Nghiên cứu giá trị chẩn đoán của chụp cắt lớp vi tính 64 dãy và đánh giá kết quả phẫu thuật nội soi sau phúc mạc điều trị hội chứng hẹp khúc nối bể thận niệu quản tt tiếng anh

MINISTRY 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 : Surgery
Code : 9720104

SUMMARY OF PhD IN MEDICINE THESIS

HANOI - 2020


THE 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


1
INTRODUCTION

1. Background
Ureteopelvic Junction Obstruction (UJPO) is one of common urinary
diseases due to internal or external causes. Depending on the extent of
damage, clinical manifestations will sooner or later, and will have
difference level of severe. The disease has a gradual effect on kidney
function. If delayed in diagnosis or properly treatment, it will lead to
impaired renal function quickly. Endoscopic surgery, especially
retroperitoneal laparoscopic surgery, has good outcome results with a 96%
of success rate, compared to 93% of open surgery, and have fewer
complications than open surgery.
Imaging diagnostics play an important role not only in diagnosis and
treatment orientation, but also in the monitoring and evaluation of UJPO
treatment. In particular, the 64-slides computer tomography (CT) is a
modern diagnostic method with high sensitivity and specificity rate, has
been widely used in diagnosis, orientation, monitoring and evaluation of
effectiveness treatment of UJPO.
In recent years, the application of 64-slides CT, as well as laparoscopic
surgery in the diagnosis and treatment of UJPO has been implemented in
Vietnam. The retroperitoneal laparoscopic technique for the treatment of

UJPO has been performed at the Urology Department of Viet Duc
University Hospital since 2007, and achieved encouraging initial success
results. Assessing the effectiveness of these methods is important to ensure
the best treatment outcomes for patients. In addition, research evidences to
suggest appropriate apparoach for different type of UJPO injuries still
limited in Vietnam. This is the issue that our thesis aims to resolve.
Based on the purpose has been mentioned above, we conducted this
study 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 gradually
going to replace the open surgery. In addition, with the contribution of
modern imaging equipment, the 64-slides computer tomography has
increasingly asserted a role for itself on the replacement of traditional
imaging methods in diagnosis, orientation and monitoring for treatment
of UJPO. 64-slides CT has a significant contributed to the success of the


2
treatment. The use of 64-slides CT, as well as laparoscopic surgery in
the diagnosis and treatment of UJPO has been applied in Vietnam
during the recent years. Assessing the effectiveness of these methods is
important to ensure the best treatment outcomes for patients. In
addition, there have been several domestic studies in Vietnam that focus
on surgery outcomes of UJPO, but evidences to suggest to suggest

appropriate apparoach for different type of UJPO injuries still limited. We
aim to answer this question by conducted a longitudinal study among
UJPO 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 for
the treatment of UJPO at Viet Duc University Hospital.
4. Thesis structure
The thesis consists of 117 pages, including 2 parts and 4 chapters: 2
pages of research rantional and objectives, 31 pages of literature review, 21
page 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
congenital urinary 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
abdominal organs 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 of
the ureteral ureter, the ureter, and down to the bladder in one direction by the
regular contraction of the renal pelvis, the junction, the ureter.
1.1.2.2. The circulation of urine when there is a narrowing of the


3
renal pelvis - ureter: urine flows through the junction following
Koff's principle, 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; external
causes: 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 of
complete 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 pelvic
wall 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 abnormal
blood 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 clinical
manifestations, including: upper urinary tract infection, symptoms of
digestive disorders such as vomiting, diarrhea, hematuria, abdominal

pain 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 further
apparoach for treatment of ureteropelvic junction obstruction.
1.1.5.1. Ultrasound: is the first screening tool to diagnose of renal
hydronephrosis due to the ureteropelvic junction obstruction,
renal hydronephrosis grading according to American Society of
Fetal Urology (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 and
severity 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


4
1.1.5.5. Retrograde pyelography: The risk of infection is high, some
surgery doctors only perform on the operating table.
1.1.5.6. Magnetic resonance imaging (MRI): It provides a very details
picture of the kidney. It is valuable in evaluating kidney function and
level 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 execution
time, high value in assessing the function, location of obstruction of the
urinary tract and the nature of obstruction to help surgery planning.

1.2. THE ROLE OF 64-SLIDES CT IN THE ASSESSMENT OF
URETEROPELVIC JUNCTION OBSTRUCTION

The multi-slides CT is a modern, easy-to-perform diagnostic
method, using small amounts of radiation, short execution time, high
value in assessing the function, location of obstruction of the urinary
tract and the nature of obstruction to help surgery planning.
64-slides CT with angiography and vascular model construction has
been 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 an
angiogram.
Based on the size of the renal parenchyma, the kidney function could
be assessed by 64-slides. This technique has been evaluated that can be
used to replace MAG3 radiography in the evaluation and functional
prediction of kidney postoperative.
Nowadays, multi-slides CT scan has been proved to be a highly
effective and cheaper method than other modern diagnostic methods in
evaluating 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 through
the skin or through retrograde ureter; open or laparoscopic surgery to
reconstruct the junction; Renal resection (indicated when

hydronephrosis 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


5
1.3.2.1. Plastic surgery methods before the 20th century:
Trendelenburg was the first in history to have a junction surgery at
Leizig in 1872. KUSTER (1881) was the first to successfully create a
surgery in 3-year-old boys by removing the ureter from the narrow
junction and plug back into renal pelvis at a lower position. During the
period from the nineteenth century to the twentieth century, scientists
have created many methods to help expand the sutures and urinary
system. However, these methods do not have a scientific basis of
physiology and pathophysiology of the junction. So these surgeries no
longer 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 the
straight 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 the
regenerating renal pelvis junction around the tube, according to Davis's
principle.

- Method of dissecting the joint through endoscopic reverse ureter;
Method of creating endoscopic junction through the skin; Method to cut
acucise 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 open
surgery. The success rate in laparoscopic surgery is 96% compared with
open surgery is 93%; help to reduce the number of days in hospital,
shorter incision length, improve pain symptoms and analgesic time, less
complications than open surgery.
Includes retroperitoneal and peritoneal endoscopic surgery. The
choice 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 evaluation
criteria includes clinical improvement, improvement of circulation,


6
reduction of renal fluid retention, renal function. Each study relied on
different materials to evaluate the above parameters.
1.4. RESEARCHES RELATED TO THE TOPIC
1.4.1. Domestic studies
There have been many domestic studies reporting the results of applying
laparoscopic surgery in the treatment of UJPO, such as Ngo Dai Hai
(2010), Nguyen Thanh Liem (2011), Nguyen Mai Thuy (2015), Nguyen
Duc Duy (2015), Truong Thanh Tung (2017)... However, the evaluation
study with the aims to determine which types of lesions will indicate the
appropriate 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 of
hospital 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 of laboratory
analysis of UJPO through assessment of renal morphology (renal fluid
retention). Results: fluid retention of kidneys was improved after 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 at
Department 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 for
retroperitoneal laparoscopic surgery at Viet Duc University Hospital:
+ Ultrasound: Hydronephrosis level I - IV, the diameter before and after
the renal pelvis > 15 mm
+ 64-slides CT: confirmation of hydronephrosis due to UJPO, renal
parenchyma 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, laboratory
results
- Patients with UJPO after surgery
- UJPO treated with other methods

7
- Patients with enal parenchyma did not absorbe dye on 64-slides CT
2.2. Methods
2.2.1. Design: prospective longitudinal study.
2.2.2. Sample size
Convinience sampling apparoach with all eligible patients will be
asked to participate in the study,
The sample size was calculated based on the sample size formula for
observation study
n=

Z21-α/2 x p (1 - p)
ε2

Which:
n: 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].
ε: Margin of error 0,05
Based on the formula, we calculated n = 1,96 ×1,96 × 0,98 × 0,02/ 0,0025 = 30
The total number of patients in this study was 62 patients.
2.3. Study procedures
Eligible patients were selected using a structural designed form. The
sequence of steps is as follows
2.3.1. Process
- Step 1: Clinical examination, subslinical (blood tests, urine tests,
ultrasound, 64-slides CT).
- Step 2: Perform the surgery, at the same time, during the observation
surgery, assess several variables to compare with the results on CT scan

images..
- Step 3: Monitor and evaluate surgical outcomes
+ During surgery and postoperative period.
+ Evaluation of long-term outcomes after 3 months: Examination of
clinical and subclinical (blood tests, urine tests, 64-slides CT).
+ Evaluation of long-term outcomes after 12 months: Examination of
clinical and subclinical (blood tests, urine tests, ultrasound).
2.3.2. Study indicators
2.3.2.1 Pre-surgery
- Clinical: Age, gender, weight, clinical symptoms.
- Imaging diagnosis:
+ Ultrasound measures the diameter before, after the renal pelvis, the
thickness of kidney parenchyma.


8
+ 64-slides CT: The thickness of renal parenchyma, level of
hydronephrosis, the origin of the of ureter from the renal pelvis (high,
low), the characteristics of renal vascular distribution, the level of
obstruction 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, the
sonde 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 urinary
infections 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.


9

- After 12 months: Based on clinical symptoms and ultrasound.
* Tốt: No obstruction.
- Clinical symptoms: No functional symptoms, no palpable kidney.
- Ultrasound: Improvement compared to before surgery: renal pelvis is
smaller; the dilatation of the kidney decreases compared to before
surgery ≥ 1 level, the kidney dilates below the grade III.
* Moderate: Not completely obstruction.
- Clinical symptoms: Sometimes there are symptoms of urinary
infections or low back pain.
- Ultrasound: The level of hydronephrosis did not decrease compared to
before the surgery or decreased but the kidney was still at grade III. No
significantly decrese of size of renal pelvis.
* Bad
- Clinical symptoms: Recurrent urinary infections or frequent lower back pain,
palpable kidney.
-Ultrasound: Thin renal parenchyma, dimension of renal pelvis does not
decrease, or increase compared to before surgery, renal dilatation does
not decrease or increase.
2.4 Statistical analysis and ethical consideration: Data analyze using
SPSS 16.0 software.
The study was completely harmless, not dangerous to patients.
CHAPTER 3: RESULTS
From May 2020 to October 2017 at Urological Surgery – Viet Duc
University Hospital, there was 62 patients with age > 16 years old had
retroperitoneal laparoscopic surgery for the treatment of UJPO.
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 ≥ 60
years 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 of
hospitalization (91.94%). Clinical examination showed that
palpable kidney 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
creatinine but 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


10
renal dilatation accounted for the highest percentage
(43.55%). There was 29.03% of patients had grade 3 kidney
dilatation, 25.81% of patients had grade 4 kidney dilatation.
3.1.3.2. 64-slides CT
Table 3.7; 3.8; 3.9. CT-64 slides characteristics before surgery
NonPlastic
plastic
Total
surgery
psurgery
64-slides CT
value
n = 23
n = 62
n = 39 (%)
(%)
(%)

1
0(0)
1 ( 4,3 )
1 ( 1,6 )
2
14 (35,9) 13 (56,5) 27 (43,6)
The level of
0,018
hydronephrosis
3
10 (25,6)
8 (34,9)
18 (29)
4
15 (38,5)
1 (4,3)
16 (25,8)
No
33 (84,6)
9 (39,1) 42 (67,7)
Artery
<0,001
abnormalities
Yes
6 (15,4)
14 (60,9) 20 (32,3)
The origin of Normal 24 (61,5)
23 (100) 47 (75,8)
ureter comes
<0,001

from the renal
pelvis
High
15 (38,5)
0 (0)
15 (24,2)
Normal
16
(41)
20
(87)
36
(58,1)
Ureter
<0,001
circulation
Poor
23 (59)
3 (13)
26 (41,9)
No
37 (94,9) 22 (95,7) 59 (95,2)
<0,001
Kidney stones
Yes
2 (5,1)
1 (4,3)
3 (4,8)
The grade 4 hydronephrosis in the group of patients who had plastic
surgery was 38.5%, much higher than the group of patients who had no

plastic surgery (p <0.05).
The rate of patients who did not have plastic surgery with abnormal
arteries on CT images (60.9%) was higher than the plastic surgery
group (15.4%), p <0.01.
The rate of high origin of ureter comes from the renal pelvis in the
group of patients having plastic surgery was 38.5% (p <0.05); No
patients 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% in
the 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: the


11
method of ureteral displacement accounted for the highest proportion with
19% (12 patients), followed by adhesive removal of 16% (10 patients) and
2% (1 patient) was cross-cutting of blood vessels to pin down the renal
pelvis 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 was
10.26%, 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
Plastic
surgery
n = 39

Characteristics

Non-plastic
surgery
n = 23 (%)

Total

p-value

n = 62 (%)

Surgical times
116,02 ± 24,01 91,3 ± 6,59 106,8 ± 29,40 0,005
(Mean/SD)
Amount of blood lost
37,02 ± 15,43 29,91 ± 17,16 31,02 ± 17,78 0,0001
during surgery (ml)
Numbers of trocars
3
25 (64,1)
23 (100)
48 (77,4)
0,001
4
14 (35,9)
0 (0)
14 (22,6)
Cutting-off renal pelvis

Yes
21 (53,85)
0 (0)
21 (33,87)
0,001
No
18 (16,15)
23 (100)
41 (66,13)

The surgery time, the number of trocar and the amount of blood lost
TB during surgery in the non-plastic group were significantly lower
than in the plastic surgery group.
3.2.1.2 Comparison of evaluation in surgery
100% of patients have normal overall status during surgery. The high
origin of ureter in the plastic group also accounts for a very high
proportion with 35.9%, while no patients have this condition in the nonplastic group.
3.2.1.3 Comparison of complications in surgery
Table 3.14. Comparison of complications in surgery
Complications in
surgery
Bleeding

No

Plastic
surgery
n = 39
(%)
39 (100)

Nonplastic
surgery
n = 23
(%)
22 (95,65)

Total
n = 62
(%)
61 (98,39)

pvalue
0,37


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Torn
peritoneum

Yes
No
Yes

0 (0)
38 (97,44)
1 (2,56)

1 (4,35)
23 (100)

0 (0)

1 (1,61)
61 (98,39)
1 (1,61)

0,63

There was 1 patient in the non-plastic group who had a bleeding
accident in surgery due to damage to the genital veins, the blood loss
was about 10ml but was treated immediately during the surgery (Patient
Hoang Van A., born in 1980, case number N39-12360), and 1 patient
with peritoneal tear complications in plastic surgery group.
3.2.2. Evaluation during postoperative
Bảng 3.15. Evaluation during postoperative
Plastic
Non-plastic
Total
surgery
surgery
pPostoperative
value
TB ± SD
TB ± SD
TB ± SD
(n = 39)
(n = 23)
(n = 62)
The duration of
46,84 ± 19,97 31,3 ± 13,41 40,98 ± 19,22 < 0,001

intestinal motility
The duration to
drain the
66,53 ± 26
43,83 ± 15,61 57,97 ± 25,08 < 0,001
abdominal cavity
The duration to
70,32 ± 21,7 64,7 ± 15,24
68,2 ± 19,57 < 0,001
take pain medicine
Non-plastic surgery patients had a shorter recovery time than those of
plastic surgery patients (p <0.05).
- Complications after surgery: 7 patients had complications after
surgery. In particular, 3 patients with urinary infections, 2 patients with
urine leakage, 2 patients with wound infections.
- Mean of hospitalization was 8.74 days (SD = 6.17). There is no
difference between plastic and non-plastic surgery patients
3.2.3 Assessment of long-term outcomes
After 3 months, 100% of patients were re-assessed by 64-slides CT
scan. 2 patients had to undergo surgery again because of recurrent
narrowing and had to switch to open surgery. These 2 patients were
removed from the follow-up list at 12 months.
After 12 months, 100% of patients were re-assessed by ultrasound.
3.2.3.1 After 3 months


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Figure 3.3. Diameter of renal pelvis on CT before - after surgery
The mean diameter of the renal pelvis on CT was significantly reduced
when comparing between pre- and postoperative in both groups with

and without plastic surgery (p <0.001).

Figure 3.4. Thickness of renal parenchyma on CT before and after surgery
Thickness of renal parenchyma on CT increased significantly after 3
months of surgery in both plastic and non-plastic groups (p <0.001).

Figure 3.5. The level of hydronephrosis on CT before and after surgery
The rate of hydronephrosis on CT before and after surgery decreased on
both group

Figure 3.6. Poor ureter circulation on CT before and after surgery
The rate of Poor ureter circulation on CT significant decreased
from 41,94% to 1,61% 3 months after surgery (p < 0,001).
Table 3.18. Surgery outcomes after 3 months
Plastic
Non-plastic
Total
General
surgery
surgery
p-value
criteria
n=39 (%)
n=23 (%)
N=62 (%)
Good
35 (89,74)
20 (86,96)
55 (88,71)
Moderate

2 (5,13)
3 (13,04)
5 (8,06)
0,31
Bad
2 (5,13)
0 (0)
2 (3,23)
After 3 months, the rate of patients with good treatment outcomes
was 88.71%, there was no significant difference between the plastic and
non-plastic groups (p = 0.31).


14
2 patients (ID N39-12659 and N39-9513) with poor treatment
outcomes were transferred to open surgery. These 2 patients had plastic
surgery. After surgery, thay was discharged from hospital, but after 3
months, they still had low back pain. The results of CT scan still have
images of UJPO, so we have to switched to open surgery for treatment.
Early results of re-surgery were recurrent narrowed at the junction of
renal pelvis. Both patients had a good outcomes after the open surgery.
3.2.3.2 After 12 months

Figure 3.7. Diameter of renal pelvis on ultrasound before - after surgery
Mean diameter of renal pelvis on ultrasound have been decreased at
1 month, and 12 months after surgery (p <0.001). In particular, the
plastic surgery group had a significant reduction from 40.41 mm to
16.43 mm after 1 month and 14.63 mm after 12 months. The nonplastic group decreased from 29.17 mm to 13.23 mm after 1 month
and 11.38 mm after 12 months.

Figure 3.8. The level of renal dilatation on ultrasound before – after surgery
The rate of patients with grade 3 and 4 renal dilatation significant
decreased after 1 months of surgery in both groups
After 12 months, the rate of patients with good outcomes based on
clinical and ultrasound criteria was 95%.
Logistic regression showed no significant associations between
surgery methods, cutting-off renal pelvis, baseline renal parenchyma,
origin of ureter comes from the renal pelvis, and artery abnormalities
and surgery outcomes
3.3. The role of 64-slides in the dignoses of UJPO
Comparison of renal pelvis diameter on CT scan and intraoperative
evaluation, the results showed a high agreement of the two


15
measurements with kappa coefficient=0.93 (p <0.001). The sensitivity
was 97.2% and the specificity was 96.2%.
Comparison of the origin of ureter from the renal pelvis on CT scan
and assessment during surgery showed a high agreement of the two
measurements with a kappa coefficient=0.82 (p <0.001). The sensitivity
and specificity of CT 64-slides were 85.71% and 95.83%, respectively.
Comparison of abnormal arteries on CT scans and intraoperative
evaluation showed a high agreement of the two measurements with a
kappa coefficien=0.81 (p <0.001). The sensitivity and specificity of CT
64-slides were 80% and 97.62% respectively.

(a)

(b)

Figure 3.4. CT scan image and in-surgery image of artery abnormalities
a: CT scan image; b: In-surgery image
(Source: Patient Đặng Hồng C., born 1961, ID N39-722)
CHAPTER 4: DISCUSSION
4.1. GENERAL CHARACTERISTICS OF STUDY PATIENTS

- Age: In our study, the mean age of patients was 29.1. In particular, the
majority were young people from 18 to <30 years old and , middle aged
from 30 to <40 years old. Our research results are also consistent with
the results of other domestic and international studies.
- Gender: In our study, men are the majority (61.29%) with a male /
female ratio was about 1.5:1. Other studies on adults show similar
results. Truong Thanh Tung et al showed that the male/Female ratio was
1.5:1. Another study by Nguyen Duc Duy also reported a similar ratio
with a male to female ratio of was 1.15
- Clinical symptoms: The common symptom of hospitalization in our
study is low back pain (91.94%), meanwhile, hematuria symptoms are
very low with only 3.23%. The rate of accidental finding was 4.84%.
This result is also consistent with the results of other studies. Thus, it
can be seen that the clinical symptoms of UJPO in adults are nonspecific and may be confused with many other urinary tract diseases.
On the other hand, some patients do not have suspicious symptoms but
are only detected through periodic health examinations; this results
showed that the characteristics of the disease can be slow and dull. Our
results suggest that regular health checkups should be recommended


16
regularly for early detection and treatment.
- Characteristics of imaging diagnoses
+ Ultrasound: In our study, 100% of patients had preoperative

ultrasound. Mean diameter of renal pelvis was 36.2 ± 14.1 mm. The
results of our study showed a agreement with several studies that have
been done. Although the anterior diameter of the renal pelvis recorded
in the study was very high, most patients did not show significant
clinical symptoms and renal failured. Perhaps because of the slow
progression of the disease, it used to be diagnosed late and is often
overlooked.
+ 64-slides CT: In our study, 100% of patients were performed 64slides CT scan. Similar to the results of ultrasound, CT scan results also
showed that 100% of patients detected hydronephrosis at different
levels from 1 to 4. This result was consistent with the rate of stasis on
ultrasound.
In addtion, 64-slides CT scan also detected 32.3% of patients with
abnormal arteries. This is also consistent with the proportion of patients
with UJPO caused by vascular abnormalities is 29% - 65%.
According to the results in Table 3.9, the proportion of patients with
high origin of ureter comes from the renal pelvis (24.2%); obtuse angle
of ureteral - renal pelvis (77.4%); poor circulation (41.9%) and 4.8% of
patients were accompanied by kidney stones. These are very important
information in preoperative diagnosis because it help the surgeon to
determine the most appropriate surgical method, access path of surgery
and plastic technique for each specific case.
4.2. THE ROLE OF 64-SLIDES CT IN THE DIAGNOSES OF UJPO

In order to evaluate the role of 64-slides CT scans, we conducted a
study on 62 patients. These patients were performed 64-slides CT
before surgery, and compared with some characteristics observed during
surgery, evaluate the treatment outcomes based on improvement of
some indicators before - after treatment.
Our study is the first in Vietnam to assess the role of CT scans in the
diagnosis of UJPO as well as to calculate the sensitivity and specificity

of this method in pre-surgical assessment compared with image during
surgical.
In this study, comparison of abnormal artery between CT and in-surgery
assessment, the results showed a agreement of 91.94% and Kappa
coefficient was 0.8079 (p <0.001) with the sensitivity and specificity of
80% and 97, 62%, respectively.
Our results are also showed the similar with the results from other
studies around the world. Rouviere et al. conducted a comparative study


17
between conventional angiography and multidisciplinary angiography and
determined sensitivity and specificity up to 100% and 96.6% for
identifying abnormal blood vessel. In another comparative study between
spiral CT and intraoperative evaluation, Khaira et al reported a positive
prediction with a sensitivity of 100% and a specificity of 91%. According
to a Rabah et al study, CT helps diagnose variations of the renal tubular
blood vessels with an accuracy of 85 - 100%, detecting abnormal blood
vessels at the junction with an accuracy of 83.3%. According to research of
Keeley et al, multi-slides CT scan helps detect abnormal blood vessels with
sensitivity 91-100% and specificity 97-100%. The results of Madan et al
(2017) showed that positive predictive value of UJPT due to vascular
abnormalities on CT was 95.5%.
The sensitivity of CT in detecting the cause of the obstruction was
determined to be 100%, much higher than 74% of X-ray in patients with
UJPO. In our study, compared the evaluation on computerized
tomography with the assessment in surgery, the sensitivity and
specificity of CT is over 85%. In the Braun study, multi-slidews CT
detected 44% of patients with vascular abnormalities. When compared
with this result in laparoscopy and open surgery, the results were

similar, only 1 patient was unclear due to many causes leading to UJPO
in that patient.
We all know, UJPO may be due to internal or external causes. In the
pediatric patient group, endocrine urinary abnormalities due to
excessive collagen deposition are arguably the most important cause for
the diseases. In adults, indirect causes, includes infections, kidney
stones - ureters, surgery complications, ischemia or trauma of blood
vessels of renal pelvis. Cancian et al (2017) showed the differences in
the pathogenesis mechanism of UJPO in 2 groups with and without
vascular abnormalities. The conclusion was that UJPO in patients with
vascular abnormalities is a progressive process, silently and chronicly,
this explains why UJPO patients with vascular abnormalities often
showed clinically manifest when they were at high age. In all cases,
although specific causes can be identified, the most important thing is to
determine the presence of abnormal blood vessels before performing
laparoscopic surgery due to the risk of bleeding and vascular
complications. Thus, in this context, a modern diagnostic tool with high
sensitivity and specificity in detecting vascular abnormalities such as
multidisciplinary CT is very valuable.
In our study when comparing the diameter of renal pelvis on CT scan
images and assessment in surgery, the results showed that the agreement
rate was 96.78%, Kappa coefficient = 0.9338 with p <0.001. Sensitivity


18
and specificity are 97.2% and 96.2%, respectively. Computerized
tomography also has high sensitivity and specificity in the position and
angle diagnosis of UJPO (> 80%).
It is also important to evaluate the kidney function and improvement
of circulation after surgery. In the past, radioisotope imaging was one of

the important imaging methods that helped to evaluate these functions.
However, this method has a high cost and risks of radiation exposure. In
addition, based on the size of the renal parenchyma during CT scan, it is
possible to assess renal function. Therefore, we rely on the
improvement of renal pelvis diameter, renal parenchyma thickness,
level of hydronephrosis, and ureters circulation before and after surgery
as part of monitoring to evaluate surgery outcomes. Results showed that
the above indicators have been significant improved after 3 months of
surgery. The use of multi-slides CT to assess the outcomes of treatment
has also been used by many authors around the world. According to
research results of Mitsui et al (2018): there is a close relationship in
predicting renal function based on kidney CT scans at 1, 3 , 12 months
after surgery (r-value are 0.806; 0.592 and 0.764, respectively; p
<0.001). Authors conclude: it is possible to use CT to replace MAG3
radiographic isotopes in evaluating and predicting renal function after
surgery. This method is low cost, reducing the risk of radiation
exposure. Jacob T et al (2016) showed a similar results in the
assessment of renal function when using radioisotopes and CT scans (r
= 0.9, p <0.0001) and concluded that it is possible that CT could be
replaced radioactive isotope imaging in evaluating renal function in
patients with UJPO. The author believed that for patients with normal
renal function, renal scan is not really valuable. In these cases, the use
of renal radiography is not necessary because it increases the cost of
treatment, prolongs treatment time and increases the risk of radiation
exposure for patients. Yuanshan et al. used CT scans to evaluate the
effectiveness of surgery for UJPO by assessing renal morphology (renal
fluid retention). The study showed that the retention of kidney fluid was
improved after 3 and 12 months of surgery.
Thus, our research results are also consistent with the findings of the
authors in the world in assessing the role of multidisciplinary computed

tomography in UJPO. Multidisciplinary CT method plays an important
role in pre-surgical evaluation in patients with UJPO, provides
important images including the presence and location of blood vessels,
and shows the details of anatomical of the renal pelvis. All contribute to
the process of planning and selecting appropriate surgical and treatment
methods for patients. Recently, multidisciplinary CT has been also


19
applied in clinical practice to help monitor and evaluate after surgery
and has been widely used by many authors around the world as a
criterion to evaluate the effectiveness of surgery. Besides the values
mentioned above, CT is also easy to assessed with a lower cost than
other modern imaging devices. More research is needed to evaluate the
effectiveness of multi-slides CT compared with other modern imaging
techniques in Vietnam in order to recommend the use of this technique
in lower level hospitals.
4.3. TREATMENT OUTCOMES OF RETROPERITONEAL
LAPAROSCOPIC SURGERY

4.3.1. General characteristics
In our study, 63% (39/62) patients underwent plastic surgery. The
remaining of 37% (23/62) had non-plastic surgery. In particular, the
method of ureteral displacement accounted for the highest proportion
with 19%, followed by adhesion with 16% and 2% of patients with
genital of abnormal vein surgery.
The common disadvantage of non-plastic techniques is that it is not
possible to cut pathological junctions as well as not able to displace
renal pelvis in case of extreme blood vessels under pinched junction.
One difficulty in applying plastic cutting techniques is the problem of

suturing in the body, especially the retroperitoneal cavity, causing
fatigue for the surgeon and extending the operation time compared to
non-plastic techniques.
In Vietnam, most medical facilities, especially at national level
hospitals, surgeons can perform regular laparoscopic surgery that
requires a lot of stitches such as removed ureteral stones on the back or
pyelonephritis. Therefore, the stitching in the body is no longer too
difficult and should be considered when choosing the technique of the
junction reconstruction in endoscopic surgery to treat patients.
The second group of patients in our study consisted of patients with
external causes of UJPO, without intrinsic stenosis. It is important to
identify the exact the cause of the UJPO, because at that time we only
eliminated these external causes and not interfered with the junction
(not reconstruct). Research has demonstrated that this group of patients
significantly improved the time of surgery, the duration of recovery
after surgery but the surgical results were still guaranteed.
The role of Lasix test
After opening the renal pelvis, most of patients had clearly visible of
the renal pelvis and ureter, the upper renal pelvis was enlarged
adequately on CT scan and/or the ureter had a high origin from the renal
pelvis. These patients were cut and reconstructed immediately without


20
using Lasix test. But in fact, there are patients after surgery to release
ureter pyelonephritis, renal pelvis does not dilate clearly and ureter
comes normally from the renal pelvis, after the release of renal pelvis,
abnormal ureters of small blood vessels or fibrosis organization after
surgery, the renal pelvis morphology remained unchanged or changed
very little. In the first time, we thought that the cause was due to

external causes and not performed plastic surgery, but when they were
examined again after surgery, some patients had to have JJ's catheter
reinstalled soon after surgery or had addition surgery for reconstrucing
the renal pelvis. From there, we think that there must be some other
major cause of obstruction, in particular, the cause from the inside of
renal pelvis wall, and not merely an external cause. So if there is a
cause from external then why the renal pelvis does not stretch. This
could be explained vy all patients with UJPO are incompletely
obstruction, they still have urine circulation to the ureters but the speed
is slow and the flow is small compared to normal, but the level of
obstruction was depended on each differene cases, patients whose had
enlarged stretch of renal pelvis after the surgery is usually due to the
very obstructing and there is no debate about the issue of perform
plastic or non-plastic methods or not.
The remaining patients, due to the less level of obstruction, better
circulation, so with normal urine flow, their condition is not clearly
expressed. There are also patients who are completely obstruction due
to external causes of ureteropelvic junction obstruction. We use Lasix
20mg intravenously for these cases in combination with fast infusion of
0.9% natriclorite, waiting for an average of 15 minutes (8-30). After
injection Lasix, we observed the enlargement of renal pelvis very
clearly. After identifying the obstruction position, we decided to cut and
reconstruct the renal pelvis. Patients with abnormal lower arteries, we
release to eliminate the effects of abnormal lower arteries and inject
Lasix. After waiting for 15-30 minutes, the renal pelvis morphology did
not change, the flow of urine was good. We decided to move the ureters
without reconstructing the renal pelvis junction. The case due to other
external causes if Lasix test is negative, we did not conduct plastic
methods. These cases show good results again.
Thus the role of Lasix in these cases is necessary. In addition, lasix test

also identified obstruction cases due to external causes that are not required
plastic method, which helped significantly shorten the surgery time.
4.3.2. In-surgery assessment
4.3.2.1. In-surgery:
• Cutting-off renal pelvis while reconstructing the junction


21
In our study, the proportion of patients with renal pelvis dilatation
was 33.87%. When analyzing the surgical factors associated with the
surgical results, we found that there was no significant difference in the
surgical results between patients with or without cutting-off of renal
pelvis (p> 0.05).
• The amount of blood lost during surgery: Our research results
showed that the amount of blood lost was 31.02 ± 17.78 ml; range d
from 0 to 100ml. Our results are not different with some other
studies. However, there are also studies that show lower results, and
there are also studies that show higher blood loss. The reason for the
above differences is partly due to the different characteristics of the
study subjects and the method of calculating the amount of blood
lost in surgery.
• Surgical time: The mean surgery duration was 106.8 minutes. In
particular, the mean surgery time in the non-plastic group was 91.3
minutes, shorter than the plastic group (116.02 minutes) (p <0.05). This
shows that if we can identify the exact cause of the obstruction, the
duration of surgery can be shortened. According to the report of Ngo
Dai Hai el al, the mean operation time for was about 130 minutes. By
Calvet et al, the mean time for surgery was 159 minutes. Thus, on the
same adult subjects, and performing laparoscopic surgery method, our
surgery time is shorter than other studies. There are many factors that

influence this indicator. However, in our research, we found that two
main factors contributed to shortening our surgery time. The first is the
experience of the surgeon. As in the study of Singh O et al (2011), the
author followed 100 patients treated with laparoscopic surgery. These
100 patients were divided into 2 groups: group I consisted of 50 patients
who had their first surgery, 50 patients who were operated more than
one time called group II. Results showed that the mean surgery time in
group I was 190 minutes, which was higher than that in group II (142
minutes, p <0.005). The author has drawn a conclusion that the
experience of the surgeon will help reduce the time of surgery, reduce
the rate of complications and increase the success rate of surgery. The
retroperitoneal laparoscopy method has been applied by Viet Duc
hospital since 2007, so its experience has been a factor contributing to
shortening the surgery time. Secondly, we have applied lasix during
surgery to detect group of patients with external causes, so that no
interference with the junction will significantly improve the surgery
time. Therefore contributing to increasing the effectiveness of the
surgery, reducing risks of complications during the treatment.


22
• In-surgery complications: The rate of complications was low, only 1
patient had bleeding and 1 patient had peritoneal tear during surgery.
Our results are similar to other studies.
4.3.2.2. Short-term outcomes assessment
• Duration of hospital stay and postoperative: The mean
hospitalization time was 8.74 days (SD = 6.17). In which, the mean
time for postoperative was 4.74 days.
• Complications after surgery: The rate of patients having
complications after surgery was 11.30%. Of which, 3 patients had

urinary tract infections, 2 patients had urine leakage, 2 had wound
infections. The results are similar to other studies.
4.3.2.3. Long-term outcomes assessment after surgery
Until present, there has been no consensus on postoperative
evaluation. But overall evaluation criteria include clinical improvement,
improvement of circulation, reduction of renal fluid retention, and renal
function improvement. Each study relied on different criteria to evaluate
the above indicators. For example, Wang et al (2019) used ultrasound
and CT images to evaluate surgery success. Zhang et al (2019) used the
improvement of renal hydronephrosis on ultrasound to evaluate the
effectiveness of treatment. Yuanshan et al used CT scans to evaluate the
effectiveness by assessing renal morphology (renal fluid retention).
Hamedanchi et al (2020) used doppler ultrasound to monitor postsurgery outcomes.
In this study, due to the conditions of the patients, the available of
hospital’s equipments, as well as the research team's judgment, the
implementation of preclinical indications before and after surgery is not
adequate. This makes it difficult to establish a surgical outcome
evaluation standard for all 62 cases. However, we agree with other
authors on criteria for evaluating the results of surgery, especially with
Tc-MAG3, which is still the best technique of postoperative evaluation
for junction stenosis. However, due to the risks of radiation exposure,
high costs and long implementation time, the indication for all patients
before and after the surgery is very difficult, especially in lower level
hospital. Therefore, we set criteria for evaluating surgical results of this
study based on clinical, ultrasound and 64-slides CT as mentioned in
section 2.3.3.
The overall success rate in our study is 96.77%. This result shows
the similarity with most retroperitoneal laparoscopic surgery studies on
patients with UJPO conducted in Vietnam and around the world. Across
the world, successful rate in the studies of Meng Q, Kumar, Yang and

23
Martina showed the succesful rate ranged from 96.6% to 98%. In
Vietnam, Ngo Dai Hai et al reported that the treatment results for 100
cases of UJPO have similar successful rate as open surgery (good
results were account for 87%), but shorten the hospital stay and have
highly aesthetic.
Thus, the effectiveness of retroperitoneal laparoscopic surgery for
treatment of UJPO in our research is also consistent with other results
around the world. In a meta-analysis evaluated the surgery outcomes in
patients with UJPO with vascular abnormalities, the results showed that
retroperitoneal laparoscopic surgery plays a special role in the treatment
of UJPO because of it’s high rate of successful that not significant
difference with the gold standard of previous open surgery.
CONCLUSION
We conducted a study on 62 patients with UJPO under treatment by
retroperitoneal laparoscopic surgery at the Department of Urology
Surgery at Viet Duc University Hospital from May 2012 to October
2017, we concluded as followed:
1. 64-slides CT scan with renal vascular investigation plays an
important role in pre-surgical evaluation in patients with UJPO
- 64-slides computed tomography has the high diagnostic value to
determine the pathology of the UJPO: all patients were performed CT
before surgery with the rate of 100% of patients with renal fluid
retention, of which, 29% was at level 3 and 25.8% was level 4.
- There was 34.3% (20/62) of patients had abnormal lower artery
appearance. Comparison of abnormal arteries on CT scan and
intraoperative evaluation, the results showed a high agreement of the
two measurements with a kappa coefficient = 0.81 (p <0.001). The

sensitivity and specificity of CT 64 series are 80% and 97.62%
respectively.
- Comparison of renal pelvis diameter, origin of ureter from the renal
pelvis, the agreement of the two measurements was high with kappa
coefficient > 0.7 in both criteria (p <0.001) . Sensitivity and specificity
were 80% or more.
- In addition, CT scan also added a value in the assessment of the
function of pathological kidneys with 41.9% (26/62 patients) patients
with poor ureter circulation.