Anderson-Hines Open Pyeloplasty in the Treatment of Pyelo-Ureteral Junction Syndrome: Results from 36 Cases

Goal: To evaluate the results and complications of open pyeloplasty according to Anderson-Hynestechnic. Patients and Methods: We conducted a retrospective study from 2000 to 2014. The study included 36 cases of opening the ureteropyelic junction operated pit syndrome according to Ander-son-Hynes technique. Results: Lumbotomy was used in all patients. A pelvic pyelolithotomy for lithiasis was performed in two patients (5.5%) and un-winding of a lower polar pedicle in 3 cases (8.3%). The average duration of response was 119 ± 15 min. The average length of hospital stay was 11.2 ± 3 days. Patients were followed for a mean of 10 months. Thirty-five patients were asymptomatic and in one case lower back pain persisted. IVU to 6 months showed a permeable junction in 97.2% of cases. Seven patients (19.4%) had short-term complications. Ureteropelvic stenosis was the only complication in the medium and long term in one case (2.8%). The success rate of the Pyeloplasty was 97.2%. Conclusion: The open pyeloplasty as An-derson-Hynes remains the treatment of choice in our context SJPU with great results. The indications tend to decrease in favor of laparoscopic pyeloplasty.


Introduction
The syndrome of pyelo-ureteral junction (SJPU) or hydronephrosis is the most frequent malformations of the urinary tract system. The incidence of congenital hydronephrosis is about 5 per 100,000 births [1]. SJPU corresponds to a dilation of the pyelocalicielles cavities upstream of an obstacle situated at the level of the pyelo-ureteral junction [2]. The etiology is often congenital. It is either an aperistaltic junction segment, or aberrant vessels or a high insertion ureter [1] [3].
The standard treatment for SJPU remains open pyeloplasty according to the Anderson-Hynes technique [4]. This technique has a success rate greater than 90% [1] [3].
Nowadays, the management of SJPU is marked by the development of so-called mini-invasive techniques which are laparoscopic pyeloplasty and endopyelotomies.
In Congo, an earlier study on the diagnosis and treatment of pyelo-ureteral junction syndrome in 13 cases was published in 2004 by Bouya, et al. [5]. Our work proposed to study the Anderson-Hynestechnic [4] in order to evaluate the results obtained and the short, medium and long term complications.

Framework and Methods of Study
This was a retrospective study on the medical records of patients operated for an anomaly of the pyeloureteral junction, in the urology-andrology department of University Hospital, Brazzaville, from 2000 to 2014. Diagnostic of pyelo-ureteral junction syndrome was based on ultrasonography, urography and tomography result.
We included in the study any patient with pyelo-ureteral junction syndrome, operated by Anderson-Hynes [4] open pyeloplasty, who had a complete medical record. Operated patients whose records were incomplete were not included. We classified hydronephrosis into 4 types as proposed by CendrenMoulard and Valeyer. Type1: localized dilatation with pelvis; Type 2: dilation of the pelvis and calices, but rapid impregnation of the cavities and good thickness of the parenchyma; Type 3: Large pelvic-calyx dilation with a fuzzy and incomplete image within normal delays, very clear thinning of the cortex; Type 4: silent kidney [6].
In total, 36 files were the subject of this study.
The variables studied were: whether preoperative nephrostomy was performed, the approach used for pyeloplasty, intraoperative exploration, associated procedures, intraoperative drainage (transnephro-anastomotic or transpyelo-anastomotic drain), intraoperative incidents, duration of interventions, average duration of drains and bladder catheter, average length of hospital stay, short-term complications, medium and long-term complications, follow-up (clinical intravenous urography and tomograhy) after average of 12 months.
After the discharge of the service, the patients were reviewed at 1 month for a clinical control. During this check, the presence of residual pain and the condition of the wound was assessed. At three months, clinical and ultrasound control was performed. At 6 months, antomograhy was performed to assess the permeability of the anastomosis and ureter. Clinical and ultrasound control was per-

Characteristics of the Population
During the study period, 36 patients met our inclusion criteria. The average age of our patients was 29.4 years, extreme (7 and 53 years). There was male predominance in 63.9% (23 cases) with a 2/1 sex ratio. The patients came from Brazzaville in the majority of cases (32 cases) Pointe-Noire (3 cases) and Kinkala (1 case).
Clinically, the circumstances of discovery were multiple. Flank or lumbar pain was the most common form of discovery (28 cases). The other circumstances were repeated urinary tract infection (5 cases), hematuria (2 cases) and abdominal mass (1 case).
Physical examination was normal in 29 cases. He had noted a large kidney in 1 case; a sensitivity of the lumbar fossa in 6 cases.
Paraclinically, cytobacteriological examination of urine (ECBU) was performed in all patients. It had allowed isolating a germ in 6 cases. It was an Escherichia coli (4 cases) and Klebsiella pneumoniae (2 cases). These urinary tract infections had been treated by antibiotic therapy in relation to the results of the antibiogram. This examination is performed systematically in all our patients preoperatively to sterilize the urine before any intervention.

Results
Preoperative nephrostomy was performed in 11 patients. The surgical approach was the lombotomy in the 11th intercostal space in all cases. Intraoperative exploration revealed pyelo-ureteral junction stenosis in all cases, peripelitis in two patients (5.5%) with pyeliclithiasis. In three patients (8.3%), there was evidence of an inferior polar vessel crossing the pyelo-ureteral junction.
Resection of the pyelo-ureteric junction, sometimes associated with remodeling of the renal pelvis, followed by pyelo-ureteral anastomosis using the Anderson Hynes technique. The pyelo-ureteral anastomosis was made by two suture contin. The suture material used was vicryl® Absorbable Yarn 4/0.
Two patients (5.5%) underwent pyelolithotomy for pyeliclithiasis associated with the treatment of pyelo-ureteral junction syndrome.
Three patients (8.3%) had an aberrant lower polar vessel decay ( Figure 1) associated with treatment.
The drainage was transpyeloanastomotic in 56% of the cases, transurethral in 17% of the cases, and in 28% of the cases, it did not have drainage. The drainage of the renal lodge by a Redon drain was systematic in all cases (36 cases).
In the short term, seven patients had complications. It was a parietal suppuration in 3 cases, treated by antibiotic adapted to the isolated germ, and a urinary leakage by the operative wound in 4 cases supported by drainage of the urine.
In the medium and long term, one patient (2.8%) had pyelo-ureteral stenosis.
The success rate of pyeloplasty was 97.2% (n = 35).    Diao et al. [7] performed lombotomy in 83.4% of cases. It has the advantage of combining a good exposure on the pyelo-ureteral junction, to allow an excellent section of the pelvis and to realize an impervious anastomosis [3]. However, it has the disadvantage of causing non-esthetic scars, causing significant postoperative pain and causing parietal weakness and evenenation [2] [8] [9]. To avoid these complications of lombotomy, other minimally invasive surgical techniques have been developed (laparoscopy, endopyelotomy) giving functional results comparable to open surgery [10] [11] [12]. In our study, two patients (5.56%) underwent pyelotithomy with pyeloplasty for pyelic computation. Bentani et al. [13] found a renal calculus associated with SJPU in 17.8% of cases.
We have considered the pyelo-ureteral junction syndrome as the factor favoring the occurrence of pyelic calculus. However, several authors believe that the stasis of urine alone is not enough to explain the occurrence of lithiasis: the urinary metabolic factors (hypercalciuria) of lithogenesis are necessarily associated [14]. In addition, in three patients (8.3%), there was evidence of an inferior polar vessel crossing the pyelo-ureteral junction. These patients had undergone a decrease in the inferior polar vessel associated with pyeloplasty. These results are comparable to those observed by Kirakoya et al. [15], who found rates of 11.4%.
These vessels have been demonstrated in 30% to 70% of cases of pyelouretral junction syndrome [16]. The implementation of transpyelo-ureteral drainage associated with drainage of the renal lodge is recommended [3], but there is no consensus regarding drainage. Excretory drainage seems to be an immediate safety factor, limiting the risk of fistula and urinoma. It does not affect the long-term prognosis and the occurrence of recurrence. In our study, one case of peritoneal breccia and 1 case (2.78%) of pleural breccia were observed. The peritoneal gap had been treated peroperatively by suture. The pleural breccia had been repaired immediately. The frontal chest x-ray performed on day 1 postoperative had not revealed a pneumothorax. These incidents are also reported in the literature in similar proportions [7]. The haemorrhagic incidents have been described [16].
The mean duration of the intervention in our study was 119 ± 15 min. This operating time is comparable to those reported in the literature (90 -120 min) [1] [3] [7]. The operative time in open surgery is generally lower than that of laparoscopic pyeloplasty. This operating time in laparoscopic pyeloplasty varies from 180 to 480 min in the literature [1]. The mastery of laparoscopic techniques by the different teams has improved the operating time. Thus Bentani et al. in Morocco [13] find an average operative time of 175.5 min. Soulie et al. [18], in France, an average time of 150 min. The average hospital stay in our study was 11.2 days with extreme 7 -30 days. This stay is comparable to those reported in the literature: between 10

Conclusion
Anderson-Hynes open pyeloplasty remains the treatment of choice for SJPU in our context with excellent results. But its indications tend to decrease in favor of laparoscopic pyeloplasty, which reproduces the Anderson-Hynes technique with comparable functional results and less morbidity. Thus, the arrival of laparoscopic and endoscopic surgery in our therapeutic arsenal is necessary because it will contribute to the reduction of the length of hospitalization of patients.