) 37,02 ± 15,43 29,91 ± 17,16 31,02 ± 17,78 0,0001Numbers of trocars
The surgery time, the number of trocar and the amount of blood lost
TB during surgery in the non-plastic group were significantly lowerthan in the plastic surgery group
3.2.1.2 Comparison of evaluation in surgery
100% of patients have normal overall status during surgery Thehigh origin of ureter in the plastic group also accounts for a very highproportion with 35.9%, while no patients have this condition in the non-plastic group
3.2.1.3 Comparison of complications in surgery
Table 3.14 Comparison of complications in surgery
Complications in
surgery
Plastic surgery
plastic surgery
p-value
n = 39 (%)
n = 23 (%)
n = 62 (%) Bleeding No 39 (100) 22 (95,65) 61 (98,39) 0,37
Yes 0 (0) 1 (4,35) 1 (1,61)
Torn No 38 (97,44) 23 (100) 61 (98,39) 0,63
