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Sen H, Bayrak O, Erdem Yilmaz A, Turgut O, Ozturk M, Erturhan S, Seckiner I. Evaluation of the results of laser endopyelotomy with two different technique in ureteropelvic junction obstruction. J Pediatr Urol 2021; 17:397.e1-397.e6. [PMID: 33583746 DOI: 10.1016/j.jpurol.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
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.
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Belikov AV, Skrypnik AV. Soft tissue cutting efficiency by 980 nm laser with carbon-, erbium-, and titanium-doped optothermal fiber converters. Lasers Surg Med 2018; 51:185-200. [DOI: 10.1002/lsm.23006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2018] [Indexed: 11/10/2022]
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Rassweiler J, Klein J, Goezen AS. Retroperitoneal laparoscopic non-dismembered pyeloplasty for uretero-pelvic junction obstruction due to crossing vessels: A matched-paired analysis and review of literature. Asian J Urol 2018; 5:172-181. [PMID: 29988898 PMCID: PMC6033199 DOI: 10.1016/j.ajur.2018.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/21/2017] [Accepted: 10/30/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To compare laparoscopic Anderson-Hynes pyeloplasty (LAHP) and retroperitoneal laparoscopic YV-pyeloplasty (LRYVP) in ureteropelvic junction obstruction (UPJ) in presence of a crossing vessels (CV). METHODS Our database showed 380 UPJO-cases,who underwent laparoscopic retroperitoneal surgery during the last 2 decades including 206 non-dismembered LRYVP, 157 dismembered pyeloplasties LAHP, and 17 cases of laparoscopic ureterolysis. Among them 198 cases were suitable for a matched-pair (2:1) analysis comparing laparoscopic retroperitoneal non-dismembered LRYVP (Group 1, n = 131) and dismembered LAHP (Group 2, n = 67) in presence of a crossing vessel. Patients were matched according to age, gender, kidney functions, and obstruction grade. Complications were graded according to modified Clavien-classification. RESULTS Comparative data were similar between both groups (LRYVP vs. LAHP) including mean operating time (112 min vs. 114 min), complication rates (4.2% vs. 7.3%) mainly Grade 1-2 according to Clavien classification, and success rates (90% vs. 89%). These results reflected in the reviewed literature indicate that LRYVP provides the advantage of minimal dissection in case of CV with similar outcome. However, redundant pelvis and anteriorly crossing vessels still require a dismembered pyeloplasty LAHP. CONCLUSION LRYVP has achieved similar results compared with the previous golden standard of open surgery, especially in case of crossing vessels apart from presence of a redundant pelvis or anteriorly crossing vessel. This can be further improved when using the small access retroperitoneoscopic technique respectively mini-laparoscopy.
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Affiliation(s)
- Jens Rassweiler
- Department of Urology and Pediatric Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heibronn, Germany
| | - Jan Klein
- Department of Urology, Medical School Ulm, University of Ulm, Ulm, Germany
| | - Ali Serdar Goezen
- Department of Urology and Pediatric Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heibronn, Germany
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Elmussareh M, Traxer O, Somani BK, Biyani CS. Laser Endopyelotomy in the Management of Pelviureteric Junction Obstruction in Adults: A Systematic Review of the Literature. Urology 2017; 107:11-22. [PMID: 28438625 DOI: 10.1016/j.urology.2017.04.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/10/2017] [Accepted: 04/14/2017] [Indexed: 11/29/2022]
Abstract
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%.
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Affiliation(s)
- Muhammad Elmussareh
- St James's University Hospital, Leeds Teaching Hospital Trust, Leeds, United Kingdom
| | - Olivier Traxer
- Department of Urology, GRC Lithiase Université Paris 6, Paris, France
| | - Bhaskar Kumar Somani
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Khan F, Ahmed K, Lee N, Challacombe B, Khan MS, Dasgupta P. Management of ureteropelvic junction obstruction in adults. Nat Rev Urol 2014; 11:629-38. [PMID: 25287785 DOI: 10.1038/nrurol.2014.240] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Pelviureteric junction obstruction (PUJO) of the kidney can lead to a number of different clinical manifestations, which often require surgical intervention. Although the success of pyeloplasty and endopyelotomy are good, there are still a number of patients who fail primary treatment and develop secondary PUJO. These treatment failures can be a challenging cohort to manage. This article aims to provide a comprehensive overview on the surgical options available to the urologist for managing secondary PUJO as well as providing some guidance on assessing factors that will influence management decisions.
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Affiliation(s)
- Alistair Rogers
- Department of Urology, Freeman Hospital, Heaton, Newcastle upon Tyne, NE7 7DN, UK
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Ureteroscopic holmium:YAG laser endopyelotomy is effective in distinctive ureteropelvic junction obstructions. Wideochir Inne Tech Maloinwazyjne 2011; 6:144-9. [PMID: 23255973 PMCID: PMC3516940 DOI: 10.5114/wiitm.2011.24692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 06/02/2011] [Accepted: 06/10/2011] [Indexed: 11/17/2022] Open
Abstract
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.
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Abstract
PURPOSE OF REVIEW Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery. RECENT FINDINGS We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited. SUMMARY Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.
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Acher PL, Nair R, Abburaju JS, Dickinson IK, Vohra A, Sriprasad S. Ureteroscopic holmium laser endopyelotomy for ureteropelvic junction stenosis after pyeloplasty. J Endourol 2009; 23:899-902. [PMID: 19459754 DOI: 10.1089/end.2008.0550] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Peter L Acher
- Department of Urology, Darent Valley Hospital, Dartford, Kent, United Kingdom.
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Arrabal-Martín M, Jiménez-Pacheco A, Arrabal-Polo MA, Guardia FVDDL, López-León V, Zuluaga-Gómez A. Cold cutting of ureteral stenosis with endoscopic scissors. Urology 2009; 74:422-6. [PMID: 19428079 DOI: 10.1016/j.urology.2008.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Revised: 10/22/2008] [Accepted: 11/23/2008] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Miguel Arrabal-Martín
- Department of Urology, "San Cecilio" University Hospital, Granada, Andalucia, Spain.
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Canes D, Berger A, Gettman MT, Desai MM. Minimally Invasive Approaches to Ureteropelvic Junction Obstruction. Urol Clin North Am 2008; 35:425-39, viii. [DOI: 10.1016/j.ucl.2008.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Complications of laparoscopic pyeloplasty. World J Urol 2008; 26:539-47. [DOI: 10.1007/s00345-008-0266-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 04/12/2008] [Indexed: 10/22/2022] Open
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Rassweiler JJ, Subotic S, Feist-Schwenk M, Sugiono M, Schulze M, Teber D, Frede T. Minimally invasive treatment of ureteropelvic junction obstruction: long-term experience with an algorithm for laser endopyelotomy and laparoscopic retroperitoneal pyeloplasty. J Urol 2007; 177:1000-5. [PMID: 17296396 DOI: 10.1016/j.juro.2006.10.049] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Jens J Rassweiler
- Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heidelberg, Germany.
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el-Nahas AR. Retrograde endopyelotomy: a comparison between laser and Acucise balloon cutting catheter. Curr Urol Rep 2007; 8:122-7. [PMID: 17303017 DOI: 10.1007/s11934-007-0061-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Ahmed R el-Nahas
- Urology and Nephrology Center, Mansoura University, El-Gomhoria Street, PO: 35516, Mansoura, Egypt.
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Ponsky LE, Streem SB. Retrograde endopyelotomy: a comparative study of hot-wire balloon and ureteroscopic laser. J Endourol 2007; 20:823-6. [PMID: 17094762 DOI: 10.1089/end.2006.20.823] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE This study compared the immediate and long-term results and complications of hot-wire balloon endopyelotomy and ureteroscopic holmium laser endopyelotomy. PATIENTS AND METHODS Between March 1994 and January 2002, 64 patients with a primary (N = 52) or secondary (N = 12) ureteropelvic junction obstruction underwent retrograde endopyelotomy using either a fluoroscopically guided hot-wire balloon incision (N = 27) or a ureteroscopically guided, direct-vision holmium laser incision (N = 37). This study group included 46 women and 18 men aged 13 to 79 years (mean 38.9 years). The indications and contraindications to a retrograde approach were identical in each group and included documented functionally significant evidence of obstruction, no upper-tract stones, obstruction <2 cm, and no radiographic evidence of entanglement of crossing vessels at the ureteropelvic junction. Immediate and long-term outcomes were obtained from a prospective registry, with success defined as resolution of symptoms and radiographic relief of obstruction as determined by follow-up with intravenous urography, diuretic renography, or both. Follow-up ranged from 39 to 133 months (mean 75.6 months). RESULTS Length of hospital stay, indwelling stent duration, and long-term success rates (77.8% v 74.2% in the hot-wire balloon and holmium-laser group, respectively) were equivalent. However, two patients in the hot-wire balloon group developed bleeding necessitating transfusion and selective embolization of lower-pole vessels. No patient in the ureteroscopic group suffered a major complication. CONCLUSIONS These two alternatives for retrograde endopyelotomy provide comparable success rates for similarly selected patients. However, because significant hemorrhagic complications developed with greater frequency in those treated with the hot-wire balloon, our preference is for a ureteroscopic approach, as it allows direct visual control of the incision and thus, a lower risk of significant bleeding.
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Affiliation(s)
- Lee E Ponsky
- Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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Geavlete P, Georgescu D, Mirciulescu V, Niţă G. Ureteroscopic laser approach in recurrent ureteropelvic junction stenosis. Eur Urol 2006; 51:1542-8. [PMID: 17005317 DOI: 10.1016/j.eururo.2006.08.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 08/20/2006] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Petrişor Geavlete
- Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania.
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Minervini A, Davenport K, Keeley FX, Timoney AG. Antegrade versus Retrograde Endopyelotomy for Pelvi-Ureteric Junction (PUJ) Obstruction. Eur Urol 2006; 49:536-42; discussion 542-3. [PMID: 16457941 DOI: 10.1016/j.eururo.2005.11.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Accepted: 11/24/2005] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Andrea Minervini
- Department of Urology, University of Florence, Careggi Hospital, Florence, Italy
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Manikandan R, Saad A, Bhatt RI, Neilson D. Minimally invasive surgery for pelviureteral junction obstruction in adults: A critical review of the options. Urology 2005; 65:422-32. [PMID: 15780349 DOI: 10.1016/j.urology.2004.08.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2004] [Accepted: 08/20/2004] [Indexed: 10/25/2022]
Affiliation(s)
- R Manikandan
- Department of Urology, Hope Hospital, Manchester, United Kingdom.
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Abstract
The ablation of tissue by laser has several applications in urology. Most of the published research has been concerned with the treatment of benign prostatic hyperplasia (BPH). Other applications studied include superficial upper- and lower-tract transitional-cell carcinoma, urethral and ureteral strictures, ureteropelvic junction stenosis, and posterior urethral valves. The attraction of laser ablation for the treatment of BPH lies with the decreased morbidity in comparison with standard transurethral electrocautery resection of the prostate and the ability to remove tissue immediately and therefore allow a more rapid progression to catheter removal and early voiding. The three main laser wavelengths used in urology for tissue ablation are the neodymium:yttrium-aluminum-garnet when used with contact tips or high-density power settings, the potassium-titanyl-phosphate, and the holmium:YAG. This article reviews the published literature on the use of these laser wavelengths in soft-tissue ablation, focusing on the treatment of BPH.
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Abstract
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.
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Affiliation(s)
- Freddy R Mendez-Torres
- Department of Urology, Section of Minimally Invasive Urologic Surgery, Tulane University Health Sciences Center, 1430 Tulane Avenue, SL-42, New Orleans, LA 70112, USA
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Abstract
Ureteroscopy developed as an extension of cystoscopic techniques into the upper urinary tract with smaller, rigid, and flexible endoscopes. Smaller working instruments have made therapeutic procedures possible. Ureteroscopy has become the technique of choice to diagnose and treat benign essential hematuria and has a major role in treating ureteropelvic junction obstruction, upper tract neoplasms, and calculi. Finally, there is a need for smaller and more effective endoscopes and working devices.
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Affiliation(s)
- Demetrius H Bagley
- Department of Urology, Jefferson Medical College, Thomas Jefferson University, 1025 Walnut Street, Room 1108, Philadelphia, PA 19107, USA.
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Abstract
PURPOSE We review our experience with ureteroscopic endopyelotomy using a holmium laser for correction of ureteropelvic junction (UPJ) obstruction in order to further define the immediate and long-term results and complications. PATIENTS AND METHODS From 1999 to 2002, 11 men and 34 women (mean age 42 years) underwent 46 ureteroscopic holmium laser endopyelotomy procedures for treatment of primary (N=40) or secondary (N=5) UPJ obstruction. The inclusion criteria were a short (<2-cm) obstruction and absence of ipsilateral renal calculi. Demographic, intraoperative, and postoperative measures were obtained from a prospectively designed and updated database. The endopyelotomy was performed under direct vision using a semirigid (N=40) or flexible (N=5) ureteroscope with a laser setting of 1 J at 10 Hz. Radiographic confirmation of obstruction and the results of intervention was obtained by combinations of intravenous and diuretic urography, diuretic renography, ultrasonography, and CT. The first postoperative and latest radiographic follow-up studies were compared with the preoperative studies to determine whether the obstruction was resolved, unchanged, or worsened. Success was defined as symptomatic relief and radiographic resolution. RESULTS The mean operative time was 65 minutes (range 10-153 minutes). There were no intraoperative complications, although 5 patients (11.1%) experienced postoperative complications consisting of subcapsular hematoma, pyelonephritis, sepsis, urinary retention, or dysrhythmia. Forty-two patients (93%) had a hospital stay of <23 hours. Stents were removed 3 to 8 weeks (mean 5 weeks) postoperatively. The mean length of follow-up was 23.2 months (range 5-43 months). Symptoms were resolved in 65.4% of patients, improved in 7.7%, unchanged in 11.5%, and worse in 15.4%. Radiographically, at latest follow-up, the obstruction was resolved in 73.1% of patients, unchanged in 23.1%, and worse in 3.8%. Primary UPJ obstruction was associated with a symptomatic success rate of 68% compared with only 50% for secondary UPJ obstruction. CONCLUSIONS Ureteroscopic laser endopyelotomy is a minimally invasive, short-stay outpatient procedure associated with a 65.4% symptomatic and 73.1% radiographic success rate. In contrast to the findings in previous reports of results of retrograde or antegrade endopyelotomy, patients treated for primary UPJ obstruction experienced higher rates of success than those with secondary obstruction.
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Affiliation(s)
- Surena F Matin
- Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
In addition to the classic open surgery, a variety of minimally invasive therapeutic options have been developed for the treatment of ureteropelvic junction obstruction, including an endoscopic antegrade or retrograde ureteropelvic junction obstruction visually controlled incision or radioscopically controlled Acucise (Applied Medical, Laguna Hills, CA), which does not share the high success rate that results from open-surgical dismembered pyeloplasty. Laparoscopic pyeloplasty, which duplicates the open technique and differs only by the mode of access, has proven to have positive results when performed by experts, but remains a demanding technique that requires a long learning curve. Providing a three-dimensional vision, an unprecedented control of the endocorporeal instruments, and an ergonomic surgeon's position, robots may allow urologists with limited laparoscopic experience to rapidly master the endocorporeal management of ureteropelvic junction obstruction. They likely will propel minimally invasive urology forward in the next several years.
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Affiliation(s)
- Jacques Hubert
- Service d'Urologie, CHU De NANCY-Brabois, 54511 Vandoeuvre Les Nancy, France.
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25
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Abstract
PURPOSE Although open pyeloplasty remains the gold standard for treating ureteropelvic junction obstruction, endourology and laparoscopy have revolutionized the management of upper tract stenosis. We present our diagnostic and minimally invasive therapeutic algorithm for the treatment of ureteropelvic junction obstruction. MATERIALS AND METHODS A total of 13 females and 9 males with a mean age of 34.2 years suffering from ureteropelvic junction obstruction were treated with percutaneous endopyelotomy or laparoscopic dismembered pyeloplasty and followed for 47 to 61 months (mean 53.8) and 47 to 62 months (mean 52.5), respectively. Diagnosis was based on findings of ultrasound, excretory urography, furosemide washout renogram and retrograde ureteropyelography. In cases of ureteral kinking color duplex sonography and spiral computerized tomography were performed. In 14 patients with intrinsic stenosis percutaneous endopyelotomy was performed, while the remaining 8 patients (5 with crossing vessels, 2 with an extremely distended pelvis and 1 with a 2.5 cm. stricture) were treated with a laparoscopic dismembered Anderson-Hynes pyeloplasty. RESULTS In the endopyelotomy group (success rate 92.8%), mean operation time was 1.2 hours, estimated blood loss was 152 ml., unit doses of analgesics were 5.4 tablets, days of hospitalization were 4.2 and time to return to normal activities was 15.7 days. In the laparoscopic group (success rate of 100%) the aforementioned variables were 3.5 hours (p <0.05), 150 ml., 6.3 tablets, 5 and 17.8 days, respectively. Long-term followup excretory urography and/or diuretic renal scan demonstrated improvement in all patients. CONCLUSIONS Percutaneous endopyelotomy should be the treatment of choice for intrinsic ureteropelvic junction obstruction. Laparoscopic dismembered pyeloplasty, although technically challenging, provides excellent results for extrinsic or complicated ureteropelvic junction stenosis.
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Abstract
At this moment in time, endourology is incorporating extraluminal endoscopic techniques (laparoscopy, lumboscopy, retziuscopy), which the urologist is expected to master. The current advanced stage of development of intraluminal endoscopic surgery is mainly due to the most recent technological achievements (miniaturization of the lens, the use of more versatile materials and new energy sources). In the current cystourethroscopic procedures, compact endoscopes and flexible cystoscopes play an important role. The most important of these new techniques include tissue vaporisation procedures, interstitial application of substances or energies, low-pressure transurethral resection and percutaneous vesical surgery. Upper endoluminal procedures have been the ones to most benefit from modern technological developments. The most important features of present day ureterorenoscopes and their clinical applications are studied and also those of percutaneous nephroscopy (lithiasis, neoformations and others). In a review on the current situation of extraluminal endoscopy, a wide range of laparoscopic techniques--applicable to adrenal regions, kidneys, ureters, retroperitoneal and lymphatic systems, testicles and sperm ducts, bladder and prostrate gland--are discussed as well as the indications, advantages and drawbacks involved and the preferential surgical approaches.
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Affiliation(s)
- J G Valdivia Uría
- Servicio de Urología, Hospital Clínico Universitario Lozano Blesa, Zaragoza
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Hatsuse K, Ono Y, Kinukawa T, Hirabayashi S, Hattori R, Yamada S, Ohshima S. Long-term results of endopyeloureterotomy using the transpelvic extraureteral approach. Urology 2002; 60:233-7; discussion 237-8. [PMID: 12137816 DOI: 10.1016/s0090-4295(02)01756-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Katsuro Hatsuse
- Department of Urology, Narita Memorial Hospital, Toyohashi, Aichi, Japan
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Abstract
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.
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Affiliation(s)
- P J Van Cangh
- Department of Urology, Catholic University of Louvain Medical School, Cliniques Universitaires St. Luc, 10 Avenue Hippocrate, B-1200 Brussels, Belgium.
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Kim HL, Hollowell CM, Patel RV, Bales GT, Clayman RV, Gerber GS. Use of new technology in endourology and laparoscopy by american urologists: internet and postal survey. Urology 2000; 56:760-5. [PMID: 11068295 DOI: 10.1016/s0090-4295(00)00731-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess the use of new technology by American urologists. METHODS Using the American Urological Association directory, surveys were sent via the U.S. postal service to 1000 randomly selected American urologists and 3065 urologists who had an Internet address listed in the directory. RESULTS Responses were received from 601 urologists (415 postal, 186 Internet). Overall, 81% of survey respondents reported performing fewer or the same number of percutaneous procedures as compared with 3 to 4 years ago and 84% reported carrying out more or the same number of ureteroscopic procedures in the treatment of patients with stone disease. Open dismembered pyeloplasty (43%) and Acucise endopyelotomy (42%) were most frequently reported as the preferred treatment for adult patients with symptomatic ureteropelvic junction obstruction. Although 60% of respondents reported that they have taken a laparoscopy course, 67% currently do not perform any laparoscopy in their practice. In addition, only 7% of urologists stated that laparoscopy comprises more than 5% of their practice. When stratified by the number of years in practice, those in practice less than 10 years were more likely than those in practice 10 to 20 years and those in practice longer than 20 years to have performed an endopyelotomy (77%, 60%, and 48%, respectively, P <0.001) and to be currently performing laparoscopy (49%, 36%, and 18%, respectively, P <0.001). CONCLUSIONS Compared with 3 to 4 years ago, American urologists are performing more ureteroscopy and fewer percutaneous stone procedures. Although most urologists have taken laparoscopy courses, this modality has not been widely incorporated into their practices at present.
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Affiliation(s)
- H L Kim
- Section of Urology, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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GIDDENS JONATHANL, GRASSO MICHAEL. RETROGRADE URETEROSCOPIC ENDOPYELOTOMY USING THE HOLMIUM: YAG LASER. J Urol 2000. [DOI: 10.1016/s0022-5347(05)67017-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- JONATHAN L. GIDDENS
- From the Department of Urology, New York University Medical Center, New York University School of Medicine, New York, New York
| | - MICHAEL GRASSO
- From the Department of Urology, New York University Medical Center, New York University School of Medicine, New York, New York
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Bernardo NO, Liatsikos EN, Dinlenc CZ, Kapoor R, Fogarty JD, Smith AD. Stone recurrence after endopyelotomy. Urology 2000; 56:378-81. [PMID: 10962298 DOI: 10.1016/s0090-4295(00)00670-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate whether repair of the ureteropelvic junction (UPJ) obstruction reduces the incidence of stones in stone-forming patients with concurrent UPJ obstruction. METHODS We performed a retrospective study evaluating 90 patients with UPJ obstruction who underwent endopyelotomy and simultaneous stone extraction (group A) and 80 patients without UPJ obstruction who underwent only stone extraction (group B). Group A consisted of 52 men and 38 women with an average age of 54.4 years (range 15 to 82), and group B of 46 men and 34 women with an average age of 53.5 years (range 8 to 94). Metabolic evaluation was available in 47 patients of group A and 42 patients of group B. RESULTS We achieved a stone-free state in all patients of both groups. Stone recurrence was observed in 7 patients (8%) in group A and in 32 patients (40%) in group B. Nine of 47 patients (19%) in group A showed metabolic abnormalities. In group B we found 30 of 42 patients (71.4%) with metabolic abnormalities. CONCLUSIONS Our results suggest that correction of the anatomic obstruction facilitates the drainage of the previously entrapped urine, and thus decreases the incidence of recurrent urinary stone formation.
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Affiliation(s)
- N O Bernardo
- Department of Urology, Albert Einstein College of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York 11040, USA
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Abstract
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.
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Affiliation(s)
- G Janetschek
- Department of Urology, University of Vienna, Austria
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Gerber GS, Kim JC. Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction. Urology 2000; 55:198-202; discussion 202-3. [PMID: 10688078 DOI: 10.1016/s0090-4295(99)00530-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the effectiveness and morbidity of ureteroscopic endopyelotomy in adults with ureteropelvic junction (UPJ) obstruction. METHODS Twenty-two patients (13 women, 9 men) with a mean age of 44 years (range 18 to 86) underwent retrograde ureteroscopic endopyelotomy in the treatment of primary (n = 18) or secondary (n = 4) UPJ obstruction. All procedures were performed using a 6F to 8.5F semirigid ureteroscope with either a 3F electrocautery probe (n = 16) or a 365-microm holmium laser fiber (n = 6). Postoperatively, a tapered 14/7F endoureterotomy stent (n = 11) or standard 7F to 8F double pigtail stent (n = 11) was left in place for 6 to 7 weeks. Radiographic follow-up was obtained using intravenous urography or renal scintigraphy. RESULTS With a median follow-up of 20.5 months, the success rate was 82% (18 of 22 patients). Follow-up of at least 6 and 12 months was available in 21 (95%) and 17 (77%) of 22 patients, respectively. The mean operative duration was 63 minutes, and all but 1 patient was hospitalized for less than 24 hours. No bleeding complications or other serious morbidity were encountered. No difference in treatment outcome was found on the basis of the size of the stent placed postoperatively, the incision type (cautery versus laser), or the etiology of the obstruction. CONCLUSIONS Ureteroscopic endopyelotomy is an effective, minimally invasive treatment option for patients with primary or secondary UPJ obstruction.
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Affiliation(s)
- G S Gerber
- Department of Surgery, University of Chicago Pritzker School of Medicine, Illinois 60637, USA
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