Retrograde Acucise Endopyelotomy: Is It Worth Its Cost?

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.

Laparoscopic pyeloplasty in a solitary kidney

BACKGROUND

A 40-year-old male presented with right-sided abdominal pain and no lower urinary tract symptoms. Examination was unremarkable, apart from mild right renal angle tenderness.

INVESTIGATIONS

Renal function, full blood count and C-reactive protein levels were all normal. Ultrasound of renal tract, abdominal computed tomography (CT) and (99m)Tc-mercaptoacetyltriglycine (MAG3) renogram confirmed ureteropelvic junction obstruction.

DIAGNOSIS

The ureteropelvic junction obstruction of the right kidney was identified, with a crossing lower pole renal vessel as the possible cause. An absent left kidney was also noted.

MANAGEMENT

Laparoscopic transperitoneal dismembered Anderson-Hynes pyeloplasty was performed, with posterior transposition of the crossing lower pole vessel.

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.

Acucise endopyelotomy: A technique with limited efficacy for primary ureteropelvic junction obstruction in adults

AIM

To retrospectively evaluate the ef fi cacy of Acucise endopyelotomy in a series of patients with primary ureteropelvic junction obstruction (UPJO).

METHODS

Twenty-four patients with a symptomatic primary UPJO underwent Acucise endopyelotomy. Patients with high-grade hydronephrosis and/or poor renal function were excluded. Patients were followed by ultrasound imaging, intravenous urography, diuretic renography, and clinical review.

RESULTS

The overall success rate was 58% (14/24 patients), with a median follow up of 32 months. Of the ten patients in whom Acucise endopyelotomy failed, seven underwent open pyeloplasty, one required nephrectomy, and two received a permanent ureteral stent. A poor outcome was noted in patients without perioperative extravasation.

CONCLUSIONS

Our experience with Acucise endopyelotomy indicates that the success rate is lower than initially reported. Larger studies are needed to clarify the role of Acucise endopyelotomy in comparison with other techniques.