Adult endopyelotomy: impact of etiology and antegrade versus retrograde approach on outcome

Percutaneous management of ureteropelvic junction obstruction

PURPOSE OF REVIEW

The development of endoscopic and minimally invasive techniques has revolutionized the treatment of ureteropelvic junction obstruction (UPJO). Patients can now undergo successful UPJO repair without the morbidity and complications associated with open surgery. Laparoscopic and robotic repair has supplanted open surgery as the gold standard, but percutaneous endoscopic treatment remains a relevant alternative to more invasive surgery. This review will focus on the percutaneous approach for the treatment of UPJO.

RECENT FINDINGS

Percutaneous endopyelotomy was popularized during the 1980 s due to advances in the field of endourology, allowing for well tolerated and reliable percutaneous access to the kidney. After percutaneous access to the kidney is achieved, the narrowed ureter at the UPJ is incised in a full thickness fashion in the posterolateral position from the ureteral lumen to the periureteral fat. Success rates for this procedure are nearly 90% at high-volume centres. The ideal patient who has success with percutaneous endopyelotomy has a short segment of narrowing less than 2 cm, no crossing vessel, good ipsilateral renal function and mild hydronephrosis.

SUMMARY

Although the development of laparoscopic and robotic approaches to pyeloplasty has produced outcomes that surpass those of percutaneous endopyelotomy, it remains a viable option in the appropriately selected patient, but success rates tend to decrease with longer follow up.

The Comparative Effectiveness of Treatments for Ureteropelvic Junction Obstruction

OBJECTIVE

To examine the effectiveness of the 3 primary treatments for ureteropelvic junction obstruction (ie, open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy) as assessed by failure rates.

MATERIALS AND METHODS

Using MarketScan data, we identified adults (ages 18-64 years) who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was failure (ie, need for a secondary procedure). We fit a Cox proportional hazards model to examine the effects of different patient, regional, and provider characteristics on treatment failure. We then implemented a survival analysis framework to examine the failure-free probability for each treatment.

RESULTS

We identified 1125 minimally invasive pyeloplasties, 775 open pyeloplasties, and 1315 endopyelotomies with failure rates of 7%, 9%, and 15%, respectively. Compared with endopyelotomy, minimally invasive pyeloplasty was associated with a lower risk of treatment failure (adjusted hazards ratio [aHR] 0.52; 95% confidence interval [CI], 0.39-0.69). Minimally invasive and open pyeloplasties had similar failure rates. Compared with open pyeloplasty, endopyelotomy was associated with a higher risk of treatment failure (aHR 1.78; 95% CI, 1.33-2.37). The average length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P <.001).

CONCLUSION

Endopyelotomy has the highest failure rate, yet it remains a common treatment for ureteropelvic junction obstruction. Future research should examine to what extent patients and physicians are driving the use of endopyelotomy.

Endoscopic Removal of a Nitinol Mesh Stent from the Ureteropelvic Junction after 15 Years

We report a rare case of a patient with a large stone encrusted on a nitinol mesh stent in the ureteropelvic junction. The stent was inserted in the year 2000 after failure of two pyeloplasty procedures performed due to symptomatic ureteropelvic junction stenosis. By combining minimally invasive urinary stone therapies-extracorporeal shock wave lithotripsy, semirigid ureterorenoscopy with laser lithotripsy, and percutaneous nephrolithotomy-it was possible to completely remove the encrusted stone and nitinol mesh stent that was implanted for 15 years, rendering the patient symptom and obstruction free.

Ureteropelvic obstruction and renal stones: etiology and treatment

The simultaneous surgical management of ureteropelvic junction obstruction (UPJO) with concomitant renal stones has evolved the last 20 years; hence, the ideal minimally invasive technique is still controversial. Laparoscopic and robot-assisted laparoscopic operations allow precise surgical maneuvers and were thought to simplify the reconstruction steps of the procedure, especially in the treatment of complex cases with large stones. The aim of this study was to summarize the available perioperative and functional outcomes of minimally invasive available techniques. A non-systematic review of the literature was performed using a free-text protocol in the MEDLINE database. The terms used were "ureteropelvic junction obstruction," "renal calculi" and "renal stones." Furthermore, other significant relevant studies cited in the reference lists of the selected papers were also evaluated in the structure of this review. Currently, available evidence suggests that both laparoscopic and robotic-assisted techniques offer excellent surgical solutions in the field of UPJO reconstruction and renal stones removal. In the hands of experienced surgeons, laparoscopic and robotic pyeloplasty with concomitant stone removal is a safe procedure with high stone-free rates and UPJ patency. Minimally invasive pyeloplasty should constitute the first choice of treatment for concomitant renal stones and ureteropelvic junction obstruction.

Transperitoneal mini-laparoscopic pyeloplasty and concomitant ureteroscopy-assisted pyelolithotomy for ureteropelvic junction obstruction complicated by renal caliceal stones

OBJECTIVE

To present our experience of combining transperitoneal mini-laparoscopic pyeloplasty (mini-LP) and concomitant ureteroscopy-assisted pyelolithotomy (U-P) for ureteropelvic junction obstruction (UPJO) complicated by renal caliceal stones in the same session.

METHODS

Between May 2007 and December 2011, mini-LP and concomitant U-P was performed in nine patients with UPJO and ipsilateral renal caliceal stones. Stone location and burden were preoperatively assessed. After pyelotomy with appropriate length (about 4 mm), a 16-Fr catheter sheath replaced the uppermost or lowermost laparoscopic trocar and was introduced directly into the renal pelvis under the guidance of a guide wire and laparoscopic vision. A 7.5F rigid ureteroscopy passed through the catheter sheath into the plevis. Intracorporeal lithotripsy and/or pressure irrigation via a pump was used for caliceal stone removal. Subsequently, laparoscopic pyeloplasty was performed in a standard fashion. Postoperative imaging was assessed.

RESULTS

The calculi sizes ranged from 2 to 11 mm (mean, 7.1 mm) and an average of 3 stones per patient was removed (range, 1 to 6 stones). Complete stone clearance confirmed by postoperative imaging was achieved in all patients. Mean operative time was 210 minutes, and estimated blood loss was 20 mL. Mean hospital stay was 5 days (4-7). Stent was removed after 4-8 weeks. No intraoperative or postoperative complications were noted during a mean follow-up of 18.5 months (range, 6 to 24 months).

CONCLUSIONS

Mini-LP and concomitant U-P are simple and effective alternatives for the simultaneous management of UPJO complicated by coexisting ipsilateral renal caliceal stones.

Transperitoneal laparoscopic dismembered pyeloplasty in unusual circumstances--is the outcome comparable to that achieved in familiar pathologies?

OBJECTIVE

To compare the operative outcome, morbidity profile, and functional outcome after transperitoneal laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction in unusual circumstances (intrinsic pathology in anomalous kidneys or unusual extrinsic pathologies; group 1) to the outcome after this procedure in familiar pathologies (normally located kidneys with intrinsic dysfunctional segment or extrinsic compression due to a crossing vessel; group 2).

METHODS

The patients were evaluated in detail. All patients underwent transperitoneal laparoscopic dismembered pyeloplasty. The operative and postoperative parameters were recorded. Patients were followed up after the procedure on a 3-month protocol. Imaging was repeated at 1 year. No intervention during the follow-up period (ie, nephrostomy, ureteral stenting, or redo pyeloplasty) and improvement in the hydronephrosis grade and diuretic renogram parameters was interpreted as procedural success. The operative, postoperative, and follow-up parameters in the 2 groups were compared.

RESULTS

Group 1 included 17 patients with intrinsic pathologic features and renal anomalies with ureteropelvic junction obstruction due to unusual extrinsic pathology. All procedures were successfully completed with the laparoscopic approach. A significant difference was noted in the mean operative duration (group 1, 196.9 ± 10.3 minutes; group 2, 125.44 minutes, P = .00). The other operative and postoperative parameters were comparable. No significant operative or postoperative events were noted. A total of 14 patients (group 1) completed the 1-year follow-up protocol. The success rate was 92.9% (13 of 14) in group 1 and 97.9% (44 of 45) in group 2 (P = .42).

CONCLUSION

The procedural duration for laparoscopic dismembered pyeloplasty in unusual circumstances is longer than in familiar pathologies. However, the morbidity profile and functional outcome in these 2 scenarios were comparable.

Percutaneous nephroscopic surgery

With the development of techniques for percutaneous access and equipment to disintegrate calculi, percutaneous nephroscopic surgery is currently used by many urologists and is the procedure of choice for the removal of large renal calculi and the management of diverticula, intrarenal strictures, and urothelial cancer. Although it is more invasive than shock wave lithotripsy and retrograde ureteroscopic surgery, percutaneous nephroscopic surgery has been successfully performed with high efficiency and low morbidity in difficult renal anatomies and patient conditions. These advantages of minimal invasiveness were rapidly perceived and applied to the management of ureteropelvic junction obstruction, calyceal diverticulum, infundibular stenosis, and urothelial cancer. The basic principle of endopyelotomy is a full-thickness incision of the narrow segment followed by prolonged stenting and drainage to allow regeneration of an adequate caliber ureter. The preferred technique for a calyceal diverticulum continues to be debated. Excellent long-term success has been reported with percutaneous, ureteroscopic, and laparoscopic techniques. Each approach is based on the location and size of the diverticulum. So far, percutaneous ablation of the calyceal diverticulum is the most established minimally invasive technique. Infundibular stenosis is an acquired condition usually associated with inflammation or stones. Reported series of percutaneously treated infundibular stenosis are few. In contrast with a calyceal diverticulum, infundibular stenosis is a more difficult entity to treat with only a 50-76% success rate by percutaneous techniques. Currently, percutaneous nephroscopic resection of transitional cell carcinoma in the renal calyx can be applied in indicated cases.

Percutaneous endopyelotomy for secondary ureteropelvic junction obstruction: Prognostic factors affecting late recurrence

OBJECTIVE

To determine prognostic variables which influence late recurrence after initially successful percutaneous endopyelotomy for secondary ureteropelvic junction obstruction (UPJO).

MATERIAL AND METHODS

Between July 1987 and March 2002, 67 patients with secondary UPJO were treated with percutaneous endopyelotomy at our center. Long-term follow-up data were available for 50 patients with initially successful results (42 after a single treatment and eight after repeated endopyelotomy). Follow-up excretory urography and diuretic renal scans were performed for objective evaluation. Late recurrence was diagnosed if obstruction developed after > 1 year of follow-up. Univariate (Kaplan-Meier method) and multivariate (Cox regression model) analyses of pre-, peri- and postoperative factors were carried out for detection of significant variables affecting the late recurrence rate.

RESULTS

The follow-up period ranged from 1.27 to 13.85 years (mean 6 +/- 4.3 years). Late recurrence of UPJO was observed in seven cases (14%): 4/42 initially successful cases (9.5%) and 3/8 cases of repeated endopyelotomy (37.5%). In univariate analysis, the significant factors were severity of stenosis at the UPJ (p = 0.04), preoperative serum creatinine (p = 0.04), repetition of endopyelotomy (p = 0.03) and development of postoperative complications (p = 0.02). In multivariate analysis, all of the above factors, with the exception of severity of stenosis at the UPJ, were independent significant factors affecting late recurrence.

CONCLUSIONS

As late recurrence was observed in 14% of cases after percutaneous endopyelotomy, long-term follow-up is needed, especially in patients with elevated preoperative serum creatinine, those in whom postoperative complications developed and those in whom a first attempt at endopyelotomy failed.

Lasers in percutaneous renal procedures

INTRODUCTION

Since the invention of lasers in 1960, they have been increasingly used in medicine. In this review paper, the types of lasers used in urology, in addition to their applications to percutaneous renal surgery will be reviewed. Specifically, use of lasers in the percutaneous management of renal stones, upper tract transitional cell carcinoma and stricture will be reviewed.

MATERIALS AND METHODS

Pubmed was searched for citations since 1966. The following terms were used: "lasers", "calculi", "endopyelotomy", and "transitional cell carcinoma".

RESULTS

Due to its minimal depth of penetration, holmium laser has proven to be safe and efficacious. It is currently the primary energy source for flexible instrumentation, and also has demonstrated efficacy in percutaneous lithotripsy (faster than ultrasonic lithotripsy and safer than electrohydraulic lithotripsy). Holmium laser been used for antegrade endopyelotomy and percutaneous resection of upper tract transitional cell carcinoma.

CONCLUSIONS

Holmium laser is safer than other lasers and has become the gold standard for laser lithotripsy for flexible instrumentation. It has been used successfully in the percutaneous management of renal stones, ureteropelvic junction obstruction, and upper tract transitional cell carcinoma. Holmium laser is an alternative energy source to conventional lithotripters and electrocautery for endopyelotomy and resection of upper tract transitional cell carcinoma.

Retrograde ureteroscopic holmium laser endopyelotomy in a selected population of patients with ureteropelvic junction obstruction

OBJECTIVE

Significant controversy remains concerning the best way to treat ureteropelvic junction obstruction (UPJO). This study evaluates subjective and objective outcomes of retrograde holmium laser endopyelotomy in a selected population with UPJO.

MATERIAL AND METHODS

Forty-seven patients with UPJO were referred to retrograde endopyelotomy between April 2004 and March 2007. Patients with a very large pelvis, a high insertion of the ureter, a renal split function below 20% or a long (>2 cm) stenosed ureteropelvic segment, and patients younger than 18 years were not selected for endopyelotomy, but subjected to laparoscopic pyeloplasty. Renal function was estimated on renal diuretic scan before and after surgery with a mean renographic follow-up of 35 weeks. Subjective results were based on questionnaires which were returned from 44 patients with primary (n=37) or secondary (n=7) obstruction (mean follow-up 110 weeks). Success criteria were defined as symptom relief and improved or preserved renal function.

RESULTS

Twenty-nine patients (66%) experienced complete symptom resolution and 10 patients (23%) had significant symptom improvement (i.e. no need for pain-killing medication). Five patients (11%) had unchanged symptoms. No difference in postoperative renal function was observed between these three groups of patients. The differences between preoperative and postoperative renal function were non-significant in each group. No major complications were observed. Five patients (11%) were referred to retreatment owing to unchanged symptoms.

CONCLUSION

Retrograde ureteroscopic endopyelotomy is a safe and effective treatment option in patients with primary and secondary UPJO when selected properly.

Treatment of ureteropelvic junction obstruction using a detachable inflatable stent: initial experience

OBJECTIVE

We describe a new method for treating ureteropelvic junction (UPJ) obstruction using a detachable inflatable stent positioned via a cystoscopic transvesicular approach.

CONCLUSION

Eleven patients with UPJ obstruction were treated using a detachable inflatable stent, 64% of whom experienced complete pain relief. In 82% of patients, no obstruction was seen on renograms obtained after the procedure. The initial results achieved in the treatment of UPJ obstruction with a detachable inflatable balloon are promising, but further research in a larger patient population is required.

Is Antegrade Endopyelotomy Really Less Invasive than Open Pyeloplasty?

OBJECTIVE

We investigated the invasiveness of antegrade endopyelotomy and open pyeloplasty in two consecutive series of patients with ureteropelvic junction obstruction.

PATIENTS AND METHODS

98 patients were treated by open pyeloplasty from 1980 to 1991, and 137 patients by antegrade endopyelotomy from 1991 to 1999. Diagnosis of ureteropelvic junction obstruction was made by excretory urogram and/or antegrade pyelography, diuretic renography and retrograde pyelography. Invasiveness was evaluated by the postoperative need for analgesics, the complication rate and the residual long-term symptoms after surgery.

RESULTS

The postoperative need for opiate analgesics was significantly higher in patients after open pyeloplasty than after antegrade endopyelotomy. Ten percent of the patients complained of problems with the lumbotomy scar after open pyeloplasty, which was not encountered after endopyelotomy. Complications after open pyeloplasty occurred in 24% and were more severe than the 11% seen after endopyelotomy. The primary success rate after open pyeloplasty was 98 and 89% after antegrade endopyelotomy. The long-term success rate, > or = 24 month postoperatively, was 96% (median follow-up 37 (24-196) months) and 76% (median follow-up 32 (24-73) months), respectively.

CONCLUSION

Open pyeloplasty and endopyelotomy both have a high success rate with better patency results after open pyeloplasty. Open pyeloplasty is more invasive and has a higher morbidity. Endopyelotomy is a minimally invasive procedure with faster recovery, fewer and minor complications, significantly less need for peri- and postoperative analgesics, less residual pain due to the access, and no functional and esthetic sequelae of lumbotomy.

Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results

OBJECTIVES

To analyse the indications and long-term results of endoscopic and minimal access approaches for the treatment of ureteropelvic junction (UPJ) obstruction and to compare them to open surgery.

METHODS

A review of the literature from 1950 to January 2007 was conducted using the Ovid Medline database.

RESULTS

A lack of standardisation of techniques used to diagnose UPJ obstruction and to follow up treated patients introduces a degree of inaccuracy in interpreting the success rates of the various modalities of treatment. However, there is no indication that any one of these techniques is affected by this to a greater or lesser extent than another. Open pyeloplasty achieves very good (90-100% success) results, endopyelotomy and balloon disruption of the UPJ fail to match these results by 15-20%, and minimal access pyeloplasty produces results that are at least as good as those of open surgery but with the advantages of a minimal access approach.

CONCLUSIONS

Minimal access pyeloplasty is likely to gradually replace endopyelotomy and balloon disruption of the UPJ for the treatment of UPJ obstruction. The much higher cost of robotic pyeloplasty and greater availability of laparoscopic expertise in teaching centres are likely to limit the dissemination of robotic pyeloplasty.

Retrograde endopyelotomy: a comparison between laser and Acucise balloon cutting catheter

Endopyelotomy and laparoscopic pyeloplasty are the preferred modalities for treatment of ureteropelvic junction obstruction because of their minimally invasive nature. There are continuous efforts for improving endopyelotomy techniques and outcome. Retrograde access represents the natural evolution of endopyelotomy. The Acucise cutting balloon catheter (Applied Medical Resources Corp., Laguna Hills, CA) and ureteroscopic endopyelotomy using holmium laser are the most widely accepted techniques. The Acucise catheter was developed to simplify retrograde endopyelotomy and made it possible for all urologists, regardless of their endourologic skills. The Acucise catheter depends on incision and dilatation of the ureteropelvic junction under fluoroscopic guidance, whereas ureteroscopy allows visual control of the site, depth, and extent of the incision; the holmium laser is a perfect method for a clean precise incision. Review of the English literature showed that the Acucise technique was more widely performed, though laser had better (but not statistically significant) safety and efficacy profiles.

Antegrade percutaneous endopyelotomy

Ureteropelvic junction obstruction (UPJO) is a well-known pathologic condition with several potential associated urologic complications. The treatment for UPJO has evolved dramatically during the past two decades with the advent of minimally invasive treatment options. This has resulted in shorter hospital stays, reduced postoperative pain, and quicker convalescence compared with the gold standard, open pyeloplasty. Antegrade (percutaneous) endopyelotomy is one of the many minimally invasive treatment options for this disorder. In this article, we review the technical aspects, outcomes, and current role of antegrade endopyelotomy in the treatment of UPJO.

Antegrade versus Retrograde Endopyelotomy for Pelvi-Ureteric Junction (PUJ) Obstruction

OBJECTIVES

To compare complication and success rates of antegrade and retrograde endopyelotomy performed over 10 years and to define possible risk factors associated with treatment failure.

METHODS

From 1994 to 2004, 61 patients underwent a total of 68 endoscopic treatments: 19 antegrade and 49 retrograde endopyelotomy procedures. Antegrade endopyelotomy was always performed using diathermy. In the first 18 procedures retrograde endopyelotomy was performed using diathermy. In the most recent 30 procedures the incision was made using holmium laser. Endoluminal ultrasound was used in 78% of retrograde endopyelotomy and in 5% of antegrade endopyelotomy.

RESULTS

The retrograde endopyelotomy patients demonstrated significantly lower complication rates (12.5% vs. 42%) and shorter hospital stay (1.5 vs. 7 days) than the antegrade endopyelotomy patients. The mean follow up of the patients who remained free from disease recurrence during the study period was 46 and 24 months for the antegrade and retrograde endopyelotomy group, respectively. The overall success rate (mean time to failure) of antegrade and retrograde endopyelotomy was 56% (31 months) and 70% (17 months), respectively. There was no statistically significant increase in the overall success rate of retrograde endopyelotomy using endoluminal ultrasound per se. Stratifying retrograde endopyelotomy by the type of energy used for the incision, the overall success rate (mean time to failure) was 80% (10 months) and 53% (21 months) for Holmium laser and diathermy, respectively (p = 0.0626).

CONCLUSIONS

The overall success of antegrade and retrograde endopyelotomy in this series appears to be largely a factor of lead-time bias and is similar enough to recommend retrograde endopyelotomy with holmium laser on the basis of its relative safety and shorter hospital stay.

Renal imaging: what the urologist wants to know

Preoperative imaging in renal surgery is of utmost importance in contemporary surgical practice. From a diagnostic standpoint, imaging discovers many renal tumors incidentally before they become symptomatic. These tumors often are amenable to partial renal resection or minimally invasive surgical approaches. In general, surgical interventions for renal abnormalities have evolved to a less invasive endourologic or laparoscopic approach. Selection of the appropriate surgical intervention for renal tumors, collecting system tumors, and hydronephrosis depends heavily on the anatomy of the renal pathology. Thus, renal imaging is crucial in clinical decision-making. This article reviews the contribution of imaging to the surgical management of renal tumors, upper tract urothelial tumors, and ureteropelvic junction obstruction.

MANAGEMENT OF SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION AFTER FAILED PRIMARY LAPAROSCOPIC PYELOPLASTY

PURPOSE

Laparoscopic pyeloplasty has been established as a minimally invasive alternative to open pyeloplasty. However, little is known about the treatment of patients in whom this technique fails. We present our experience with treating ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty.

MATERIALS AND METHODS

From August 1993 to September of 2003, 227 patients underwent laparoscopic pyeloplasty for primary ureteropelvic junction obstruction. Of these patients 10 (4.4%), including 6 females and 4 males 24 to 62 years old (mean age 42.1), underwent secondary treatment after laparoscopic pyeloplasty failed. The type of secondary intervention varied by anatomical factors, and patient and surgeon preference. Success was defined as symptomatic relief and improved radiographic imaging at latest followup.

RESULTS

Secondary interventions were repeat laparoscopic pyeloplasty in 1 patient, retrograde endoscopic balloon dilation in 2 and endopyelotomy in 7 (laser, cold knife and cutting balloon endopyelotomy in 3, 2, and 2, respectively). No postoperative complications were seen. Patients were followed for a mean of 25.5 months (range 3 to 96) after the second procedure. Seven of 10 secondary interventions (70%) were successful with no obstruction on followup imaging. Three of 10 interventions (30%) failed, namely 1 laparoscopic pyeloplasty, 1 endoscopic balloon dilation and 1 laser endopyelotomy. Failure of the second procedure occurred at a mean of 9.3 months.

CONCLUSIONS

When given the choice, most patients select endoscopic management after failed primary laparoscopic pyeloplasty due to its minimally invasive nature and low complication rate. Success rates are 70% with repeat intervention. Some patients require a third intervention.

Percutaneous antegrade endopyelotomy: long-term results from one institution

OBJECTIVES

To assess the long-term efficacy of percutaneous antegrade endopyelotomy for the treatment of ureteropelvic junction (UPJ) obstruction performed at a single institution during a 10-year period. We provide alterations in investigation and management strategies on the basis of the results.

METHODS

From July 1990 to June 2001, 80 patients with clinical and radiographic evidence of UPJ obstruction underwent percutaneous endopyelotomy for the treatment of primary (n = 61) or secondary (n = 19) UPJ obstruction. The mean patient age was 35 years (range 4 to 76). Percutaneous endopyelotomy was performed in a standard fashion using either a hooked-knife (n = 77) or holmium laser (n = 3).

RESULTS

With a mean patient follow-up of 55 months (range 16 to 138), the overall success rate was 67% (53 of 79). The success rate for primary and secondary UPJ obstruction was 65% (39 of 60) and 74% (14 of 19), respectively. The mean time to failure was 15 months (range 1 to 79). Operative intervention for 24 of 26 patients with failure included open pyeloplasty (n = 18, 75%), indwelling ureteral stenting (n = 2, 8%), retrograde balloon dilation (n = 1, 4%), and nephrectomy (n = 3, 13%). Two asymptomatic patients with recurrent radiographic evidence of obstruction elected conservative follow-up. Significant crossing vessels were encountered at open pyeloplasty in 15 (83%) of 18 patients.

CONCLUSIONS

Our long-term results of percutaneous endopyelotomy demonstrated somewhat lower success rates than that reported in published studies. Long-term follow-up is critical in identifying late failures. The high prevalence of crossing vessels encountered at open pyeloplasty provided further evidence to support its role in endopyelotomy failure. Routine preoperative helical computed tomography to detect significant crossing vessels is recommended. Patients with crossing vessels are likely better served with operative techniques that specifically address this issue, namely open or laparoscopic pyeloplasty.

Acucise™ endopyelotomy in a porcine model: procedure standardization and analysis of safety and immediate efficacy

PURPOSE

The study here presented was done to test the technical reliability and immediate efficacy of the Acucise device using a standardized technique.

MATERIALS AND METHODS

56 Acucise procedures were performed in pigs by a single surgeon who used a standardized technique: insert 5F angiographic catheter bilaterally up to the midureter, perform retrograde pyelogram, Amplatz super-stiff guidewire is advanced up to the level of the renal pelvis, angiographic catheters are removed, Acucise catheter balloon is advanced to the ureteropelvic junction (UPJ) level, the super-stiff guide-wire is removed and the contrast medium in the renal pelvis is aspirated and replaced with distilled water, activate Acucise at 75 watts of pure cutting current, keep the balloon fully inflated for 10 minutes, perform retrograde ureteropyelogram to document extravasation, remove Acucise catheter and pass an ureteral stent and remove guide-wire.

RESULTS

In no case did the Acucise device present malfunction. The electrocautery activation time was 2.2 seconds (ranging from 2 to 4 seconds). The extravasation of contrast medium, visible by fluoroscopy, occurred in 53 of the 56 cases (94.6%). In no case there was any evidence of intraoperative hemorrhage.

CONCLUSIONS

This study revealed that performing Acucise endopyelotomy routinely in a standardized manner could largely preclude intraoperative device malfunction and eliminate complications while achieving a successful incision in the UPJ. With the guidelines that were used in this study, we believe that Acucise endopyelotomy can be completed successfully and safely in the majority of selected patients with UPJ obstruction.

Ureteropelvic Junction Obstruction: Determining Durability of Endourological Intervention

PURPOSE

We evaluated the durability of endourological intervention for ureteropelvic junction obstruction and established guidelines for postoperative surveillance.

MATERIALS AND METHODS

Since 1989, 150 patients have undergone endourological intervention for ureteropelvic junction obstruction, of whom 127 (53 men and 74 women) 13 to 79 years old (mean age 40.4) underwent postoperative evaluation at our center. These 127 patients are the study group reported. Endourological management consisted of hot wire balloon endopyelotomy in 25 patients, percutaneous endopyelotomy in 67 and ureteroscopic laser endopyelotomy in 35. Success in this study was strictly defined as symptomatic relief plus radiographic resolution on excretory urogram and/or diuretic renogram. Statistical analysis was performed to assess mean time to failure and develop Kaplan-Meier re-stenosis-free survival estimates.

RESULTS

Followup was 1 to 128 months (mean 22). Time to failure was 0.9 to 32.4 months (mean +/- SD 10.3 +/- 9.4). Kaplan-Meier estimates of time to re-stenosis (failure) were 6 months in 12% of patients, 12 in 22%, 18 in 24%, 24 in 27%, 30 in 32% and 36 in 37%. After 3 years no further failures were observed and Kaplan-Meier estimates remained unchanged.

CONCLUSIONS

The long-term probability of success, which is estimated to be 63.3% in this series, is somewhat lower than that reported in the literature. It likely is a result of longer followup and a more strict definition of success that includes functional and symptomatic relief. Our data suggest that while most failures become evident within the first 12 months, failure can develop as late as 3 years after intervention. As such, patients should be followed at least that long to ensure a durable result.

Retrograde ureteroscopic endopyelotomy

Several different procedures can be used to treat UPJ obstruction. Retrograde ureteroscopic endopyelotomy provides a safe and adequate first line of treatment for this condition. With the advent of smaller ureteroscopes and ancillary devices, this technique has evolved to include children. Adherence to strict endourologic principles and direct visualization make retrograde ureteroscopic endopyelotomy a safe and effective treatment modality. This procedure represents an extension of the basic endoscopic skills of the urologist, creating a short learning curve and wide margin of safety.

Laparoscopic Management of Ureteropelvic Junction Obstruction in Patients With Upper Urinary Tract Anomalies

PURPOSE

We report our experience with the laparoscopic management of ureteropelvic junction obstruction in patients with upper urinary tract abnormalities.

MATERIALS AND METHODS

Between July 1994 and May 2002, 7 men and 4 women with upper urinary tract anatomical abnormalities were referred to our institution for management of symptomatic ureteropelvic junction obstruction. Anomalies included horseshoe kidneys in 5 cases, pelvic kidneys in 3, a pancake kidney in 1, a malrotated kidney in 1 and a duplicated collecting system in 1. Three patients had associated renal stones that were extracted during reconstruction. Mean patient age was 37.4 years (range 25 to 60). One patient had undergone a previously unsuccessful endopyelotomy and 2 had a history of abdominal surgery.

RESULTS

Mean operative time was 195 minutes (range 85 to 403) and mean estimated blood loss was 122 cc (range 20 to 300). No patient in this series required transfusion. Average length of hospital stay was 3.2 days (range 2 to 5). Renal function failed to improve after surgery in 1 patient with poor renal function and severe hydronephrosis. The remaining 10 patients (91%) had durable clinical and/or radiographic success during a followup of 32.6 and 21.3 months, respectively. There were no major complications.

CONCLUSIONS

Laparoscopic pyeloplasty is an effective treatment alternative for ureteropelvic junction obstruction associated with renal or urinary tract anomalies.

Cost-effective laparoscopic pyeloplasty: Single center experience

OBJECTIVE

Laparoscopic pyeloplasty (LPP) is a minimally invasive treatment option for ureteropelvic junction (UPJ) obstruction. We report here our experience of performing cost-effective LPP on 24 patients at a single center.

METHODS

Between October 1999 and March 2002, LPP was performed in 24 patients (17 male, seven female; age range 8-51 years) including two patients who had failed previous endourologic treatments. In two patients with concomitant renal stones, laparoscopic pyelolithotomy was also performed. LPP was conducted in a cost-reductive manner by both transperitoneal (n = 12) and retroperitoneal (n = 12) access. To reduce the cost, an indigenous balloon to create the retroperitoneal space, reusable ports, ordinary polyglactin suture and intracorporeal free-hand suturing were employed. To reduce operative time, antegrade stenting was also performed in some cases.

RESULTS

Laparoscopic Anderson-Hynes pyeloplasty was performed in 16, Foley Y-V pyeloplasty in five and Fenger pyeloplasty in three patients. One patient required conversion to open surgery due to tension at the anastomosis site during Anderson-Hynes pyeloplasty. The mean operating time, blood loss, analgesic (pethidine) requirement, duration of drain and hospital stay for the retroperitoneal and transperitoneal groups were 170.3 and 187.6 min, 102.2 and 145.9 mL, 125 and 136.4 mg, 2.1 and 2.5 days, and 3.4 and 4.3 days, respectively. No significant complications were encountered apart from prolonged ileus in three patients in the transperitoneal group. The mean follow-up period was 10.8 months with a range of 2-24 months. Postoperative renal scan was performed at 3 months in 21 patients, and 1 year in 11 patients. There was evidence of equivocal obstruction in one patient, but there were no obstructions in the remaining patients.

CONCLUSION

Although LPP is technically demanding, it is emerging as a viable, minimally invasive alternative to open pyeloplasty for UPJ obstruction with a success rate similar to that of open pyeloplasty. It allows the duplication of open surgery steps (unlike endoscopic procedures), thereby providing durable and sustained results. LPP can also be performed safely, effectively and efficiently in a cost-efficient manner.

Impact of hydronephrosis and renal function on treatment outcome: antegrade versus retrograde endopyelotomy

OBJECTIVES

To compare, in a single-surgeon, single-institution study, the efficacy of antegrade and retrograde endopyelotomy in terms of success rate and morbidity and to identify which risk factors affect treatment outcomes.

METHODS

The results were retrospectively reviewed for 88 patients with ureteropelvic junction obstruction treated with endopyelotomy. Antegrade endopyelotomy was performed with a hook knife, scissors, or cutting balloon device. Retrograde endopyelotomy was performed with a cutting balloon device. Objective results were based on intravenous urogram and/or diuretic nuclear renal scan findings, and subjective results were based on direct patient query and questionnaire.

RESULTS

Ninety-three endopyelotomy procedures, 64 antegrade and 29 retrograde, were performed. The mean follow-up was 37.0 months (range 5 to 76). The overall success rates between antegrade and retrograde endopyelotomy (81.3% versus 75.9%) were not statistically different (P = 0.553). Patients with massive hydronephrosis and poor initial renal function were less likely to have successful endopyelotomy. Antegrade endopyelotomy, however, was more successful than retrograde endopyelotomy in patients with massive hydronephrosis (66.7% versus 20.0%; P = 0.046). The average operative time for antegrade and retrograde endopyelotomy was 93.9 and 32.7 minutes (P <0.001), respectively. The average length of hospital stay after antegrade and retrograde endopyelotomy was 3.20 and 0.14 nights (P <0.001), respectively.

CONCLUSIONS

Both antegrade and retrograde endopyelotomy are effective treatments for ureteropelvic junction obstruction associated with minimal morbidity. Antegrade endopyelotomy appears to be more successful in patients with high-grade hydronephrosis. Retrograde endopyelotomy results in a shorter hospital stay, a shorter operative time, and less postoperative pain.

Endopyelotomy sheath: a new device to facilitate antegrade endopyelotomy

PURPOSE

Antegrade endopyelotomy is still the treatment of choice in most cases of ureteropelvic junction obstruction. In this approach using the standard technique the cold knife incision invariably falls in a different plane, which may result in a thin strip of ureteral mucosa and at times avulsion as well as difficult passage of the endopyelotomy stent. A modified technique using a new device has been studied to augment safety and the precision of incision at the ureteropelvic junction during endopyelotomy.

MATERIALS AND METHODS

The endopyelotomy sheath is a 22 cm. hollow polyurethane tube with a proximal size of 7 cm. that is 12Fr to 16Fr, tapering to 6Fr distally. This sheath is passed over a single guide wire and advanced under fluoroscopic guidance until the wider proximal end is placed across the ureteropelvic junction. The proximal end has a slit that is directed at the incision site and through which an incision is made with a cold knife.

RESULTS

To date this modified technique has been used in 16 patients. The sheath provided good space for making an incision and made the movement of the knife safe and much easier. The incision was smooth and always made at 1 place, ensuring the preservation of the maximum circumference of the mucosa across the ureteropelvic junction. Mean function +/- SEM was 36.18% +/- 6.14% (range 27% to 48%) and mean pelvic volume was 44 ml. (range 34 to 60). At a mean followup of 10 months (range 3 to 17) 14 patients (87.5%) showed objective improvement.

CONCLUSIONS

This endopyelotomy sheath simultaneously dilates the ureteropelvic junction and allows a smooth cut in a straight line at a predetermined site. By this maneuver the maximum circumference of mucosa is preserved for better healing and possibly better results. Passing the endopyelotomy stent was not a problem. This sheath makes endopyelotomy safe, easy and user friendly.

Management of failed primary intervention for ureteropelvic junction obstruction: 12-year, single-center experience

OBJECTIVES

To compare contemporary endourologic and open surgical management of failed primary intervention for ureteropelvic junction obstruction, specifically in regard to immediate and long-term results and complications.

METHODS

Since 1989, 48 patients have undergone management of failed primary intervention for ureteropelvic junction obstruction. Of these, 42 patients (21 females and 21 males; age range 16 to 68 years, mean age 34.9) underwent follow-up evaluations. These 42 patients constitute the present study group. The mode of secondary intervention was determined by individual upper tract anatomy, concurrent medical conditions, and informed patient preference. Secondary intervention included open operative repair (n = 20) or percutaneous (n = 11), ureteroscopic (n = 5), or retrograde cautery wire balloon (n = 6) endopyelotomy. Success was defined as symptomatic relief and improved calicectasis on radiographic evaluation at latest follow-up.

RESULTS

Follow-up ranged from 6 to 148 months (mean 47.7). Endourologic intervention was associated with a mean hospital stay of 2.3 nights and a complication rate of 13.6%. The long-term success rate of these endoscopic approaches was 59.1% overall, including a 71.4% success rate after a failed open operative procedure and a 37.5% success rate after a failed endourologic procedure. In contrast, open operative salvage was associated with a mean stay of 4.3 nights and a 15% complication rate. The success of open operative salvage was 95% overall, including 94.1% after failed endourologic intervention and 100% after failed open operative intervention.

CONCLUSIONS

Endourologic intervention for failed primary management of ureteropelvic junction obstruction is associated with a short hospital stay and low rate of complications. Such intervention provides acceptable success rates in the setting of prior failed open operative intervention. However, when endourologic salvage was used for prior failed endourologic intervention, the success rates were limited. This suggests that intrinsic factors such as crossing vessels or periureteral fibrosis may play a role in limiting the utility of such procedures in this setting. In contrast, open operative salvage after any prior failed intervention for ureteropelvic junction obstruction provides excellent functional results without any increase in morbidity, with, in this contemporary series, an acceptably short hospital stay. These data should help urologists and patients make well-informed treatment decisions.

Surgical management of ureteropelvic junction obstruction in adults

Ureteropelvic junction (UPJ) obstruction is a well-recognized entity that may present at any time - in fetal life, infancy, childhood, or early or late adulthood. As the most common site of obstruction in the upper urinary tract, the UPJ is an area with which urologists should be well familiar. There has been an improved understanding of the pathophysiology of primary congenital UPJ obstruction that has been reflected in the evolution of surgical options, from open surgical repair to minimally invasive surgery. Although the primary scope of this review is the surgical management of this condition, we will briefly review the pathogenesis, clinical presentation, and diagnosis of UPJ obstruction.

Cost-effective treatment for ureteropelvic junction obstruction: a decision tree analysis

PURPOSE

We determined the optimal treatment for primary ureteropelvic junction obstruction based on cost using a decision tree model.

MATERIALS AND METHODS

A comprehensive literature search for articles addressing surgical correction of ureteropelvic junction obstruction was performed and data were abstracted on operative time, hospital stay, complications and success rate. The overall cost and individual cost centers at our institution for antegrade endopyelotomy, retrograde ureteroscopic endopyelotomy, Acucise (Applied Medical Resources, Laguna Hills, California) endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were compared. A decision tree model estimated the cost of treatment and followup for each modality using commercially available software. Sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost.

RESULTS

Based on cost center review retrograde ureteroscopic endopyelotomy was the least costly procedure ($2,891). In the decision tree model the rank order of overall treatment costs was: retrograde ureteroscopic endopyelotomy ($3,842), Acucise endopyelotomy ($4,427), antegrade endopyelotomy ($5,297), laparoscopic pyeloplasty ($7,026) and open pyeloplasty ($7,119). Despite various hospital stay, operative time, equipment cost and success rate data 1-way sensitivity analysis revealed that antegrade endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were never cost effective compared with retrograde ureteroscopic endopyelotomy or Acucise endopyelotomy, while 2-way sensitivity analysis favored retrograde ureteroscopic endopyelotomy.

CONCLUSIONS

Primary cost variables for ureteropelvic junction obstruction treatments include operative time, hospital stay, equipment cost and success rate. Decision tree analysis showed that retrograde ureteroscopic or Acucise endopyelotomy is the most cost-effective treatment modality at our institution. However, cost is only 1 of a number of factors that are considered when deciding on an optimal course of treatment.

Ureteropelvic junction obstruction: an innovative approach combining metallic stenting and virtual endoscopy

PURPOSE

We report our experience with auto-expandable metallic stents for treating ureteropelvic junction obstruction.

MATERIALS AND METHODS

We treated 4 patients with a mean age of 45 years who had ureteropelvic junction obstruction with placement of a self-expandable intraureteral metallic stent (Wallstent, Schneider, Zurich, Switzerland). All patients presented with recurrent ureteropelvic junction obstruction after open pyeloplasty. Excretory urography and 3-dimensional reconstruction computerized tomography were performed 1 and 6 months after stent insertion. Virtual endoscopy images were obtained at followup due to the need to define ureteral patency.

RESULTS

Mean followup was 16 months (range 9 to 24). Wallstent placement was successful and immediate patency was achieved in all cases. During followup 3 patients required no further intervention and the stented ureteropelvic junction remained patent. In the remaining patient stricture recurred 2 months after initial stent insertion due to the ingrowth of scar tissue through the prosthesis. Additional intervention was deemed necessary after placing a longer 6 cm., completely coaxial overlapping metal stent. Virtual endoscopy and excretory urography findings concurred. Virtual endoscopy allows visualization of the stented ureteropelvic junction lumen cephalad and caudal to the prosthesis. It also enables easy navigation within the stent at different angles of view.

CONCLUSIONS

The concept of applying metallic stents for ureteropelvic junction obstruction and adjacent adynamic ureteral segments combined with virtual endoscopy is strengthened by the results of this study.

Laparoscopic treatment for ureteropelvic junction obstruction

OBJECTIVES

To assess retrospectively the subjective and objective outcomes achieved after laparoscopic treatment for ureteropelvic junction obstruction at our institutions.

METHODS

Between August 1999 and July 2001, 19 patients (11 women and 8 men), with a mean age of 31.2 years (range 17 to 67), underwent laparoscopic treatment for ureteropelvic junction obstruction. Of these, 17 patients were eligible for postoperative analysis. Nine of these patients had a history of prior surgical intervention on the affected side. The patients were subjectively assessed by an analog pain scale performed before and at least 6 months after surgery. Preoperatively, patients had a diuretic renal scan to confirm the presence of obstruction. Helical computed tomography was also performed preoperatively to assess for the presence of crossing vessels. The renal scan was repeated at least 12 weeks after surgery to document the relief of obstruction objectively.

RESULTS

Helical computed tomography correctly predicted the presence of crossing vessels in 12 patients (63%). The Anderson-Hynes and Fenger pyeloplasty techniques were performed in 16 and 2 patients, respectively. In 1 patient, a small crossing vein over the ureteropelvic junction was identified and divided without complications. The average operative time was 240 minutes (range 128 to 470). The blood loss was minimal, and no open conversions were required. The mean hospital stay was 2.9 days (range 2 to 7). Two postoperative complications occurred (11.7%). The average subjective follow-up was 14.4 months (range 6 to 27), and the average objective follow-up was 7.8 months (range 3 to 12). Of 17 assessable patients, 16 (94%) had subjective and objective success (postoperative improvement in analog pain score and half-life of radiotracer washout). The average split renal function improved from 34.1% to 38.5% (P <0.01).

CONCLUSIONS

On the basis of our data, laparoscopic pyeloplasty has a similar success rate compared with the traditional open approach and better results than other minimally invasive techniques. Longer follow-up and further experience are needed to validate these data.

Long-term results of endopyeloureterotomy using the transpelvic extraureteral approach

OBJECTIVES

To review our clinical results to confirm the long-term efficacy of the operative technique of endopyeloureterotomy using the transpelvic extraureteral approach that we developed.

METHODS

We treated 123 patients with ureteropelvic junction obstruction or upper ureteral stenosis by percutaneous endopyeloureterotomy using the transpelvic extraureteral approach between 1988 and 1999. All were followed up for at least 1 year (mean 58 months). Sixty-eight patients were male and 55 female between the ages of 3 and 78 years (mean 36). We evaluated the efficacy of our procedure preoperatively and then regularly every 6 to 12 months postoperatively using excretory urography and technetium-99m DTPA renography.

RESULTS

Our results showed that 115 (90.6%) of 127 procedures relieved the obstruction without any severe complications. In the 107 cases of ureteropelvic junction obstruction, we alleviated the stricture in 96 (90%). In the 20 cases of upper ureteral stenosis, our procedure alleviated the stricture in 19 (95%). In the 47 cases of a stenotic segment of 2 cm or more in length, 43 of our procedures led to a significant improvement (91.5%). Long-term follow-up of the 123 patients revealed late recurrence in 5 patients, despite the initial success.

CONCLUSIONS

Percutaneous endopyeloureterotomy using the transpelvic extraureteral approach should be considered the first choice of treatment for ureteropelvic junction obstruction and upper third ureteral stenosis, even if the stenotic segment is 2 or more cm long.

Laparoscopic pyeloplasty: the first 100 cases

PURPOSE

Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction obstruction. Long-term followup has not yet been reported. We present experience with the first 100 consecutive cases of laparoscopic pyeloplasty performed at our institution.

MATERIALS AND METHODS

A retrospective review of 100 consecutive laparoscopic pyeloplasties in 99 patients (means age 37.3 years) between August 1993 and January 1999 was performed. All patients had radiographic evidence of obstruction with signs, symptoms or deterioration of renal function. Repair was for primary ureteropelvic junction obstruction in 83 patients and secondary obstruction in 17. The 4 types of repairs performed were Anderson-Hynes dismembered (71 cases), Y-V plasty (20), Heineke-Mirhulicz (8) and Davis intubated ureterotomy (1). Type of repair used was dictated by intraoperative findings. Twenty patients had nonobstructing renal stones and underwent concomitant pyelolithotomy. All patients were assessed for symptoms and radiographic evaluation for anatomical obstruction.

RESULTS

Average operating room time was 4.2 hours, which decreased with surgeon experience. Average blood loss was 181 cc and hospital stay was 3.3 days. Two patients required blood transfusion. A crossing vessel was found in 57 patients. With a mean clinical and radiographic followup of 2.7 and 2.2 years, respectively, 96% of the patients were free of obstruction on followup radiographic imaging. Of the patients who underwent concomitant pyelolithotomy, 18 (90%) were stone-free at last followup. All failures occurred within the first postoperative year. There were 12 complications in this series.

CONCLUSIONS

In experienced hands laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction. The results appear durable and comparable to open pyeloplasty with decreased postoperative morbidity.

Endopyelotomy in poorly functioning kidney: is it worthwhile?

BACKGROUND

Endopyelotomy is a minimally invasive surgical alternative for primary ureteropelvic junction (UPJ) obstruction. However, its success in poorly functioning kidneys is controversial.

PATIENTS AND METHODS

In this retrospective study, 34 endopyelotomies performed on poorly functioning kidneys between January 1993 and December 1997 were reviewed. Of these, 13 patients had a glomerular filtration rate (GFR) <15 mL/min (Group I) and 21 had a GFR of 15 to 25 mL/min (Group II). All the patients insisted on endopyelotomy to avoid open surgery. Antegrade endopyelotomy was performed by the twin guidewire rail technique with a cold knife. An indwelling stent was kept for 2 to 6 weeks. Patients were followed up with assessment of symptoms and diuretic renograms at 3, 6, and 12 months postoperatively.

RESULTS

Endopyelotomy was considered successful in 8 of 13 patients (62%) in Group I. Success was achieved in 19 of 21 patients (90%) in Group II.

CONCLUSION

Endopyelotomy can be performed for improvement of symptoms. Stabilization or improvement in GFR is less pronounced in poorly functioning kidneys with primary UPJ obstruction.

The role of endourology in ureteropelvic junction obstruction

Endopyelotomy has benefited from abundant confirmatory investigations, and significant progress in different technical modalities has occurred. Retrograde techniques, including the Acucise (Applied Medical, Laguna Hills, CA) cutting balloon and the ureteroscopic Holmium laser incision, are becoming preferred approaches while the other modalities retain their specific indications. Long-term results and potential complications have been carefully studied and reported. Better identification of risk factors has prompted precise preoperative investigations and allowed for careful patient selection, leading to improved results. These results approach those of open pyeloplasty, but with minimal morbidity.

Percutaneous endopyelotomy

Percutaneous endopyelotomy, introduced over 15 years ago, is a well-established alternative to open operative pyeloplasty for management of ureteropelvic junction (UPJ) obstruction. Although several variations of the technique have been described, the goal in all cases is to develop a full thickness incision though the obstructing proximal uretra that extends out to the peripyeloureteral fat and heals over an internal stent. Though a percutaneous endopyelotomy can be considered for almost any patient with primary or secondary UPJ obstruction, it is particularly valuable in the setting of upper tract stones that can then be managed simultaneously. This article reviews the indications, techniques, and outcomes of percutaneous endopyelotomy.

Laparoscopic surgery in urology

Not more than 10 years ago, laparoscopy was introduced to the armamentarium of urology. The start was slow, with pelvic lymphadenectomy, nephrectomy and varicocelectomy being about the only indications. However, very soon great enthusiasm developed, and almost every urological operation was performed by means of laparoscopy. For several reasons this exaggerated enthusiasm had to be followed by disappointment. First of all, laparoscopy turned out not to be as easy as many would have liked it to be. Due to a low frequency of operations, many surgeons were never able to overcome their learning curve, and the early literature reflects this problem. Unlike general surgery where cholecystectomy developed into a pacemaker operation, which forced everybody to go ahead with laparoscopy, urology was long searching for good and frequent indications for this new technique. Within the last few years, the pendulum has swung back to the other side. Adrenalectomy was one of the first indications where laparoscopy proved superior to open surgery in every aspect. Several other good indications have followed, some of which, namely cryptorchidism, nephrectomy and pyeloplasty, will be presented in detail to give an example. But the breakthrough that recently occurred is due to the success of laparoscopy in the field of oncologic surgery. Laparoscopic radical nephrectomy has shown its surgical efficiency as well as its oncologic efficacy. However, the main interest is now focused on radical prostatectomy, since this is the most frequently performed operation in urology by now. Recently this operation could be developed to a standardized technique, but only time will tell its true impact. Several indications will change in the future, but laparoscopy is here to stay.