Percutaneous endopyeloplasty: description of new technique

PURPOSE: We present a novel technique of percutaneous endopyeloplasty, in which the conventional longitudinal endopyelotomy incision is precisely sutured in a horizontal Heineke-Mikulicz fashion through the solitary percutaneous tract, thus, achieving Fenger-plasty type of repair of the ureteropelvic junction. MATERIALS AND METHODS: Percutaneous endopyeloplasty was performed in 9 patients with primary ureteropelvic junction obstruction. Essential steps of our novel technique include retrograde placement of a ureteral catheter over a guide wire into the renal pelvis, establishing conventional percutaneous renal access, creating a conventional longitudinal endopyelotomy incision and performing full-thickness horizontal suturing of the endopyelotomy incision in Heineke-Mikulicz fashion. Suturing was done using the novel 5 mm. Sew Right 5 SR laparoscopic suturing device (LSI Solutions, Rochester, New York) passed through the nephroscope. RESULTS: Percutaneous endopyeloplasty was technically successful in all 9 patients. Mean total operative time was 100.8 minutes (range 62 to 140.), including an endopyeloplasty suturing time of 26.6 minutes (range 14 to 54.). We placed 1 to 4 endopyeloplasty sutures per case. Blood loss was minimal, mean hospital stay was 2.2 days (range 2 to 3) and the ureteral Double-J stent (Medical Engineering Corp., New York, New York) was removed in 2 weeks. At a mean followup of 4 months all operated kidneys showed relief of obstruction, as confirmed by clinical improvement in symptoms and improved renal drainage on excretory urography and diuretic renography. CONCLUSIONS: Percutaneous endopyeloplasty is technically feasible, safe and effective. Potential advantages over conventional endopyelotomy include wider caliber reconstruction of the ureteropelvic junction, full-thickness healing with primary intent, minimal urinary extravasation and shorter stenting duration. To our knowledge the initial clinical experience is presented.     

Long-term success of antegrade endopyelotomy compared with pyeloplasty at a single institution

BACKGROUND AND PURPOSE: The classic standard for surgical repair of ureteropelvic junction (UPJ) obstruction has been open pyeloplasty, with a 95% success rate. Antegrade endopyelotomy is a less-invasive option with a slightly lower success rate. However, recent data call into question the long-term durability of UPJ repair. We present the long-term success of treatment of UPJ obstruction comparing these two modalities. Patients and METHODS: We reviewed the medical records of patients undergoing percutaneous antegrade endopyelotomy or open and laparoscopic pyeloplasty for UPJ repair in our practice from 1988 to 2004. Success was defined as both radiographic and symptomatic improvement. We evaluated the impact of preoperative factors, including prior surgical repair, crossing vessels, renal function, and calculi, on success. RESULTS: The estimated 3-, 5-, and 10-year recurrence-free survival rates for the endopyelotomy group (N = 182) were 63%, 55%, and 41%, respectively, compared with 85%, 80%, and 75% for the pyeloplasty group (N = 175; P < 0.001). Of the failed endopyelotomies undergoing salvage open repair, 8 of 26 (31%) had crossing vessels. Poor renal function and previous failed pyeloplasty decreased success in the pyeloplasty group. Variation from standard cold-knife incision adversely affected endopyelotomy success. CONCLUSIONS: Long-term success rates after both endopyelotomy and pyeloplasty are worse than previously reported. Although most failures in both groups occurred within 2 years, failures continue to appear after 5 and 10 years, and patients should be followed accordingly. In view of these results of endopyelotomy, laparoscopic pyeloplasty may prove to be the preferred minimally invasive approach to repair UPJ obstruction.     

Creation of ureteropelvic junction obstruction and its correction by chemical glue-assisted laparoscopic dismembered pyeloplasty

PURPOSE: We established a porcine model of ureteropelvic junction (UPJ) obstruction using a laparoscopic technique and assessed the outcome of standard suture-assisted and chemical glue-assisted laparoscopic pyeloplasty. MATERIALS AND METHODS: Female domestic pigs (N = 20) underwent laparoscopic suture-ligature to create UPJ obstruction. One month later, laparoscopic end-to-end anastomosis was performed to correct the obstruction: with standard suturing techniques in 10 animals and with chemical (cyanoacrylate) glue in the other 10. Postoperative ureteral stents were not used. Four weeks postoperatively, intravenous urography was performed to evaluate the patency of the anastomoses. The UPJ was procured by laparotomy to assess the anastomoses and periureteral fibrosis histologically. RESULTS: The UPJ obstruction was created in an average of 15 +/- 6 minutes. There was no early postoperative mortality. Eighteen pigs survived for at least 1 month, and UPJ obstruction developed in 17 (95%). Microscopically, the lumen of the UPJ was partially occluded, measuring an average of 40% +/- 5% of normal. After laparoscopic correction, a patent UPJ was found in seven of nine animals treated with traditional sutures. Among the eight animals with chemically glued anastomoses, none had a patent UPJ, and severe periureteral adhesions and intraluminal fibrosis were noted at the pyeloplasty site. Marked ureteral tortuosity was present in six of the eight pigs receiving glue-assisted pyeloplasty but in none of the animals having suture-assisted pyeloplasty. CONCLUSIONS: Ureteropelvic junction obstruction was established by laparoscopic suture-ligature in a porcine model with a 95% success rate. Chemical glue-assisted anastomosis was inferior to standard laparoscopic sutures for pyeloplasty to correct the obstruction.     

Single-center comparison of laparoscopic pyeloplasty,Acucise endopyelotomy,and open pyeloplasty

PURPOSE: To compare Acucise endopyelotomy (Applied Medical, Irvine, California), laparoscopic pyeloplasty, and open pyeloplasty in the treatment of ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS: A retrospective review of all adult patients undergoing surgical correction of UPJ obstruction between December 1999 and August 2001 at Vanderbilt University Medical Center was performed. Patients undergoing UPJ correction with Acucise endopyelotomy (N = 9), laparoscopic pyeloplasty (N = 16), and open pyeloplasty (N = 7) were compared in regard to demographic information, operative data, recovery parameters, cost data, and outcome (as determined by diuretic renography, the Whitaker test, or both). RESULTS: Success rates of 56%, 94%, and 86% were obtained for Acucise endopyelotomy, laparoscopic pyeloplasty, and open pyeloplasty, respectively. There were no differences between the Acucise endopyelotomy and laparoscopic pyeloplasty groups in age, American Society of Anesthesiology (ASA) score, length of follow-up, estimated blood loss (EBL), hospital stay, total hospital cost, or analgesic requirement. The Acucise patients demonstrated shorter operating times (1.7 v 3.3 hours; P < 0.001) and time to oral intake (7.9 v 16 hours; P = 0.008) than the laparoscopic pyeloplasty group. When the laparoscopic pyeloplasty patients were compared with the open pyeloplasty patients, there was no difference in operative time, EBL, time to oral intake, or total hospital costs. The laparoscopically treated patients demonstrated significantly lower analgesic requirements (27.2 v 124.2 mg of morphine sulfate equivalent; P = 0.02) and shorter hospital stays (1.4 v 3.0 days; P = 0.03) than the open surgery patients. The Acucise patients demonstrated shorter operative time (1.7 v 3.4 hours; P < 0.001), shorter hospital stay (1.3 v 3.0 days; P = 0.02), and lower analgesic requirement (22.4 v 124.2 mg of morphine sulfate equivalent; P = 0.02) than the open surgery patients. CONCLUSIONS: Laparoscopic pyeloplasty achieves a success rate equal to that of open pyeloplasty while providing a recovery similar to that obtained with Acucise endopyelotomy and is gaining popularity as the treatment of choice for UPJ obstruction.     

Retrograde ureteroscopic endopyelotomy for the treatment of primary and secondary ureteropelvic junction obstruction in children

The use of endopyelotomy in children with ureteropelvic junction (UPJ) obstruction remains controversial. Although most investigators reported good results with percutaneous or retrograde balloon cautery incision, there are distinct advantages associated with a ureteroscopic approach. Three male children, ages 11, 12 and 17 years, underwent ureteroscopic endopyelotomy for treatment of UPJ obstruction (one primary and two secondary). The procedures were performed using 6F to 8.5F semirigid instruments and the holmium laser. All three patients underwent endopyelotomy without complication. The mean operative time was 80 minutes. Two patients were discharged home the day of the procedure, and the third patient was hospitalized for less than 24 hours postoperatively. With follow-up of 6 to 11 months, two patients are asymptomatic, with no radiographic evidence of obstruction. The 12-year-old boy had continued obstruction following endopyelotomy. At the time of open pyeloplasty, a large crossing vessel was noted, which appeared to be the source of obstruction. Ureteroscopic endopyelotomy can be performed with minimal morbidity and hospitalization in children. Further clinical experience is needed to assess the relative efficacy of this procedure in comparison with other forms of endopyelotomy in children.     

Percutaneous endopyelotomy for ureteropelvic junction obstruction

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

Laparoscopic pyeloplasty in secondary obstruction

PURPOSE: To evaluate the management of secondary ureteropelvic junction (UPJ) obstruction by laparoscopic pyeloplasty. MATERIALS AND METHODS: Thirteen patients with symptomatic secondary UPJ obstruction undergoing laparoscopic pyeloplasty were included. Eight patients had obstruction on the right side and five patients on the left. The causes of obstruction were: failed Acucise retrograde endopyelotomy in seven patients, open pyelolithotomy in three, open pyeloplasty in one, retrograde endopyelotomy with laser in one, and laparoscopic pyeloplasty in one. Laparoscopic transperitoneal pyeloplasty was performed in all patients. A Double J stent was introduced antegrade and intraoperatively and removed 6 weeks later in all patients. RESULTS: Laparoscopic transperitoneal pyeloplasty was successful in 12 patients (92.3%). Operative time ranged from 135 to 270 minutes, with a mean of 195 minutes. The mean hospital stay was 2.2 days (range 2 to 5 days). Follow-up ranged from 16 to 36 months with a mean of 22.4 months. Blood loss was insignificant in all surgeries, and no conversion or intraoperative complications occurred. CONCLUSIONS: Laparoscopic pyeloplasty for secondary UPJ obstruction in our series was performed without conversion to open surgery. The initial results were similar to those of primary laparoscopy in our series or those of open pyeloplasty reported in the literature. These results led us to consider the laparoscopic correction as a good alternative in such cases.     

Laparoscopic pyeloplasty

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

Percutaneous endopyelotomy

Percutaneous endopyelotomy, introduced over 15 years ago, is a well-established alternative to open operative pyeloplasty for management of ureteropelvic junction (UPJ) obstruction. Although several variations of the technique have been described, the goal in all cases is to develop a full thickness incision though the obstructing proximal uretra that extends out to the peripyeloureteral fat and heals over an internal stent. Though a percutaneous endopyelotomy can be considered for almost any patient with primary or secondary UPJ obstruction, it is particularly valuable in the setting of upper tract stones that can then be managed simultaneously. This article reviews the indications, techniques, and outcomes of percutaneous endopyelotomy.     

Results of selective management of ureteropelvic junction obstruction

BACKGROUND AND PURPOSE: Controversy continues over the need to image the ureteropelvic junction (UPJ) before endopyelotomy to detect crossing vessels. We evaluated a selective management model for UPJ obstruction. PATIENTS AND METHODS: Intraoperative ultrasonography was performed before endopyelotomy in 19 men and 16 women. Patients with large (>4-mm) crossing vessels underwent open or laparoscopic pyeloplasty; the others had ureteroscopic or percutaneous endopyelotomy with electrocautery or the holmium laser. RESULTS: Crossing vessels were found in 25 of the 35 patients and a high-inserting ureter in 4. The vessels were >4 mm in nine patients, seven of whom had successful pyeloplasty and two of whom were managed expectantly with good results. Endopyelotomy was successful in 94% without a crossing vessel and 70% of those with a crossing vessel. The overall success rate (absence of symptom and resolution of obstruction on renal scintigraphy) was 89%. CONCLUSION: Selective management of UPJ obstruction, avoiding endopyelotomy in the presence of a large crossing vessel, appears to improve the success rate.     

Contemporary management of ureteropelvic junction obstruction: practice patterns in Minnesota

BACKGROUND AND PURPOSE: Ureteropelvic junction (UPJ) obstruction can be addressed surgically by an open, laparoscopic, endoscopic, or fluoroscopic procedure. Our objective was to establish what surgical alternatives are currently offered by urologists in Minnesota. MATERIALS AND METHODS: A questionnaire was sent to 174 members of the Minnesota Urological Society. Practice settings were characterized as rural, urban, or metropolitan on the basis of the ZIP-code classifications of the Minnesota Ambulance Association and state geographic legislation. Respondents were asked to select initial treatment options for an adult patient with flank pain, decreased renal function, and hydronephrosis secondary to UPJ obstruction. RESULTS: Whereas 60% of the respondents would offer open pyeloplasty, only 12% would offer it as the only treatment option. The two most common minimally invasive therapies offered were the Acucise balloon (48%) and percutaneous antegrade endopyelotomy (48%). Rural urologists were more likely to offer Acucise balloon incision (71%) than were urban (28%; P=0.045) or metropolitan (55%; P=0.412) urologists. CONCLUSIONS: The majority of urologists still offer open pyeloplasty as first-line therapy for UPJ obstruction. Further emphasis should be placed on increasing the availability of endoscopic and laparoscopic procedures.     

Endopyelotomy outcome as a function of high versus dependent ureteral insertion

Objectives. To determine whether a high versus a dependent ureteral insertion significantly affects the outcome of endopyelotomy for management of ureteropelvic junction (UPJ) obstruction.Methods. Sixty patients with UPJ obstruction were treated with an endopyelotomy by way of either an antegrade percutaneous approach (n = 36) or a retrograde hot-wire balloon incision (n = 24). In these 60 patients, the ureteral insertion was high on the renal pelvis in 19 (32%), dependent in 25 (42%), and indeterminate in 16 (26%). Intravenous urography was performed 4 to 6 weeks after stent removal (8 to 12 weeks after endopyelotomy) and then at 6 to 12-month intervals. Success of the procedure was defined as resolution of symptoms and decrease in hydronephrosis compared with pre-endopyelotomy studies.Results. With a follow-up range of 2 to 41 months (mean 10.3), the overall success rate was 80%. This rate was independent of whether the procedure was performed in an antegrade or retrograde fashion. A successful result was achieved in 15 (78.9%) of those with a high insertion, 19 (76%) of those with a dependent insertion, and 14 (87.5%) of those with an equivocal insertion; these differences were not statistically significant (P = 0.72).Conclusions. The type of ureteral insertion (ie, high versus dependent) had no significant impact on the outcome of endopyelotomy by way of either a percutaneous or retrograde approach. As such, these anatomic variations need not play a role in a decision-making algorithm for contemporary management of UPJ obstruction.     

Minimally invasive approaches to ureteropelvic junction obstruction

This review covers minimally invasive treatments for ureteropelvic junction obstruction in the adult, including endopyelotomy (antegrade and retrograde), endopyeloplasty, laparoscopic pyeloplasty, and robotic pyeloplasty. The relevant literature is summarized, and a rational algorithm for management is proposed.     

Laparoscopic pyeloplasty

Open pyeloplasty has long been considered the gold standard for the relief of ureteropelvic junction (UPJ) obstruction, but the incisional morbidity led urologists to explore less invasive alternatives such as endopyelotomy and the Acucise cutting balloon. Laparoscopic pyeloplasty was introduced in 1993 and has since been performed in patients as young as 2.5 years. The operation should be considered in patients with UPJ obstruction caused by a crossing vessel, high ureteral insertion, failed prior procedures, high-grade hydronephrosis, or marginal differential renal function. Hynes-Anderson, Foley Y-V, and Fenger procedures can all be performed laparoscopically, generally with excellent results. The procedure requires advanced laparoscopic skills and so is available in only a few medical centers at present.     

Endopyelotomy failure is associated with reduced urinary transforming growth factor-beta1 levels in patients with upper urinary tract obstruction

BACKGROUND AND PURPOSE: We previously demonstrated that obstructed ureteropelvic junction (UPJ) segments from patients who had secondary pyeloplasty after endopyelotomy failure expressed transforming growth factor-beta1 (TGF-beta1) at levels significantly lower than patients who had primary pyeloplasty. In order to determine whether these differences in secreted TGF-beta1 are detectable preoperatively in the urine, the TGF-beta1 concentration of urine from patients undergoing endopyelotomy was determined and compared with that from subjects without urologic disease. MATERIALS AND METHODS: Bladder and renal pelvic urine from the obstructed side was obtained from patients (N = 34) undergoing primary endopyelotomy for UPJ obstruction. Bladder urine was also obtained from sex- and age-matched patients (N = 26) having no evidence of urinary tract obstruction. The TGF-beta1 concentration was determined by ELISA and normalized to the creatinine concentration. RESULTS: The bladder urine TGF-beta1 concentration was significantly (P < 0.02) higher in patients with UPJ obstruction (86.1+/-20.5 pg/mg of creatinine) than in those without obstruction (29.7+/-8.0 pg/mg creatinine). The TGF-beta1 concentration in the bladder urine of patients who underwent endopyelotomy and later returned because of UPJ obstruction (25.7+/-12.3 pg/mg of creatinine; N = 6) was not significantly different from the value in unobstructed patients but was significantly lower (P < 0.01) than in patients for whom endopyelotomy was successful (100+/-24.29 pg/mg of creatinine; N = 28). The renal pelvic urinary TGF-beta1 concentration was higher in patients for whom endopyelotomy was successful (772+/-490.1 pg/mg of creatinine) than in patients who underwent endopyelotomy and later returned because of UPJ obstruction (126.1+/-41.9 pg/mg of creatinine). CONCLUSIONS: These data suggest that preoperative concentration of TGF-beta1 in the bladder urine of patients with UPJ obstruction who fail endopyelotomy is not significantly different from that in subjects with no urologic disease and significantly lower than in those patients for whom endopyelotomy is successful. Thus, the preoperative bladder urine concentration of TGF-beta1 may assist in selecting patients for this operation, although further investigation is necessary.     

Retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction

BACKGROUND AND PURPOSE: Retroperitoneoscopy is an established procedure for renal surgery. We evaluated our results with retroperitoneoscopic pyeloplasty for ureteropelvic junction (UPJ) obstruction. PATIENTS AND METHODS: In 14 female and 10 male patients, a retroperitoneoscopic pyeloplasty was performed (13 right/11 left). Four patients had previously had an endopyelotomy. The operation was performed using standard retroperitoneoscopic technique with the patient in a flank position. After preparation of the ureter and renal pelvis, the UPJ was resected in 22 patients in an Anderson-Hynes pyeloplasty. Twenty of these patients had a crossing vessel. The other two patients, who had small renal pelves, were operated on with a Fenger pyeloplasty. In all patients a 7F double-J stent was placed. RESULTS: The mean operative time was 189 minutes (range 70-360 minutes), and the average blood loss was 110 mL (range 50-400 mL). There were no intraoperative complications, although one patient with adhesions and scarring after previous endopyelotomy had to be converted to open surgery. The transurethral catheter was left for 7 days in the first 10 cases and for 4 days in the 14 subsequent patients. The hospitalization time was 9.7 and 7.5 days, respectively. The only postoperative complication was a urinoma, which was punctured. The double-J catheter was removed after an average of 4.6 weeks (range 4-8 weeks). Intravenous urography 6 weeks later showed no obstruction. The mean follow-up time was 11.5 months (range 1-24 months) with no signs of obstruction on ultrasonography. CONCLUSIONS: Retroperitoneoscopic pyeloplasty for UPJ obstruction is a safe and effective procedure. Our short-term results are similar to those of open pyeloplasty with the advantage of a minimally invasive approach.     

Ureteropelvic junction obstruction repair: when, how, what?

PURPOSE OF REVIEW: To review factors that affect the success of ureteropelvic junction obstruction repair and recent developments in minimally invasive procedures for the repair of ureteropelvic junction obstruction. RECENT FINDINGS: Recent reports and studies further confirm earlier findings that the success rate of endopyelotomy is decreased when a crossing vessel is the primary cause of ureteropelvic junction obstruction, poor renal function and significant hydronephrosis. Various minimally invasive procedures have emerged recently for the treatment of ureteropelvic junction obstruction. These include laparoscopic pyeloplasty, robotically assisted laparoscopic procedures, and percutaneous endopyeloplasty. These procedures offer potential advantages over conventional endopyelotomy, including better success rates in the presence of crossing vessels, wider caliber reconstruction of the ureteropelvic junction, and full-thickness healing with primary intent. SUMMARY: With such a large variety of minimally invasive procedures for the treatment of ureteropelvic junction obstruction available, the treatment choice for ureteropelvic junction obstruction must be based on several factors, including the success and morbidity of the procedures, the surgeon's experience, the cost of the procedure, and the patient's choice.     

Salvage laparoscopic pyeloplasty in the worst case scenario: after both failed open repair and endoscopic salvage

BACKGROUND AND PURPOSE: Historically, open pyeloplasty has been the gold-standard treatment for primary ureteropelvic junction (UPJ) obstruction, with success rates >90%. Over the past decade, laparoscopic pyeloplasty has emerged as a highly successful alternative for primary UPJ and secondary obstruction. For patients failing open pyeloplasty, endoscopic procedures such as antegrade and retrograde endopyelotomy have been used as salvage therapies with success rates as high as 87.5%. Persistent obstruction after an initial open pyeloplasty and a subsequent unsuccessful salvage endoscopic procedure presents a difficult scenario, often necessitating complex and challenging repairs. We reviewed our experience with salvage laparoscopic pyeloplasty as a reconstructive option for this difficult group of patients. PATIENTS AND METHODS: Between January 2002 and April 2005, 66 laparoscopic pyeloplasties were performed. Four patients, who had persistent obstruction after both open pyeloplasty and subsequent salvage endoscopic procedures, were the subject of this analysis. Operative time, length of stay (LOS), pain score resolution, and physiologic success rates were evaluated. Success was defined as resolution of obstruction on physiologic testing (renal scan). RESULTS: The mean operative time was 310 minutes and the mean LOS 1.2 days. Three patients experienced resolution of obstruction by nuclear scan. The remaining patient, who has persistent obstruction but stable function on nuclear scan and resolution of pain, has refused evaluation with Whitaker testing. All patients have experienced at least 50% reduction of pain. Utilizing our strict physiologic criteria for success, including a diuretic T(1/2) of <10 minutes, a success rate of 75% was obtained. CONCLUSION: Our series of laparoscopic reconstructions of the UPJ in patients failing both an initial open pyeloplasty and subsequent salvage endoscopic procedures is the largest in the literature at present. As in open surgery, the ability to respond to intraoperative findings with techniques such as flap repair and renal mobilization are essential. Although time consuming, these repairs can be successful and maintain the advantages of laparoscopy.     

Reliability and validity of endoluminal sonography in a porcine model of ureteropelvic junction obstruction

PURPOSE: The objective of this study was to evaluate the usefulness and reliability of endoluminal ultrasonography in ureteropelvic junction (UPJ) obstruction and to describe the changes in sonographic appearance that take place during obstruction and after treatment. MATERIALS AND METHODS: Twelve large healthy white female pigs were randomly divided into two groups: Group 1 (laparoscopic pyeloplasty) and group 2 (cutting balloon endopyelotomy). Percutaneous and endoluminal ultrasonographic and fluoroscopic studies were analyzed during the three phases of the study. The first phase included premodel documentation of a normal urinary tract and laparoscopic UPJ obstruction. During the second phase 6 weeks later, diagnosis and endourologic treatment were performed. Fifteen weeks after obstruction management, follow-up imaging studies and postmortem evaluation of all animals were performed. RESULTS: At the end of the study, group 1 had a lesser degree of fibrosis in the muscle-adventitia layers and periureteral repercussion, as well as a better peristaltic recovery. The animal study shows a positive correlation among the results of the pathologic and the endoluminal ultrasonographic studies in UPJ obstruction. CONCLUSIONS: Endoluminal ultrasonography provides excellent information regarding ureteral and periureteral anatomy. Among the two techniques evaluated in the study, laparoscopic pyeloplasty caused the lesser reaction at the reconstructed area. Fibrous replacement at the muscle-adventitia layers and periureteral area may be useful as indicators of the better therapeutic technique as well as for the assessment of post-therapeutic ureteral evolution and recurrences.     

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.