MANAGEMENT OF SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION AFTER FAILED PRIMARY LAPAROSCOPIC PYELOPLASTY

Pelviureteric junction obstruction in adults: A systematic review of the literature

Background

Pelviureteric junction obstruction (PUJO) is a common urological disorder that can present at any stage of life. The underlying etiology in children has been well studied; however, a gap exists in the literature for the adult population. Herein, we performed a systematic review of the literature to evaluate the current evidence on the underlying etiologies of adult patients presenting with PUJO.

Materials and methods

Four electronic databases were searched for relevant studies assessing the underlying etiologies of pelviureteric junction obstruction in adults. Studies were assessed for eligibility based on predefined inclusion and exclusion criteria, and a critical appraisal of methodological quality and risk of bias was performed. Finally, qualitative and quantitative data analyses were performed.

Results

Twelve studies comprising a total of 513 patients with radiologically confirmed PUJO met the inclusion criteria and were included in our analysis. The most common finding was crossing vessels, which were observed in 50.5% of patients, followed by intrinsic ureteral stenosis (27.1%), adhesions (15.3%), and high insertion of the ureter (10.1%).

Conclusions

The underlying etiologies of PUJO in adults remain unclear. This study indicated that obstruction secondary to crossing vessels is the most common cause of obstruction in adults and occurs more frequently than in the pediatric population.

Salvage minimally invasive robotic and laparoscopic pyeloplasty in adults: a systematic review

Introduction

A UPJO is a blockage of the ureter that affects urine flow. UPJO is mainly treated by an open approach, however, in recent years minimally invasive techniques are taking place. These techniques include robotic and laparoscopic pyeloplasty. Some patients require a redo after a primary intervention. A systematic review was conducted through the examinations of the efficacy and safety of a robotic redo pyeloplasty in adult patients from previous literature reviews.

Methods

A literature search was made through PubMed. A selection process was done based on our eligibility criteria. The data were represented numerically, listed on tables and analyzed cumulatively using Microsoft Excel.

Results

Twenty studies were included in this review, of which nine were studies on robotic outcomes () (157 patients), 10 on laparoscopic (210 patients), and one review by Zhang et al., focused on both types of surgeries. Two papers (24 patients) from the robotic studies and one paper (21 patients) from the laparoscopic studies were excluded from the intra and post-operative characteristics because not enough data were available and were only included for the success and complication rates. The success rate for the robotic studies was 88.5% while the laparoscopic studies had a success rate of 91%. However, the robotic studies had a complication rate of (11.8%) while the laparoscopic studies had a complication rate of (15.9%). Conversion surgery was required in one patient undergoing laparoscopic surgery.

Conclusion

The minimally invasive methods are becoming more viable in adult patients with rUPJO, considering its effectiveness and fast recovery. This can lead to a new era of robotic assisted surgeries to becoming the gold standard.Abbreviations: Systematic review: Redo robotic and laparoscopic pyeloplasty in adults; UPJO = Ureteropelvic junction obstruction; rUPJO = redo ureteropelvic junction obstruction.

Comparison of Secondary and Primary Minimally Invasive Pyeloplasty in the Treatment of Ureteropelvic Junction Obstruction: A Systematic Review and Meta-Analysis

Objective: To compare the outcomes of secondary minimally invasive pyeloplasty (MIP) versus primary MIP for the patients with ureteropelvic junction obstruction (UPJO). Materials and Methods: We searched all the literature of PubMed, Web of Science, EMBASE, and Cochrane Library comparing secondary MIP and primary MIP and performed a systematic review and meta-analysis. Results: We included 15 studies involving 1637 patients with 1371 in the primary MIP group and 266 in the secondary MIP group. There were no significant differences in length of hospital stays, and the risk of hematuria, urinary tract infection, intestinal obstruction, stent complications, and overall complications (P > .05). Comparing with the secondary MIP group, the primary MIP group has shorter operative time (mean difference [MD] = -36.91 minutes, 95% confidence interval [CI]: -50.21 to -23.62, P < .00001), less estimated blood loss (MD = -16.70 mL, 95% CI: -31.60 to -1.80, P = .03), lower risk of urinary leakage and injury of blood vessel (relative risk [RR] = 0.32, 95% CI: 0.11-0.93, P = .04) (RR = 0.10, 95% CI: 0.02-0.61, P = .01), and higher success rate (RR = 1.07, 95% CI: 1.02-1.11, P = .003). The robot-assisted pyeloplasty is superior to the laparoscopic pyeloplasty in controlling the amount of blood loss in the secondary operation. Conclusions: Considering the poorer outcomes of secondary surgery, we believe that special attention should be paid to not missing crossing vessels, and it would be more prudent to perform a more definitive procedure with pyeloplasty instead of endopyelotomy for primary UPJO.

Redo laparoscopic pyeloplasty for recurrent ureteropelvic junction obstruction: Propensity score matched analyses of a high-volume center

PURPOSE

Review the experience of redo laparoscopic pyeloplasty (RLP) in patients with recurrent ureteropelvic junction obstruction (UPJO) in comparison to primary laparoscopic pyeloplasty (PLP) and redo open pyeloplasty (ROP), and determine the feasibility and effectiveness of RLP for recurrent UPJO in children.

METHODS

We retrospectively reviewed the clinical data of patients treated with transperitoneal PLP, RLP, and ROP for UPJO from December 2015 to December 2022. The Propensity score matching (PSM) was used to balance confounding variables. RLP patients were 1:4 matched with PLP and 1:3 matched with ROP. The primary outcomes were failure and post-operative complications. Complications were classified according to the Clavien-Dindo grading system.

RESULTS

The study included ten patients who underwent RLP, 43 patients who underwent ROP, and 412 patients who underwent PLP. The follow-up time ranged from 6 to 36 months in the RLP group, 12 to 60 months in the PLP group, and 24 to 54 months in the ROP group. In the RLP group, no failure but three post-operative complications (Clavien grade II) were observed during the follow-up. Compared with the PLP group, the older age, higher weight, larger pre-operative anteroposterior diameter (APD) and APD/cortical thickness (P/C ratio), longer operation time, and post-operative length of stay (LOS) in the RLP group (P < 0.05). After PSM, longer operation time and post-operative LOS were observed in the RLP group (P < 0.05). Compared with the ROP group, the older age, higher weight, and longer post-operative LOS in the RLP group (P < 0.05). After PSM, longer post-operative LOS was observed in the ROP group (P < 0.05). The failure and complication rates were comparable between RLP and PLP or RLP and ROP (P > 0.05).

CONCLUSIONS

Our result demonstrated that RLP performed as well as PLP except for a longer operation time. Compared with ROP, RLP has the advantages of a clearer surgical view, sufficient exposure, clearer anatomical landmark position, and minor trauma with a comparable clinical outcome. On experienced hands, RLP for recurrent UPJO after is a safe and effective procedure and should be considered an excellent alternative to the more commonly recommended ROP in select patients.

Concomitant management of renal calculi and recurrent ureteropelvic junction obstruction with percutaneous nephrolithotomy and antegrade balloon dilation

Objective

This study aimed to present our experience of concomitant management of renal calculi and recurrent ureteropelvic junction obstruction (UPJO) with percutaneous nephrolithotomy (PCNL) and antegrade balloon dilation.

Methods

We retrospectively reviewed 31 patients who underwent PCNL and antegrade balloon dilation for treatment of renal calculi and recurrent UPJO. The inclusion criterion was the presence of UPJO after failed pyeloplasty with ipsilateral renal calculi. Success was defined as achievement of both symptomatic and radiographic resolution of any stones and obstruction.

Results

All operations were successful without grade III or higher postoperative complications. A stone-free status was observed in all patients and the overall success rate of the procedure was 87.1% (27/31). The success rate of the procedure was significantly higher in patients with mild or moderate preoperative hydronephrosis (96%) than in those with high-grade preoperative hydronephrosis (50%). Moreover, the success rate of the procedure was lower in patients with poor preoperative renal function (0%) than in those with good or moderate renal function (93.1%).

Conclusion

Combined PCNL and antegrade balloon dilation management represents a safe and effective approach for patients with renal calculi and recurrent UPJO after failed pyeloplasty.

Risk Factors and Management Options for the Adult Failed Ureteropelvic Junction Obstruction Repair in the Era of Minimally Invasive and Robotic Approaches: A Comprehensive Literature Review

Guidelines for the management of pyeloplasty failure remain elusive given the rarity of this condition and the difficulty of integrating and analyzing reported outcomes given the varying definition of failures. In this article, we aim to review the existing literature on risk factors that may influence the surgical outcomes of reconstructive pyeloplasty for ureteropelvic junction obstruction. Furthermore, we discuss management options and review success outcomes of treatment options for patients with pyeloplasty failure.

Laparoscopic pyeloplasty versus open pyeloplasty for recurrent ureteropelvic junction obstruction in children

INTRODUCTION AND OBJECTIVES

Recurrent ureteropelvic junction obstruction (UPJO) in children is an operative challenge. Minimally invasive endourological treatment options for secondary UPJO have suboptimal success rates; hence, there is a re-emergence of interest about redo pyeloplasty. The present study presented experience with laparoscopic management of previously failed pyeloplasty compared with open redo pyeloplasty in children.

STUDY DESIGN

Twenty-four children with recurrent UPJO who underwent transperitoneal dismembered laparoscopic pyeloplasty were studied. Operative, postoperative, and follow-up functional details were recorded and compared with those of open pyeloplasty (n = 15) carried out for recurrent UPJO by the same surgeon during the same study period.

RESULTS

Demographic data were comparable in the laparoscopic and open groups, except for a significantly lower GFR in the open group (24.8 vs 38.2 ml/min, P = 0.0001). Mean time to failure of the original repair was 20.2 months (23.6 months for redo laparoscopic pyeloplasty, 18.8 months for redo open). The success rate of laparoscopic redo pyeloplasty was 91.7 vs 100% in open redo pyeloplasty. Compared with redo open pyeloplasty, the mean operative time was longer (211.4 ± 32.2 vs 148.8 ± 16.6, P = 0.002), estimated blood loss was higher (102 vs 75 ml, P = 0.06), while hospital stay was shorter and pain score was lower in the laparoscopy group (P = 0.02) in the laparoscopic group. There were no intraoperative complications, while the postoperative complication rate was similar in the two groups (20.8 vs 20.0%).

DISCUSSION

Before the laparoscopic approach became a viable option, endopyelotomy was widely used for managing recurrent UPJO. However, the success rate of endopyelotomy for secondary UPJO was approximately 10-25% lower than for open pyeloplasty. Redo pyeloplasty had excellent results, with reported success rates of 77.8-100%. Laparoscopic redo pyeloplasty is becoming a viable alternative to open redo pyeloplasty in many centers with experience in minimally invasive techniques. The present study revealed that redo laparoscopic pyeloplasty appeared to have advantages over redo open surgery, in that it was associated with shorter hospital stay (4 vs 6 days, P = 0.046), reduced postoperative pain score (P = 0.02), and less need for postoperative analgesia (P = 0.001), still with comparable successful outcomes and patient safety. However, the procedure had a longer operative times and more blood loss.

CONCLUSION

Laparoscopic pyeloplasty is a viable alternative to open pyeloplasty in children with recurrent UPJO, with shorter hospital stays and less postoperative pain. However, the procedure is technically demanding and should be attempted in high-volume centers by laparoscopists with considerable experience in laparoscopic reconstructive procedures.

Matched comparison of primary versus salvage laparoscopic pyeloplasty

PURPOSE

To compare our experience with salvage laparoscopic pyeloplasty, using a matched control set of primary laparoscopic pyeloplasty patients.

METHODS

We retrospectively reviewed patients who underwent laparoscopic pyeloplasty from 1996 to 2014 by a single surgeon. At least 12 months of follow-up was required. Salvage patients were matched 1:3 with primary patients. Matching was based on age ±5 years, body mass index (BMI) ±5, and type of pyeloplasty (dismembered vs. non-dismembered). Primary outcome was failure as defined as re-intervention following laparoscopic pyeloplasty (does not include temporary stenting without definitive retreatment).

RESULTS

Of 128 laparoscopic pyeloplasty procedures, ten were salvage. These patients were matched to 26 patients who underwent a primary laparoscopic pyeloplasty in a 1:3 manner. One salvage pyeloplasty failed to match due to BMI, and the closest matches were made. Four salvage patients had one overlapping match, reducing the primary group to 26 patients. There were no differences in pre-, intra-, and postoperative variables between groups, except for operative time (salvage 247 min, primary 175 min, p = 0.03). With similar duration of radiologic and symptomatic follow-up, there was no significant difference in the rate of freedom from intervention.

CONCLUSION

When matching for factors that could affect success, salvage laparoscopic pyeloplasty performed as well as primary pyeloplasty except for a longer operative time. In experienced hands, salvage laparoscopic pyeloplasty for ureteropelvic junction obstruction recurrence after prior pyeloplasty is a safe and effective procedure, and should be considered an excellent alternative to the more commonly recommended endopyelotomy.

Definitive Management of Failure After Pyeloplasty

INTRODUCTION

Failure after pyeloplasty is difficult to manage. We report our experience managing pyeloplasty failures.

METHODS

We retrospectively reviewed the case log of a single surgeon, from August 1996 to August 2014, to identify all patients undergoing a surgical procedure after failed pyeloplasty. We excluded patients without follow-up exceeding 1 year from initial postpyeloplasty procedure. Failure was defined as a need for additional definitive intervention.

RESULTS

Of 247 laparoscopic pyeloplasties, 68 endopyelotomies and 305 simple laparoscopic nephrectomies reviewed, 41 were performed after previous pyeloplasty and had sufficient follow-up. Laparoscopic nephrectomy was performed in nine patients. All three secondary laparoscopic pyeloplasties were successful. Of 29 secondary endopyelotomies, 10 (34%) were successful. Of the 19 failures after secondary endopyelotomy, 12 patients had tertiary pyeloplasty (5 laparoscopic and 7 open surgical), 5 (26%) underwent tertiary endopyelotomy, and 2 (11%) required nephrectomy. Our overall endopyelotomy success rate was 38% (13/34) vs 100% (11/11) for secondary or tertiary pyeloplasty (4 patients lost to follow-up). Median time to failure was 5 months for endopyelotomy. Median follow-up for patients free from intervention was 40.2 months.

CONCLUSIONS

Secondary pyeloplasty (including both laparoscopic and open surgical approach) is more than twice as successful as endopyelotomy after failed pyeloplasty. Secondary pyeloplasty is an excellent alternative to endopyelotomy in select patients with failure after initial pyeloplasty.

Functional Results of Laparoscopic Pyeloplasty in Children: Single Institute Experience in Long Term

OBJECTIVE

The aim of this study was to evaluate the long-term functional outcomes of laparoscopic pyeloplasty (LP) in children for consecutive cases of single institute.

MATERIALS AND METHODS

Our laparoscopy database was investigated for children in terms of LP between June 2008 and April 2015. All the patients had ureteropelvic junction obstruction (UPJO) and LP was performed. Demographic data including age, gender, side of UPJO, operation time, estimated blood loss (EBL), hospital stay and complications according to Clavien classifications were recorded. Renal ultrasonography and diethylenetriamine penta-acetate (DTPA) scintigraphies were respectively performed 3, 12 and 24 months after surgery. Statistical analyses were performed and p value was accepted as significant at <0.05.

RESULT

Mean follow-up was 34 ± 4.7 months. The mean age was 13 (6-72) months. A total of 153 (110 boys and 43 girls) LP patients enrolled. Of that, 93 (60.78%) LP were in left side and 60 (39.21%) were in right side. Three cases needed open conversation according to difficulties in anastomosis. Aberrant crossing vessel was observed in 12 (7.84%) patients. The mean operation time was 155 ± 21 min and the mean EBL was 22 ± 11.1 ml. The mean hospital stay was 3.4 days. Anastomotic leakage was the common complication (in 13 patients) that was successfully managed conservatively (Clavien 1). Eight patients experienced unsuccessful LP and underwent open pyeloplasty (Clavien 3b). The mean split renal function significantly increased in DTPA scintigraphy in follow-up. The overall success was 91%.

CONCLUSIONS

The LP procedure can be an effective and safe surgical method for childhood UPJO, specifically in the experienced hands of pioneer centers.

Retrograde Endopyelotomy with Cutting Balloon™ for Treatment of Ureteropelvic Junction Obstruction in Infants

PURPOSE

The aim of this study is to analyze results of retrograde endopyelotomy with cutting balloon for treatment of ureteropelvic junction obstruction (UPJO) in infants.

METHODS

We routinely treat patients with UPJO under 18 months of age with retrograde high-pressure balloon dilatation of the pelviureteric junction (PUJ). During the procedure, in these cases where narrowing at the PUJ persists, endopyelotomy with cutting balloon is performed. Endopyelotomy is performed over guidewire with 5-mm Cutting Balloon™ under fluoroscopic control. Double-J stents is left in situ for 4 weeks. We retrospectively analyzed the postoperative, clinical, and radiological outcome infants treated with cutting balloon endopyelotomy between 2007 and 2015.

RESULTS

Sixteen patients required cutting balloon endopyelotomy to achieve complete resolution of narrowing of the waist observed during high-pressure balloon dilatation of the PUJ. Mean operative time was 35 ± 21 min (mean ± SD) and hospital stay was <24 h in all patients. Complete resolution of the narrowing at the PUJ under fluoroscopy was achieved in all cases, with no perioperative complications. One patient presented with urinary tract infection, postoperatively (Clavien grade II). Preoperatively, all cases had grade IV SFU hydronephrosis with parenchymal thinning. During follow-up, resolution of the hydronephrosis was observed in 11 patients (grade I SFU). In four infants, there was an improvement of the hydronephrosis (grade II SFU) and the renogram curve. In one case, an open pyeloplasty was required due to persistent hydronephrosis and obstructive curve.

CONCLUSION

We believe that endopyelotomy with cutting balloon could be a valid and safe option in minimally invasive management of UPJO in infants.

Robotic laparoscopic pyeloplasty

BACKGROUND AND OBJECTIVES

We aimed to assess the feasibility and outcomes of complex ureteropelvic junction obstruction cases submitted to robotic-assisted laparoscopic pyeloplasty.

METHODS

The records of 131 consecutive patients who underwent robotic-assisted laparoscopic pyeloplasty were reviewed. Of this initial population of cases, 17 were considered complex, consisting of either atypical anatomy (horseshoe kidneys in 3 patients) or previous ureteropelvic junction obstruction management (14 patients). The patients were divided into 2 groups: primary pyeloplasty (group 1) and complex cases (group 2).

RESULTS

The mean operative time was 117.3 ± 33.5 minutes in group 1 and 153.5 ± 31.1 minutes in group 2 (P = .002). The median hospital stay was 5.19 ± 1.66 days in group 1 and 5.90 ± 2.33 days in group 2 (P = .326). The surgical findings included 53 crossing vessels in group 1 and 5 in group 2. One patient in group 1 required conversion to open surgery because of technical difficulties. One patient in group 2, with a history of hemorrhagic rectocolitis, presented with peritonitis postoperatively due to a small colonic injury. A secondary procedure was performed after the patient had an uneventful recovery. At 3 months, significant improvement (clinical and radiologic) was present in 93% of cases in group 1 and 88.2% in group 2. At 1 year, all patients in group 2 showed satisfactory results. At a late follow-up visit, 1 patient in group 1 presented with a recurrent obstruction.

CONCLUSIONS

Robotic pyeloplasty appear to be feasible and effective, showing a consistent success rate even in complex situations. Particular care should be observed during the colon dissection in patients with previous colonic pathology.

Long-term follow-up results of laparoscopic pyeloplasty

Purpose

To assess the long-term follow-up results of laparoscopic pyeloplasty for ureteropelvic junction obstruction.

Materials and Methods

Sixty-five patients (mean age, 43.8 years) who underwent standard laparoscopic pyeloplasty by transperitoneal approaches were enrolled in this study. The chief complaint was flank pain (n=57 patients); the remaining cases were detected incidentally. Twenty-three patients had undergone previous abdominal surgeries, including open pyeloplasty and endopyelotomy. Mean stricture length was 1.06 cm. Grade 3/4 and 4/4 hydronephrosis was detected in 36 and 14 patients, respectively. An obstructive pattern was present on the renal scan in 53 patients (81.5%).

Results

Fifty-seven patients were treated with dismembered Anderson-Hynes pyeloplasty and eight patients with Fenger pyeloplasty. During the operation, crossing vessels were found in 27 patients (41.5%). Mean operating time was 159.42 minutes. Although there were no cases of open conversion, two patients with colon and spleen injuries were detected postoperatively. The mean starting time of postoperative ambulation and diet was 1.54 days and 1.86 days, respectively. Mean hospital stay was 8.09 days. Mean follow-up period was 36.5 months. Follow-up intravenous pyelography and renal scan showed improvements in 59 patients, and the radiologic success rate was 90.8%. Eight patients showed failure on radiologic or symptomatic evaluation, and the overall success rate was 87.7%. In the comparative analysis between the success and failure groups, drained amount was the only risk factor related to failure (554.41 mL. vs. 947.70 mL, p=0.024).

Conclusions

Long-term follow-up results support laparoscopic pyeloplasty as the standard treatment for ureteropelvic junction obstruction. Drained amount is a risk factor for failure of the operation.

Management of secondary pelviureteric junction obstruction

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.

Upper tract urologic LaparoEndoscopic Single-Site surgery

LaparoEndoscopic Single-Site (LESS) surgery has been developed as an extension of conventional laparoscopy to provide a minimally invasive option with fewer incisions, minimizing scars and potentially improving postoperative convalescence. These techniques have been adopted in the practice of urologic surgery, and largely employed to date for upper tract surgery by urologists in specialized centers with advanced laparoscopic practices. Herein, we review the current experience with upper tract urologic LESS surgery.

Robotic renal and upper tract reconstruction

PURPOSE OF REVIEW

To evaluate the current role of robotic surgery in upper urinary tract reconstruction.

RECENT FINDINGS

Robotic techniques have been increasingly adopted by urologists for reconstruction of the upper urinary tract. The improved dexterity, visualization, and ergonomics of robotic systems have applied naturally to reconstruction and have facilitated intracorporeal suturing compared with traditional laparoscopy. In particular, robotic techniques have been used for anastamotic suturing during minimally invasive pyeloplasty. Series of robotic pyeloplasty have demonstrated comparable long-term outcomes to laparoscopy, a shorter learning curve, subjective operator benefits, and potential advantages in operative time. Other robotic reconstructive procedures of the upper tract have included ureterocalicostomy, ureteroureterostomy, ureterolysis, and ureteral reimplantation with and without psoas hitch.

SUMMARY

Robotic techniques provide clear advantages for minimally invasive upper tract reconstruction, though the objective benefits need further delineation. These procedures are in their early experience, and larger series with prospective randomized comparison with the standard of care are warranted. Low volume of upper tract reconstruction in general will likely require multi-institutional study. Continued study of cost-effectiveness is necessary to define the optimal role for robotic reconstruction in both medical and economic terms.

Long-term follow-up for salvage laparoscopic pyeloplasty after failed open pyeloplasty

OBJECTIVES

To report our long-term experience with salvage laparoscopic pyeloplasty after a failed open procedure. Laparoscopic repair of a primary ureteropelvic junction obstruction (UPJO) is associated with very high long-term success. However, there are limited data on patients who have failed previous open pyeloplasty. We have determined that salvage laparoscopic pyeloplasty is an excellent option for these patients.

METHODS

We queried our laparoscopic pyeloplasty database of 367 patients from July 1994 to May 2007 for patients who had undergone prior open pyeloplasty. We analyzed demographic data, perioperative course, complications, and follow-up studies on identified subjects. We assessed clinical status by verbal pain scale and diagnostic studies. Radiologic follow-up consisted of diuretic renal scan, intravenous pyelography, or both.

RESULTS

We identified 9 patients (2.5%) who underwent salvage laparoscopic pyeloplasty for persistent obstruction after open pyeloplasty. The mean age of our cohort was 30.5 years (range, 19-50 years). Mean operative time was 204 minutes (range, 80-264 minutes), estimated blood loss was 105 mL (range, 20-300 mL), and mean length of stay was 2.1 days (range, 2-3 days). No intraoperative or postoperative complications were reported. All patients reported relief of symptoms in the immediate postoperative period. At a median follow-up of 66 months (range, 12-119 months), 8 of 9 patients (89%) had clinical and radiologic resolution of UPJO with stable renal function, pain free status, and a patent ureteropelvic junction. The remaining patient failed laparoscopic repair within the first year with evidence of persistent obstruction, necessitating endopyelotomy.

CONCLUSIONS

Our findings support the use of salvage laparoscopic pyeloplasty as an excellent option for patients who failed previous open pyeloplasty. This approach provides durable long-term outcomes.

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.

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.

Ureteroplasty with a cutting balloon: A novel approach to ureteric anastomotic strictures

The Peripheral Cutting Balloon device was originally described to treat in-stent coronary artery stenosis. We aim to evaluate the use of this device in the management of ureteric anastomotic strictures. Four patients with radiologically proven ureteric anastomotic strictures were treated with the Peripheral Cutting Balloon Device using an antegrade approach. Follow up ranged between 2 and 12 months. All patients' initial procedure was successful, and all patients had improvement of symptoms. No patient showed evidence of biochemical deterioration of renal function, and no periprocedural complications occurred. One patient had restenosis as a result of invasive bladder cancer and required subsequent cystectomy. The Peripheral Cutting Balloon device is a novel instrument for the treatment of ureteric anastomotic strictures. Our experience shows promising short-term results but more follow up is required.

Usefulness of Short-Term Retrievable Ureteral Stent in Pediatric Laparoscopic Pyeloplasty

PURPOSE

Methods of stenting after laparoscopic pyeloplasty have included indwelling Double-J stents and percutaneous nephrostomy tubes. The disadvantages of these methods are that they necessitate a second surgery for stent removal or require an external drainage bag. To circumvent these issues, the tolerance, safety and outcomes of using a Double-J ureteral stent with a dangler, permitting early office removal, was investigated in a series of pediatric laparoscopic pyeloplasties.

MATERIALS AND METHODS

Medical records from a consecutive series of pediatric patients undergoing transperitoneal laparoscopic pyeloplasties were reviewed. Indications for surgery included ipsilateral flank pain with severe hydronephrosis (12 patients), recurrent pyelonephritis with severe hydronephrosis (2), and hematuria and flank pain (6). All patients were discharged home within 24 to 48 hours of the procedure with prophylactic oral antibiotics. The stent was removed by postoperative day 18 during a followup office visit. Patient tolerance of the indwelling stent, outpatient removal and success of pyeloplasty were assessed.

RESULTS

A total of 20 patients underwent transperitoneal laparoscopic pyeloplasty by 1 surgeon (LAB) between 2001 and 2005. All patients underwent cystoscopy and retrograde Double-J ureteral stent placement before pyeloplasty under the same anesthesia. Mean patient age at operation was 11.3 years (median 11.3, range 4.6 to 17.2). Stents were left indwelling for a mean of 10.3 days (median 10, range 7 to 18). All patients tolerated the Double-J stent well, with 2 requiring anticholinergic therapy for mild urgency symptoms and 1 demonstrating urinary tract infection. All patients tolerated outpatient stent removal via the dangler at the office without discomfort. One patient was lost to followup. At a mean followup of 1.04 years (range 0.1 to 2.88) 17 of 19 patients (89%) had resolution of flank pain/urinary tract infections, with sonographic improvement in hydronephrosis with or without endoscopic intervention. Six patients (30%) had flank pain with or without continuous hydronephrosis and required re-stenting, and 3 also required balloon dilation. Of these 6 patients 2 (10%) had recurrent ureteropelvic junction obstruction and required open pyeloplasty. All patients are now clinically and radiologically unobstructed and asymptomatic.

CONCLUSIONS

Pediatric transperitoneal laparoscopic pyeloplasty with indwelling Double-J ureteral stent with a dangler is successful and the stent is well tolerated. Whether the duration of ureteral stenting affects the surgical success will require further controlled long-term studies.

Laparoscopic pyeloplasty versus antegrade endopyelotomy: Comparison in 100 patients and a new algorithm for the minimally invasive treatment of ureteropelvic junction obstruction

The aim of this article is to assess the treatment efficacy of percutaneous endopyelotomy and laparoscopic pyeloplasty to establish a new algorithm in the minimally invasive treatment of ureteropelvic junction obstruction (UPJO). Hospital records, office charts, and radiographic studies of patients with UPJO treated either endoscopically (n = 50), laparoscopically (n = 50), or by endopyeloplasty (n = 5) were reviewed. All percutaneous endopyelotomies were performed with a cold hook-knife technique, and all laparoscopic pyeloplasties were performed transperitoneally using an Anderson-Hynes dismembered anastomosis. Successful outcomes were defined as relief of obstruction as quantified by diuretic renal scans and/or relief of obstructive symptoms. All patients were followed for an average of 16.0 months (range, 2 to 42 months). In the endoscopically treated group, the average age was 44.6 +/- 15.6 years, estimated blood loss (EBL) was 152.1 +/- 112.8 mL, and the hospital stay was 2.5 +/- 1.0 days. There was no significant change from preoperative to postoperative creatinine (1.2 +/- 0.7 mg/dL to 1.2 +/- 0.7 [106 +/- 62 micromol/L +/- 106 +/- 62 micromol/L]). Success rates included 92% (35 of 38) for primary percutaneous antegrade endopyelotomy and 58% (7 of 12) for secondary percutaneous antegrade endopyelotomy. All of the primary percutaneous antegrade endopyelotomy failures (n = 3) had either grade 3 or grade 4 hydronephrosis. In the laparoscopic pyeloplasty group the average age was 37.9 +/- 14.8 years, EBL was 108.3 +/- 109.4 mL, and the average hospital stay was 2.6 +/- 0.9 days. There was no significant change from preoperative to postoperative creatinine (1.1 +/- 0.4 mg/dL to 1.0 +/- 0.4 mg/dL [97 +/- 35 micromol/L to 97 +/- 35 micromol/L]). Success rates included 100% (29 of 29) for primary repair and 95.2% (20 of 21) for secondary repair. There was no statistical difference in preoperative patient parameters or objective outcomes when comparing primary endopyelotomy and primary laparoscopic pyeloplasty. In skilled hands, highly successful outcomes can be expected when either antegrade endopyelotomy or laparoscopic pyeloplasty is used to treat a primary UPJO. In the instance of a UPJO associated with a high degree of hydronephrosis, patients may be better served with a laparoscopic pyeloplasty. To maximize an efficacious outcome, minimally invasive UPJO treatment decisions should be based on patient and surgeon preference, as directed by the presented algorithm.