Abstract
ABSTRACTPurpose:We aimed to assess failure rates of salvage interventions and changes in split kidney function (SKF) following failed primary repair of ureteropelvic junction obstruction (UPJO).Materials and Methods:A retrospective review of adult patients at an academic medical center who underwent salvage intervention following primary treatment for UPJO was performed. Symptomatic failure was defined as significant flank pain. Radiographic failure was defined as no improvement in drainage or a decrease in SKF by ≥7%. Overall failure, the primary outcome, was defined as symptomatic failure, radiographic failure, or both.Results:Between 2008-2017, 34 patients (median age 38 years, 50% men) met study criteria. UPJO management was primary pyeloplasty/secondary endopyelotomy for 21/34 (62%), primary pyeloplasty/secondary pyeloplasty for 6/34 (18%), and primary endopyelotomy/secondary pyeloplasty for 7/34 (21%). Median follow-up was 3.3 years following secondary intervention. Patients undergoing primary pyeloplasty/secondary endopyelotomy had significantly higher overall failure than those undergoing primary pyeloplasty/secondary pyeloplasty (16/21 [76%] vs. 1/6 [17%], p=0.015). Among patients undergoing secondary endopyelotomy, presence of a stricture on retrograde pyelogram, stricture length, and SKF were not associated with symptomatic, radiographic, or overall failure. Serial renography was performed for 28/34 (82%) patients and 2/28 (7%) had a significant decline in SKF.Conclusions:Following failed primary pyeloplasty, secondary endopyelotomy had a greater overall failure rate than secondary pyeloplasty. No radiographic features assessed were associated with secondary endopyelotomy failure. Secondary intervention overall failure rates were higher than reported in the literature. Unique to this study, serial renography demonstrated that significant functional loss was overall infrequent.
Highlights
Pyeloplasty is the gold standard for the initial repair of ureteropelvic junction obstruction (UPJO), and most surgical series have demonstrated a low failure rate with this approach (≤10%) [1]
We identified 34 adult patients meeting study criteria who underwent salvage intervention between 2008-2017 among >200 adult patients treated for UPJO at our institution, in addition to outside referrals
The primary hypothesis of this study was that, following primary pyeloplasty, the overall failure rate of secondary endopyelotomy exceeded that of secondary pyeloplasty, and that both exceeded failure rates previously reported in the literature
Summary
Pyeloplasty is the gold standard for the initial repair of ureteropelvic junction obstruction (UPJO), and most surgical series have demonstrated a low failure rate with this approach (≤10%) [1]. Failed primary intervention presents a significant challenge. The most commonly utilized secondary interventions in this setting are endopyelotomy and pyeloplasty [1]. Series comparing endopyelotomy and pyeloplasty following failed primary pyeloplasty demonstrated failure rates of 29-62% and 0-13%, respectively [6,7,8]. Failure definitions included persistent symptoms, lack of radiographic improvement, and need for further surgery. Different failure definitions and varied follow-up protocols are among the factors complicating the interpretation of head-to-head comparisons of endopyelotomy and pyeloplasty as secondary interventions
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