Endopyeloureterotomy via a transpelvic extraureteral approach

Cold cutting of ureteral stenosis with endoscopic scissors

OBJECTIVES

To study the procedure and results of cold cutting of ureteral stenosis with endoscopic scissors. Intrinsic or extrinsic ureteral stenosis can be congenital or acquired. Endoscopic dilation and incision is 1 potential option for ureteral intrinsic stenosis.

METHODS

During a 3-year period (2005-2007), a prospective study was performed of cold cutting of ureteral stenosis with endoscopic scissors in 17 consecutive patients (11 women and 6 men), aged 22-64 years. Of the 17 patients, 6 had been diagnosed with proximal ureteral stenosis, 3 with iliac ureteral stenosis, and 8 with pelvic ureteral stenosis. The procedure was performed with a semirigid 8.5Ch ureteroscope, catheterizing and dilation of the stenosis with a balloon catheter, cold cutting of the ureteral wall with scissors, including margins of healthy tissue at both ends of the stenosis, and a 6F double-J ureteral stent for 6 weeks.

RESULTS

The results were evaluated after 3 months with urography in 15 cases and diuretic renography in 2 cases. Analysis of the postoperative complications and urography was done at 12-24 months. Immediate success was obtained after the first endoscopic ureterotomy with scissors in 16 of 17 cases (94%). At 12-24 months, success was maintained in 88.5% of cases.

CONCLUSIONS

Cold cutting of ureteral stenosis with endoscopic scissors is a safe technique for the patient. This procedure could be a therapeutic option in cases of benign intrinsic ureteral stenosis of <15 mm.

Percutaneous endopyelotomy for ureteropelvic junction obstruction

Percutaneous endopyelotomy was performed 13 times on 11 patients with primary and secondary UPJ obstruction between 1994 and 2002. Excretory urogram revealed improvement in ten of eleven patients. One of the ten successfully treated patients required repeated endopyelotomy. Endopyelotomy failed in one patient, who had secondary UPJ obstruction that had been stenosed by granuloma caused by a ureteral stone. As the patient had UPJ obstruction of high insertion type with thinned renal parenchyma, nephrectomy was performed after repeated endopyelotomy. Compared with open pyeloplasty, percutaneous endopyelotomy is less invasive and is cosmetically advantageous.

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.

Retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction

PURPOSE

We developed a new approach of retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction as an alternative to conventional antegrade or retrograde endopyelotomy.

MATERIALS AND METHODS

From February 1997 to August 1999 we treated 5 cases of ureteropelvic junction obstruction due to crossing vessels that were diagnosed by helical computerized tomography. Ureterovascular hydronephrosis characterized by a malrotated renal pelvis with anterior crossing vessels was observed in 4 cases and ureteropelvic junction obstruction with a posterior crossing artery was present in 1. After endoureterotomy stent insertion under cystoscopic guidance we performed retroperitoneoscopic endopyelotomy with the kidney in standard position. Crossing vessels were transposed to a higher position to remove obstruction and fixed with peripelvic tissue via retroperitoneoscopy. In all cases a longitudinal incision approximately 1.5 cm. long was made with a potassium titanyl phosphate laser.

RESULTS

Convalescence was uneventful in all patients and the endoureterotomy stent was removed 4 to 8 weeks after surgery. Postoperatively helical computerized tomography showed the successful transposition of crossing vessels and significant hydronephrosis resolution in all cases. All patients were asymptomatic during followup of 17 to 28 months.

CONCLUSIONS

Despite our small number of patients our results are sufficient to conclude that retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels is a simple and reliable method for treating ureterovascular hydronephrosis and associated conditions.

Simplified approach to percutaneous endopyelotomy

The purpose of this report was to describe a safe, simple, and rapid approach to percutaneous antegrade endopyelotomy. In contrast to standard percutaneous endopyelotomy techniques, in this procedure, the endopyelotomy stent is placed at the outset. The endopyelotomy incision is then made with an acorn-tipped Bugbee electrode directly down onto the stent, in a manner analogous to a ureteral meatotomy in the bladder. The advantage of this approach is twofold. Primary placement of the stent helps to define the appropriate site and direction for the endopyelotomy incision, allowing marsupialization of the proximal ureter into the renal pelvis. Use of this technique also obviates the need to pass a large-caliber stent after the endopyelotomy incision has been made, thereby avoiding a potential risk of ureteropelvic junction disruption. Clinical and radiographic follow-up was available in 29 (76%) of 38 patients who underwent this procedure. Success, defined as a resolution of symptoms and decrease in calicectasis, was achieved in 24 (83%) of the 29 patients. We have found primary placement of an endopyelotomy stent and use of electrocautery as a cutting mode safely facilitates a precise endopyelotomy incision.

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.

Endopyelotomy for high-insertion ureteropelvic junction obstruction

We assessed the results of endourologic treatment of patients with a primary ureteropelvic junction obstruction (UPJO) caused by high insertion of the ureter into the renal pelvis (HIUPJO). A total of 10 patients 15 to 76 years old with preoperatively diagnosed HIUPJO were treated. Acucise retrograde endopyelotomy was performed in eight patients and percutaneous antegrade endopyelotomy in two. A stent was left in place for an average of 5.3 weeks. The subjective success rate, based on patient questionnaire and analog pain scales, was 80% at 27 months' average follow-up. The objective success rate, based on diuretic renal scanning or Whitaker test, was 70% at 26 months' mean follow-up. Overall, 60% of the patients had both an objectively and a subjectively successful outcome. The success rate for endopyelotomy in patients with UPJO caused by high insertion is similar to that reported for endopyelotomy in patients without high insertion. High insertion is not a contraindication to endopyelotomy.

Antegrade transpelvic endopyelotomy in primary obstruction of the ureteropelvic junction

The authors present a 5-year follow-up of endopyelotomy using a personal technique for cases of primary ureteropelvic junction obstruction. After percutaneous access has been gained via a lower calix, the technique involves wide opening of the renal pelvis and exploration of the peripelvic space before a 3- to 4-cm long sectioning of the ureter. The aim is to carry out all of the operation in full view and without the need for a large-caliber stent, in order to perform endopyelotomy also in pediatric patients or in presence of anomalous vessels. The follow-up demonstrates a good result in 80% of 46 patients aged 5 to 62 years; two patients underwent surgical repair. The authors think the antegrade transpelvic endopyelotomy is an endourologic operation whose results and feasibility parallel those of open surgery.