Ureteroscopic laser endopyelotomy: a single-center experience

Evaluation of the results of laser endopyelotomy with two different technique in ureteropelvic junction obstruction

INTRODUCTION

Failed pyeloplasty procedures are caused by large amounts of scarring, and peripelvic fibrosis. This finding has been associated with urinary extravasations to the operation, urosepsis or an excessive tissue reaction. The treatment options for secondary UPJO (Ureteropelvic Junction Obstruction) are the same with the options for primary procedures: in cases of very poor renal function, various pyeloplasty forms (open and laparoscopic), and ureterocalicostomy or sometimes nephrectomy may be considered in severe renal function loss. Whereas, endoscopic treatment can be considered in elective cases.

STUDY DESIGN

A total of 46 young patients who underwent endopyelotomy due to secondary ureteropelvic obstruction between January 2013 and September 2018 were included in the study. Patients underwent semirigid URS (Ureterorenoscopy) guided laser endopyelotomy until July 2015, and the patients had flexible URS guided laser endopyelotomy since July 2015.

RESULTS

The mean age of the patients was found as 17.7 ± 4.2 and 16.9 ± 5.7 years in the SURSLE (Semirigid Ureterorenoscopy Laser Endopyelotomy), and FURSLE (Flexible Ureterorenoscopy Laser Endopyelotomy) groups, respectively. Success of the procedure was confirmed in 20 (83%) patients in the SURSLE group, and 19 (86%) patients in the FURSLE group who had no obstructive symptoms based on USG, GFR and excretion curves on the renogram ordered in the 24th month. Four (16%) patients in the SURSLE group, and 3 (14%) patients in the FURSLE group were accepted as failed, their treatments were arranged for additional surgical procedures, and these patients were taken under the follow-up protocol.

DISCUSSION

This is one of the first studies comparing endopyelotomy with semirigid URS and flexible URS in patients with ureteropelvic stenosis. Long-term results with a large series of patients are not known, and our approach can be considered only as an individual method. There are different treatment options in UPJO. The use of fluoroscopy has advantages in endourologic operations. Therefore, lower radiation exposure can be a rational approach for protecting a person. Similarly, providing necessary protection also for physicians and operating room personnel is essential. In our study, shorter fluoroscopy time with SURSLE provided an advantage over FURSLE in terms of radiation exposure.

CONCLUSION

Of semirigid and flexible URS techniques that have no superiority over each other in terms of success, preferring semi-rigid URS guided laser endopyelotomy with lower ionizing radiation used, is more rational.

Factors affecting the effectiveness and success of retrograde holmium laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults

PURPOSE

To evaluate the factors affecting the effectiveness, safety, and success of retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction in adults.

METHODS

Adult patients who underwent retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy as the primary treatment of ureteropelvic junction obstruction between January 2012 and June 2016 at our clinic were retrospectively analyzed. Success was defined as the relief of symptoms and the resolution of obstruction, as assessed via radiography. Factors affecting success were analyzed, such as the clinical characteristics, procedural outcomes, complications, and the type of ureteroscopy used in the procedure.

RESULTS

Procedural success was achieved in 29 (74.4%) out of 39 patients, with a mean age of 38.3 ± 12.3 years during a median follow-up duration of 44 (33-65) months. Failure occurred at a median of 4.5 (3-22) months. It was detected that the presence of primary obstruction, ipsilateral kidney function being >30% of normal, and the length of obstruction being <1 cm positively affected procedural success (p = 0.009, p = 0.011, and p = 0.019, respectively). In the postoperative period, two Grade I and four Grade II complications were observed according to the Clavien-Dindo classification. There was a difference only in the operation time between semirigid (24) and flexible ureteroscopes (15), with the operation time being shorter with the use of a semirigid ureteroscope than with the use of a flexible uteroscope (p < 0.001).

CONCLUSION

Retrograde holmium:yttrium-aluminum-garnet laser endopyelotomy is a minimally invasive method that can be used effectively and safely as the primary treatment of patients with ureteropelvic obstruction, when long-term results are also taken into consideration. The decision of performing laser endopyelotomy should be made after a detailed evaluation of the characteristics of the patient as well as of the obstruction.

Laser Endopyelotomy in the Management of Pelviureteric Junction Obstruction in Adults: A Systematic Review of the Literature

Laser endopyelotomy (LEP) is considered as an option for the treatment of pelviureteric junction obstruction in adults. A comprehensive systematic search of the published literature was performed to assess the success rate and perioperative complications of LEP in the treatment of primary and secondary pelviureteric junction obstruction and to identify the factors that may have an impact on the success of LEP. The evidence available has significant limitations in terms of the heterogeneous study design and the definitions of outcomes. The average overall success rate of the pooled data was 75% with a mean follow-up of 29 months. Complications were predominately minor with an average rate of 12.5%.

Laser endoureterotomy and endopyelotomy: an update

PURPOSE

Although minimally invasive approach is one of the first-line treatment choices for ureteral strictures, there are still controversies on the ideal method to treat this entity. The objective of this update was to define the level of evidence around endoscopic treatment of ureteropelvic junction (UPJ) and ureteral strictures.

METHODS

We reviewed the current available literature on the PubMed database from the last decade up to May 2014 on laser endoureterotomy and endopyelotomy.

RESULTS

The level of evidence for the endoscopic treatment of UPJ and ureteral strictures is low. Despite this, it appears that endoureterotomy and endopyelotomy performed mainly with Ho:YAG laser achieve good success rates with minimal perioperative morbidity.

CONCLUSIONS

Laser endoureterotomy and endopyelotomy should be considered a reasonable treatment option in selected patients.

Minimally-invasive correction of ureteropelvic junction obstruction: do retrograde endo-incision techniques still have a role in the era of laparoscopic pyeloplasty?

BACKGROUND

This study was designed to review the long-term results and complications of the two techniques of retrograde endopyelotomy; ureteroscopic holmium laser endopyelotomy versus Acucise endopyelotomy. The results were then compared with the laparoscopic pyeloplasty results from a recent publication.

PATIENTS AND METHODS

: The study was conducted retrospectively from January 2004 to July 2007. Seventy-two patients with ureteropelvic junction obstruction (UPJO) underwent retrograde endopyelotomy using either ureteroscopic laser endoincision (42 patients) or fluoroscopic guided hot-wire balloon (Acucise) endoincision (30 patients). Preoperative radiological assessment included intravenous pyelogram (IVP), helical computerized tomography and diuretic renography. The follow-up period ranged from 12 to 42 months. Subjective success was guided by the change in the preoperative flank pain while objective success on radiological evaluation was documented by either nonobstructed curve of diuretic renogram and/or T1/2 less than 10 min.

RESULTS

The mean patient age was 42.6 ± 7.5 years for the laser group and 39.2 ± 15.1 years for the Acucise group (p = 0.24). The operative time was 66.8 ± 22.2 min in the laser group and 59.8 ± 20.3 min in the Acucise group (p = 0.84). By objective standards (renal scan), a total of 56 (77.8%) cases were successful (nonobstructed curve). This number included 34 cases in the laser group (80.9%) and 22 cases in the Acucise group (73.3%) (p = 0.2). Overall 16 failure cases were evident clinically within 1 year of the procedure (eight cases in each group). Most of the failure cases (13/16) presented with clinical obstructive symptoms during the early follow-up period (within 3 months postoperatively) and were then confirmed radiologically (six cases in the laser group and seven cases in the Acucise group) while only three patients had failures at 6, 9 and 11 months postoperatively. There was no statistically significant difference as regards intra-operative complications between the two groups (p = 0.4). Intra-operative bleeding was seen in three cases in the Acucise group while postoperatively it was reported in one case.

CONCLUSION

The retrograde endopyelotomy approach is safe and effective for the treatment of patients with UPJO. Both ureteroscopic laser and the hot-wire balloon (Acucise) techniques have an important role in the management of UPJO, especially in secondary cases, and they provide comparable long-term objective and subjective outcomes. Laparoscopic pyeloplasty provides far better results but with higher costs, and requires well-equipped centers and involves a long learning curve.

Ureteroscopic holmium:YAG laser endopyelotomy is effective in distinctive ureteropelvic junction obstructions

AIM

To evaluate the effectiveness and safety of holmium:YAG (Ho:YAG) laser endopyelotomy in distinctive ureteropelvic junction obstructions (UPJO) with distinctive aetiologies.

MATERIAL AND METHODS

Thirty-one patients diagnosed with UPJO of distinctive causes were included. Aetiology consisted of 7 congenital UPJO, 10 post-pyeloplasty UPJO, 7 post-lithotomy obstructions, 4 ureteropelvic junction obstructions post-extracorporeal shockwave lithotripsy stenoses and 3 post-ureteroscopic lithotriptic UPJO. Retrograde ureteroscopic Ho:YAG laser endopyelotomy was performed in all patients. Operation related parameters were studied

RESULTS

Average procedure duration was 46 min. Mean discharge was 1.81 days. There was no notable complication such as perforation or haemorrhage. All patients were followed for at least 12 months. The single success rate was 80.6%, leaving 6 patients undergoing secondary endopyelotomy, among whom 4 were successful while 2 required an open approach. The overall success rate was 93.5%. Failed pyeloplasty UPJO is more disposed to restenosis (p = 0.0075). Inversely implanted ureteral stent yielded a higher success rate (p = 0.0158).

CONCLUSIONS

Ho:YAG laser endopyelotomy is a safe, minimally invasive approach effective in both primary and secondary UPJO treatments. Implantation of inversed ureteral stents can be more beneficial.

Ureteroscopic holmium laser endopyelotomy for ureteropelvic junction stenosis after pyeloplasty

INTRODUCTION

Pyeloplasty is a standard and highly successful treatment for ureteropelvic junction obstruction. However, stenosis is a late complication causing symptom recurrence. The purpose of this study was to evaluate the use of holmium laser stenosis incision-"laser endopyelotomy"-to manage this.

PATIENTS AND METHODS

Fifteen adult patients were referred for loin pain recurrence after pyeloplasty. Subsequent to ureteropelvic junction stenosis confirmation with intravenous urogram and dynamic isotope renogram investigations, the patients underwent ureteroscopic laser endopyelotomy. Eleven patients had stents in situ before endopyelotomy. Ureteric stents (7F) were placed for 6 weeks postprocedure when ureteroscopy was repeated and stents removed. All patients had repeat intravenous urogram and renograms at 3 months postprocedure.

RESULTS

Patients presented at a median of 3.2 years (range, 9 months to 8 years) after pyeloplasty (nine open dismembered, three Culp, and three laparoscopic). Three patients (all nonstented) required a second incision. All patients were discharged from hospital within 23 hours with no complications. Symptomatic improvement was documented in all of the patients, and improved drainage was recorded in the 3-month nuclear scans.

CONCLUSION

Laser endopyelotomy is an appropriate minimally invasive procedure for postpyeloplasty stenosis. Results are better in patients with ureteric stents in situ before the procedure.

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.

[Retrograde endopyelotomy using Holmium-Yag laser for uretero-pelvic junction obstruction]

OBJECTIVE

To evaluate our results of retrograde laser endopyelotomy for uretero-pelvic junction obstruction.

MATERIAL AND METHODS

Retrospective study of 27 consecutive retrograde laser endopyelotomies performed on 24 patients over a six years period (June 1999 to July 2005). Sixteen stenoses were primary. The level of obstruction was severe in 13 patients and moderate in 14 patients. A polar pedicle was diagnosed by pre-operative CT-angiography in seven cases. Balloon dilatation was performed in 17 procedures. A double J ureteral stent remained in place for six weeks mean. We evaluated results by a clinical examination and an excretory urography (at 1 and 6 months then annually). Mean follow-up was 35+/-22.7 months.

RESULTS

Mean operating time and mean length of hospital stay were 49.8+/-17.9min and four days (range: 2-10 days). Two cases of pyelonephritis were observed. The overall success was 70%. In the eight unresolved cases, the failure appeared at 2.7+/-1 month mean. Success criteria were moderate level of obstruction and primary junction. Here, patients so selected have 100% of success.

CONCLUSION

Study confirmed retrograde laser endopyelotomy was safety with a short length of hospital stay. This minimally invasive procedure should be reserved to primary moderate stenoses without polar pedicle.

Comparison of surgical approaches to ureteropelvic junction obstruction: Endopyeloplasty versus endopyelotomy versus laparoscopic pyeloplasty

Several minimally invasive approaches to treatment of ureteropelvic junction obstruction are now in the urologist's armamentarium. This review provides in-depth analysis of endopyelotomy, endopyeloplasty, and laparoscopic pyeloplasty and suggests a treatment algorithm for proper patient selection to improve efficacy and minimize morbidity.

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.

Lasers in the upper urinary tract for non-stone disease

Though the most common use for lasers in the genitourinary tract is for urolithiasis, a number of other urologic conditions can be treated with lasers because of their unique ablative, destructive and hemostatic properties. This paper reviews the advantages and disadvantages of laser technology for a number of non-stone indications.

Ureteropelvic Junction Obstruction

PURPOSE

We quantified the burden of ureteropelvic junction obstruction in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

Inpatient hospitalization rates were highest in children younger than 3 years. Most patients were male and hospitalizations occurred almost exclusively at urban centers. Patients with a primary diagnosis of ureteropelvic junction obstruction between 1994 and 2000 had an overall decrease in the age adjusted rate of inpatient hospitalization from 1.1/100,000 to 0.8/100,000. Physician office visits by Medicare beneficiaries with ureteropelvic junction obstruction as the primary diagnosis showed stable overall age adjusted rates during the reported years. Between 1999 and 2003 mean inpatient length of stay and cost per child hospitalized with the primary diagnosis of ureteropelvic junction obstruction was 2.9 days and $7,728, respectively. Average length of stay decreased more for children than for adults but total inpatient spending remained stable at about $12 million.

CONCLUSIONS

The majority of ureteropelvic junction obstructions are diagnosed in the perinatal period. Surgical intervention for pediatric patients has decreased with time, while there has been an increasing trend toward the conservative management of this condition.

The role of percutaneous endopyelotomy for ureteropelvic junction obstruction

INTRODUCTION

Over the last 20 years, the surgical management of ureteropelvic junction obstruction (UPJO) has been revolutionised by the development of endourological instrumentation and several minimally invasive procedures including: antegrade or retrograde endopyelotomy, retrograde balloon dilatation, and laparoscopic pyeloplasty. Currently, in our department, we offer percutaneous antegrade endopyelotomy (PAE) as primary treatment of UPJO in adults, believing it offers less morbidity, better cosmetic results, and quicker operating time compared with open pyeloplasty.

PATIENTS AND METHODS

We performed a retrospective audit of our results for the 14 patients who underwent percutaneous antegrade endopyelotomy between January 2000 and May 2004.

RESULTS

Mean operative time was 53 min (range, 30-80 min), mean in-patient stay was 3.8 days (range, 2-7 days), and there were no major postoperative complications for this series with mean follow-up of 31.8 months (range, 12-52 months). Eleven out of the 14 patients (79%) showed radiological improvement on their 3-month MAG 3 (mercaptoacetyl-triglycyl) renogram, and 13 out of the 14 (93%) patients reported significant reduction or resolution of pain, compared with their preoperative state.

CONCLUSIONS

The majority of urologists still offer open pyeloplasty as primary treatment for UPJO with laparoscopic pyeloplasty currently an evolving procedure in the UK. Our series reports comparable success rates for PAE compared to other series. Despite these results, we feel that the future role of percutaneous endopyelotomy will be as a salvage procedure following failed open or laparoscopic surgery. However, in patients with concurrent stone disease or requiring antegrade ureteric access, percutaneous endopyelotomy would be suitable as a primary treatment option.

Minimally invasive treatment of ureteropelvic junction obstruction: long-term experience with an algorithm for laser endopyelotomy and laparoscopic retroperitoneal pyeloplasty

PURPOSE

First line treatment of ureteropelvic junction obstruction is still open dismembered pyeloplasty. The development of videoendoscopic techniques like endopyelotomy and laparoscopy offers less invasive alternatives. The long-term outcome of an algorithm selectively using these techniques is presented.

MATERIALS AND METHODS

From February 1995 to March 2006, 256 patients with ureteropelvic junction obstruction were treated with 113 laser endopyelotomies and 143 laparoscopic retroperitoneal pyeloplasties. According to changing selection criteria, an early group (92 in 1995 to 1999) treated with laser endopyelotomy for extrinsic as well as intrinsic stenoses, and a late group (164 in 2000 to 2006) treated with laser endopyelotomy for intrinsic stenosis, were evaluated. In the late group extrinsic ureteropelvic junction obstruction was treated with nondismembered pyeloplasty in cases of anteriorly and by dismembered pyeloplasty in cases of posteriorly crossing vessels or a redundant renal pelvis.

RESULTS

Operating time of laser endopyelotomy averaged 34 (range 10 to 90) minutes with a complication rate of 5.3% and a success rate of 72.6% (intrinsic 85.7% vs extrinsic 51.4%). Operating time of laparoscopic retroperitoneal pyeloplasty averaged 124 (range 37 to 368) minutes with a 6.3% complication rate and an overall success rate of 94.4% (intrinsic 100% vs extrinsic 93.8%). In the late group the LAP success rate was 98.3% with no significant differences related to the cause of ureteropelvic junction obstruction (intrinsic 100% vs extrinsic 98.1%) or the type of pyeloplasty (YV plasty 97.0% vs Anderson-Hynes 97.7%).

CONCLUSIONS

Laparoscopic retroperitoneal pyeloplasty yields an efficacy similar to that of open surgery. The inferior success of laser endopyelotomy even in optimally selected cases and the increasing expertise with endoscopic suturing may favor laparoscopic pyeloplasty with or without robotic assistance in the future.

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.

[Laparoscopic pyeloplasty]

Ureteropelvic junction (UPJ) obstruction in adults is usually symptomatic, secondary, and it tends to progress. Surgical correction of obstructed UPJ is necessary to preserve the renal function of the affected kidney. Pyeloplasty as a surgical management for UPJ obstruction in adults has proven its efficacy with high success rates on long-term results. Laparoscopic pyeloplasty in the management of primary or secondary UPJ obstruction in adults technically duplicate the open surgical technique. Laparoscopic pyeloplasty has developed to match success, morbidity and complication rates of open surgical pyeloplasty. However it was shown that laparoscopy had consistently a shorter convalescence than open surgery. Endopyelotomy is utilized to manage UPJ obstruction. Early results for endopyelotomy were promising but long-term results were not encouraging. In the management of UPJ obstruction in adults, long-term success rates for laparoscopic pyeloplasty were found to be superior to those of endopyelotomy. Therefore we believe that laparoscopic pyeloplasty will become as a standard management for UPJ obstruction in adults.

Repair of adult ureteropelvic junction obstruction in the solitary kidney: effect on renal function

OBJECTIVES

To evaluate the effect of pyeloplasty for the treatment of ureteropelvic junction (UPJ) obstruction on adult renal function in the setting of a solitary kidney.

METHODS

Since 1989, 312 patients have undergone operative intervention for UPJ obstruction. Of these, 13 patients (5 men and 8 women), aged 17 to 76 years (median 44.5), had a solitary kidney and were available for postoperative surveillance. Treatment consisted of endopyelotomy (n = 3), laparoscopic dismembered pyeloplasty (n = 3), and open dismembered pyeloplasty (n = 9). Two patients underwent two separate interventions for UPJ obstruction repair. Success was defined as symptomatic relief and radiographic resolution at the latest follow-up visit. In all patients, serum creatinine, estimated glomerular filtration rate, and weight were measured preoperatively, postoperatively, and at all follow-up examinations. Statistical analysis was performed to analyze group differences using the Wilcoxon signed-rank test.

RESULTS

The median follow-up was 22 months (range 2 to 96). Three patients experienced a treatment failure and were excluded from the analysis. At the latest follow-up visit, the postoperative serum creatinine had improved by a median of 0.6 mg/dL (range -0.2 to 6.3; P <0.0001), and postoperative estimated glomerular filtration rate had improved by a median of 24.4 mL/min (range -13.9 to 66; P <0.0001). No statistically significant difference in renal function was observed between the patients' first and last follow-up visits.

CONCLUSIONS

Operative intervention for the treatment of adult UPJ obstruction may result in symptomatic relief and, perhaps more importantly, renal functional improvement. These findings are important for effectively counseling patients and considering indications for intervention.

Ureteroscopic laser approach in recurrent ureteropelvic junction stenosis

OBJECTIVES

Endourological procedures are widely used for treating ureteropelvic junction (UPJ) obstruction. Our aim was to establish the value of using laser retrograde endopyelotomy (REP) in cases with recurrence.

MATERIALS AND METHODS

Between November 2000 and June 2005 we performed 30 REPs in recurrent UPJ obstruction with grades 3 and 4 hydronephrosis (failed pyeloplasty, 17 cases; failed endopyelotomy, 13 cases). Our series was characterized by absence of renal calculi, stenosis length<2 cm, and absence of massive hydronephrosis. We used semirigid and flexible endoscopic equipment (Wolf and Storz) and holmium:YAG laser. In 11 cases, an indwelling double J was placed for 2 wk. An indwelling pyelostent 8/12 F was postoperatively placed for 8 wk.

RESULTS

All cases were evaluated at 6, 12, and 18 mo. Ultrasonography and urography were the main follow-up investigations. At 6 mo, we found normal UPJ and pyelocaliceal system in 9 cases (30%); a reduction of the hydronephrosis degree with normal UPJ in 4 cases (13.3%); and no changes of the hydronephrosis degree in 17 cases (56.6%), but with large UPJ passage in 13 of the 17 cases (76.5%). REP success did not correlate with the degree of hydronephrosis. The success rate after 18 mo was 83.3%. Patients experienced minor complications. The mean follow-up period was 31 mo (range: 18-52 mo).

CONCLUSIONS

REP may represent an efficient minimally invasive technique in recurrent UPJ stenosis, with a reduced rate of complications, short period of hospitalization, and good anatomical and functional results.

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.

Prospective, Randomized Comparison of Ureteroscopic Endopyelotomy Using Holmium:YAG Laser and Balloon Catheter

PURPOSE

We compared the safety and efficacy of the 2 retrograde endopyelotomy techniques.

MATERIALS AND METHODS

A prospective study was done from January 2001 to October 2003. Preoperative radiological evaluation included excretory urography, multiphasic helical computerized tomography and diuretic renography. Exclusion criteria were marked hydronephrosis, ipsilateral renal function less than 25% and renal stones or a significant crossing vessel at the ureteropelvic junction. Eligible patients were randomized to ureteroscopic laser endopyelotomy and retrograde Acucise endopyelotomy (20 per group). UPJ obstruction was primary in 14 patients and secondary in 26. The ureteropelvic junction was incised in the lateral direction and an endopyelotomy Double-J stent (Medical Engineering Corp., New York, New York) was left for 6 weeks. Subjective and objective outcomes were evaluated 3 and 6 months after stent removal, and every 6 months thereafter.

RESULTS

Mean operative time +/- SD was comparable in the laser and Acucise groups (64.7 +/- 22.4 and 58.7 +/- 20.2, respectively). The overall complication rate in the Acucise group was more than in the laser group (25% vs 10%). At a mean followup of 29.9 +/- 10.8 months (range 6 to 48) the laser group showed a higher success rate than the Acucise group (85% vs 65%) but the difference in the complication and success rates was not statistically significant.

CONCLUSIONS

Despite the advanced endourological skills required for ureteroscopic laser endopyelotomy its safety and efficacy seem to be better than those of Acucise endopyelotomy. However, a larger number of patients is needed to confirm these findings.

Ureteroscopic Laser Endopyelotomy in Secondary UPJ Obstruction after Pyeloplasty Failure

OBJECTIVES

Secondary ureteropelvic junction (UPJ) obstruction after failure of open and laparoscopic repair may be challenging to resolve due to possible extensive fibrosis and the increased invasiveness of this procedure. Alternatively, ureteroscopic laser endopyelotomy may be a more acceptable procedure for patients and surgeons. We report our preliminary experience with ureteroscopic holmium laser endopyelotomy after open pyeloplasty failure and define the complications that arose and the results.

MATERIALS AND METHODS

We performed 6 retrograde endopyelotomies with a holmium laser for failed UPJ repairs following the Anderson-Hynes procedures. Patient follow-up was carried out every 3 months using sonography and renal scan, and again after 1 year using renal scan and urography.

RESULTS

Mean hospitalization was 2.1 days. Ureteroscopic laser endopyelotomy was successful in 4 cases (66.6%). In 2 patients, failure occurred at the third month of follow-up. Complications included 1 case of slight bleeding, which was resolved conservatively without the need for blood transfusion, and 2 cases of guidewire rupture.

CONCLUSIONS

Secondary UPJ obstruction is more challenging to resolve by open or laparoscopic approach. Retrograde endopyelotomy gives a valid alternative thanks to its success rate and its better acceptance by patients. We consider retrograde laser endopyelotomy the approach to choose when faced with secondary UPJ obstruction after open or laparoscopic failures.

Novel endourologic applications for holmium laser

The holmium laser is used routinely during endoscopic procedures to treat stones, strictures, and tumors of the urinary tract. We report two successful novel endourologic applications of a holmium laser: division and removal of a synthetic urethral sling mesh in one patient and fragmentation of a tempered stainless steel surgical needle in another.

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.

Laparoscopic radical nephroureterectomy: dilemma of the distal ureter

PURPOSE OF REVIEW

Laparoscopic nephroureterectomy has recently emerged as a safe, minimally invasive approach to upper tract urothelial cancers. The most controversial and challenging feature of laparoscopic nephroureterectomy is the management of the distal ureter. We review the most common methods of managing the distal ureter, with emphasis on contemporary oncologic outcomes, indications, advantages, and disadvantages.

RECENT FINDINGS

There are currently in excess of five different approaches to the lower ureter. These techniques often combine features of endoscopic, laparoscopic, or open management. They include open excision, a transvesical laparoscopic detachment and ligation technique, laparoscopic stapling of the distal ureter and bladder cuff, the "pluck" technique, and ureteral intussusception. Each technique has distinct advantages and disadvantages, differing not only in technical approach, but oncological principles as well. While the existing published data do not overwhelmingly support one approach over the others, the open approach remains one of the most reliable and oncologically sound procedures.

SUMMARY

The principles of surgical oncology dictate that a complete, en-bloc resection, with avoidance of tumor seeding, remains the preferred treatment of all urothelial cancers. The classical open technique of securing the distal ureter and bladder cuff achieves this principle and has withstood the test of time. Transvesical laparoscopic detachment and ligation is an oncologically valid approach in patients without bladder tumors, but is limited by technical considerations. The laparoscopic stapling technique maintains a closed system but risks leaving behind ureteral and bladder cuff segments. Both transurethral resection of the ureteral orifice (pluck) and intussusception techniques should be approached with caution, as the potential for tumor seeding exists. Additional long-term comparative outcomes are needed to solve the dilemma of the distal ureter.