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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: Associated Professor Vu Nguyen Khai Ca, PhD 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 INTRODUCTION 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: Assessed the role of 64-slides CT 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 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 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 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 Thesis structure The thesis consists of 117 pages, including parts and chapters: 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, pages of conclusion and 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 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 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 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 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 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 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, 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 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 - 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 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 + 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 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 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 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 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 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 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