OPEN PYELOPLASTY IN INFANTS <4 MONTHS OF AGE: ARE THE OUTCOMES WORSE THAN THAT OF OLDER PATIENTS?
Roseanne Ferriera, MD1, Smruthi Ramesh, BHSc2, Melissa McGrath, BASc2, Luis H. Braga, MD, PhD2.
1McMaster Univerity, Hamilton, ON, Canada, 2McMaster University, Hamilton, ON, Canada.
BACKGROUND: The aim of this study is to compare the complication rates of open dismembered pyeloplasty in infants <4 months of age to that of patients >4 months.
METHODS: A prospectively collected pyeloplasty database (n=257) was reviewed for patients younger than 2 years of age who underwent open dismembered pyeloplasty. Group 1 (G1) consisted of patients equal or less than 4 months of age and group 2 (G2) of patients from 5-24 months of age at time of surgery. We collected the following independent variables: patient demographics, operative time, intra-operative findings, complication/recurrence rates and postoperative analgesic profile. The primary outcome was pyeloplasty complications and ureteropelvic junction obstruction (UPJO) recurrence rates. Descriptive analyses were conducted, chi square for categorical data and T test for continuous data.
RESULTS: We identified 103 patients, 37 (36%) in G1 and 66 (64%) in G2. Median age was 3.0 months vs. 8.5 months and the mean weight was 5.8kg vs. 8.8kg in G1 and G2, respectively. All patients were diagnosed prenatally. G1 had a larger mean preoperative APD (29.4 mm vs. 24.5 mm, p=0.02), a higher proportion of patients with SFU grade IV hydronephrosis (95% vs. 70%, p=0.03) and a higher percentage of patients with differential renal function <40% (30% vs. 12%, p=0.02). Mean MAG-3 ½ time was 163 minutes in G1 vs. 54 minutes in G2 (p=0.05). Almost 90% of patients in both groups had a retrograde pyelogram and double J stent inserted. Mean operative time was similar for G1 and G2 (136 vs. 144 min, p=0.69). Intrinsic narrowing was the main etiology of UPJO, accounting for approximately 70% of cases in both groups, with no cases of crossing vessels seen. Median hospital stay was 2 days in both groups. Patients in G2 received a slightly higher number of doses of IV morphine than G1 infants (1.1 vs. 0.7 doses, p=0.01), but similar doses of oral morphine and ketorolac. The overall complication rate was 6.8% (7/103); 5.4% (2/37) in G1 vs. 7.6% in G2 (5/66) (p=0.68). Of these 7 complications, 5 were related to stent displacement (1-G1 and 4-G2) and 2 to UTIs (1 in each group). The mean percentage of improvement of APD post-pyeloplasty was 46% in G1 and 41% in G2. Recurrent UPJO rates were similar in both groups (5.4%-G1 vs. 4.5%-G2, p=0.85).
Patients younger than 4 months of age had similar surgical complications and recurrent UPJO rates when compared to older patients, suggesting that performing a pyeloplasty in this age range does not carry a significantly higher risk of complications, as once thought.
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