Abstract
M
We happily accept the remarkable success rates (>95%) with RALP. Indeed, some propose that minimally invasive pyeloplasty should finally be anointed as the “standard” in treating ureteral pelvic junction obstructions (UPJO). 1 When we grow accustomed to such high success rates, we begin to focus on perfecting the subtleties of the procedure that may be unrelated to the ultimate surgical outcome. In the case of RALP in the pediatric population, pain from urinary drainage and subjection to additional anesthesia for stent removal are the relevant secondary issues at hand. Although ureteral stent placement at the time of pyeloplasty is straightforward, it is not without problems. It is clear that if an indwelling stent is not used in children undergoing pyeloplasty, quality of life is better and there is a cost advantage. 2
Use of the CPU stent is not a technological breakthrough but rather a creative deduction from endourologic principles applied to RALP at the appropriate time. Percutaneous placement of an indwelling stent through an angiocatheter at the time of RALP was described in 2009 and 2011. 3,4 Use of pyeloureteral stents at the time of reconstruction have been an option for quite some time; the cost and anesthetic benefits of using it for an open pyeloplasty were reported in 2008. 5
Use of a CPU stent during RALP has great appeal. This preliminary report on 22 patients demonstrates an efficient technique (requiring 5–10 minutes operating room time) that might result in fewer lower urinary tract symptoms (LUTS). One obvious advantage of this technique is the ability to remove the stent in the outpatient setting without an additional anesthetic. However, it would be premature to say that use of a CPU stent over a standard indwelling stent during RALP is a superior modality of urinary diversion.
The widespread use and popularity of RALP affords us the opportunity to study urinary diversion choices in a comparative fashion. A comparative study that demonstrates superiority of CPU stenting over indwelling ureteral stenting using standard pain scales (observed and reported by parents) and medication use (i.e., oral narcotics and anticholinergics) may provide us with more conclusive evidence. For now we can consider using a CPU stent when performing a RALP for patients in whom we would like to avoid an additional general anesthetic for stent removal or who may be more likely to struggle with LUTS (i.e., patients who have required anticholinergics from previous stent placements). It is always nice to have options.