Recurrent Symptoms Following Pyeloplasty With a Normal Endoscopic Evaluation: Assessment and Outcomes of a Challenging Patient Cohort

Abstract

To aid in counseling and managing a challenging patient cohort, we review our experience using a structured endoscopic approach to assess individuals with recurrent symptoms but a normal anatomic evaluation after pyeloplasty. From 2008 to 2012, all patients presenting with recurrent symptoms after pyeloplasty for ureteropelvic junction (UPJ) obstruction were retrospectively evaluated. After baseline renal scanning, all underwent retrograde ureteropyelography, flexible ureteroscopy, UPJ balloon calibration, and provocative ureteral stenting. Patients without clear anatomic obstruction were assessed 2weeks postoperatively at the time of stent removal and reassessed serially as outpatients before considering further operative management. Nineteen patients had undergone an average of 1.4 UPJ procedures: pyeloplasty in all 19, retrograde endopyelotomy in 6, and balloon dilation in 1. Mean age was 35.2years, time from original management to symptom recurrence was 80months, Lasix T1/2 was 16.6min, and differential renal function of the affected kidney was 43%. Mean follow-up after endoscopic assessment was 16.2months. Thirteen patients (68%) achieved long-term pain-free status after endoscopic evaluation alone, and 2 (11%) were rendered symptom free after repeat robotic pyeloplasty. Of the 4 remaining patients (21%) with persistent pain after a negative endoscopic assessment, all were referred to a pain specialist. Two patients (11%) ultimately required laparoscopic nephrectomy for definitive symptom control. Our findings support evaluation with retrograde pyelography, ureteroscopy, and balloon calibration for patients with recurrent symptoms before embarking on revision pyeloplasty. Surprisingly, two-thirds of our patients achieved pain-free status with an endoscopic approach alone.