Single-Staged Surgical Treatment of PUJO in A Resource-Limited Setting: An Opinion

Opinion

The Pelviureteric junction obstruction (PUJO), a congenital pathology which is characterized by the functional obstruction at the junction between the renal pelvis and the proximal upper ureter. It may lead to renal insufficiency in long-standing cases. It presents often late in some resource-limited settings due to the lack of proper antenatal screening and delayed diagnosis or its suspicion at the initial primary and secondary health care facilities during visitations. Pyeloplasty has proven to be effective in its surgical treatment. This can be done through open approach commonly but laparoscopic and robotic pyeloplasty are minimally invasive approaches that are replacing the old traditional open approach in the developed countries due to availability of facilities and expertise. These current trends of treatment are still far from the reach of patients in most developing countries. Also, in these settings, the majority of patients lack insurance cover for care. Therefore, it behooves the urologist treating these cohorts of patients to as much as possible aim to resolve patients pathology with a single- staged surgical intervention.

As such, open pyeloplasty will continue to remain valid and probably the only option for PUJO surgical treatment for many years to come in the poor resource setting. In the light of this reality, pyeloplasty stenting is an important surgical principle that cannot be overemphasized in patients in our setting due to late presentation and recurrent infections Opinion and inflammatory fibrosis that may accompany some cases. Ureteric stenting is a key surgical principle during pyeloplasty and several types of stents ranging from the Cumming’s tube, feeding tubes to the most popular DJ stent are in use.

Although arguments rages on regarding the necessity of stenting a pyeloplasty. While this will forever continue, stenting of pyeloplasty should be individualized especially in select patients with late presentation and particularly from low resource settings. This is to guarantee a desirable and favourable outcome after pyeloplasty. Depending on the type of stent used between internal and external stent, an internal stent usage will require a second surgical intervention though minimally invasive for the stent removal.

Two-staged intervention for PUJO with an initial pyeloplasty using an internal standard double-J (DJ) stent and later removal of the stent endoscopically is appealing where a DJ stent is handy and facility for endoscopic removal is available. It minimizes the potential risk of infection which may be associated with external pyeloplasty stents. However, this adds extra cost to the overall management. In addition where default to follow-up is high due to financial constraint especially in resource-limited environments with lack of insurance cover, stent-related complications such as stent encrustation with ureteral stone formation and even urosepsis may ensue.

In view of the above, an external pyeloplasty stent may still be relevant in the poor resource setting. Because the stent is removed before the patient’s discharge without the need for endoscopic stent removal on a second visit or intervention. Although this may be at the expense of longer hospital stay, it guarantees single-staged surgery for PUJO and avoids complications resulting from default to follow-up which is fairly encountered in resource-limited environments.

In summary, a single-staged surgical treatment should be the key focus of PUJO management in a resource-limited environment. However, the benefits to risk considerations between choice of internal and external stent for pyeloplasty should be weighed vis-a-vis the stent availability, socioeconomic considerations, and the surgeon’s experience and treatment outcomes.