Treatment Of Ureteropelvic Junction Obstruction Research Articles

Comparison of the application of retroperitoneal laparoscopy and open surgery in ureteropelvic junction obstruction

Objective To review and analyze the application of retroperitoneal laparoscopy and open surgery in ureteropelvic junction obstruction, sum up clinical expeirence, and improve the skills of retropeirtoneal laparoscopic surgery. Methods Retroperitoneal laparoscopic surgery was carired out in 22 csaes of ureteropelvic junction obstruction(retroperitoneal laparoscopy group). Open surgery was carried out in 21 cases(Open surgery group). The two groups were compared in operation time, blood loss postoperative discharge time and postoperative hospital stay respectively. Results Ureteropelvic junction obstruction group was significantly less than open surgery group in intraoperative bleeding time,postoperative bleeding time and average length of stay. Operation time in ureteropelvic junction obstruction group was slightly longer than that in open surgery group [(32.0 ± 10.0) ml vs (70.0 ± 11.9) ml, (31.0 ±5.7)h vs(52.0 ±6.9)h,(7.0 ± 1.6) d vs(14.0 ± 1.4) d, (113.0 ±7.6) min vs(72.0 ± 6.8) min] (t = 7.06,8. 14,11.37,11.36, all P ＜ 0.05). Conclusions Retroperitoneal laparoscopic technology was in the treatment of ureteropelvic junction obstruction for its direct way, had non interference and pollution to laparoscopic internal organs,less damage,less pain, rapid recovery and short hospitla stay. With on going training and constantly updating technical skills and equipments, retroperitoneal laparoscopic technology will shotren the operation time, and will substitute open surgery. Key words: Ureteral obstruction; Laparoscopy; Retroperitoneal space

Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children

To examine our experience of laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction (UPJO) in the pediatric population. From November 2001 to June 2009, 112 patients underwent transperitoneal laparoscopic pyeloplasty for the treatment of symptomatic or radiographic UPJO. Data were collected retrospectively. Patients were followed at regular intervals with imaging and symptom assessment. Failure was defined as inability to complete the intended procedure, persistent flank pain, radiographic evidence of obstruction, or the need for definitive adjunctive procedures. Mean patient age was 9.4 years (0.2-20.5 years), and follow-up was available on all 112 patients with a mean duration of 15.3 months (0.6-84.5 months). There was one open conversion in the series. Mean operative time was 254 minutes (102-525 minutes). There was one minor intraoperative complication reported (0.8%). There were 12 (10.8%) postoperative complications; most were relatively minor with complete resolution and without long-term sequelae. Postoperative ultrasonography has been performed in 102 patients, with 99 (97%) patients demonstrating improvement of the UPJO. Three patients (3%) continued to have symptomatic and/or radiographic evidence of obstruction that necessitated the need for adjunctive procedures, which included laser endopyelotomy in 2 patients, and a re-do open pyeloplasty in 1 patient. Of those cases that were completed laparoscopicaly, the overall success rate was 97.2%. Laparoscopic pyeloplasty for UPJO in the pediatric population is technically challenging; however, with experience, one can expect excellent success rates comparable to open pyeloplasty, with minor complications with reasonable operative times.

Robot-Assisted Laparoscopic Pyeloplasty With and Without a Ureteral Stent

Robot-assisted laparoscopic pyeloplasty (RALP) has been shown to be an efficacious treatment for ureteropelvic junction obstruction. Although the use of a ureteral stent is commonplace, the water-tight anastomosis possible with robotic assistance may obviate its need. We report a feasibility study of unstented RALPs and present our experience with both the stented (SRP) and unstented (URP) approach. A retrospective review of RALPs completed at our institution from 2003 to 2008 was performed. Thirty-five patients had postoperative stents. Seventeen RALPs were completed without ureteral stents. Narcotic requirements, operative time, estimated blood loss, daily drain output, length of stay, and complications were examined. Fifty-two patients underwent RALP without conversion to open procedure (35 SRP, 17 URP). Operative time was significantly less in the URP group (p = 0.01). URPs required less narcotics and had shorter length of stay. Three complications were reported after SRP, whereas two patients with URP experienced transient ureteral obstruction, which resolved after 4 weeks with an indwelling ureteral stent. Postoperative renograms showed improved drainage in all but four patients (two SRPs and two URPs), each of whom had subjective improvement in symptoms postoperatively. Our data suggest that URP is a safe and feasible procedure for the treatment of ureteropelvic junction obstruction. There were no clinically significant differences between the stented and unstented groups. Further prospective evaluation is needed; however, URP can be performed by an experienced surgeon in a carefully selected patient.

Intermediate Term Outcomes Associated With the Surveillance of Ureteropelvic Junction Obstruction in Adults

We determined the outcome of minimally symptomatic adult ureteropelvic junction obstruction in a group of patients treated conservatively with an active surveillance regimen. A total of 27 patients with asymptomatic or minimally symptomatic ureteropelvic junction obstruction were treated conservatively. All patients were evaluated with diuretic renograms. Ureteropelvic junction obstruction was defined by an obstructive pattern of the clearance curve and/or T1/2 greater than 20 minutes. Followup consisted of an office visit and renogram every 6 to 12 months. Cases of greater than 10% loss of relative renal function of the affected kidney, development of pyelonephritis and/or more than 1 episode of acute pain were considered active surveillance failures, and treatment was recommended. Of the 27 patients 6 were lost to followup, leaving 21 (median age 47 years) with sufficient followup for analysis. In the 4 patients (19%) who initially presented with mild pain that led to the diagnosis of ureteropelvic junction obstruction, the pain completely resolved. Ipsilateral relative renal function decreased significantly in 2 patients (9.5%, mean reduction 14%). Pain worsened in 3 patients (14.3%) and de novo pain occurred in 1 (4.7%). Surgical intervention for ureteropelvic junction obstruction was required in 6 patients (29%) at an average of 34 months. In total 15 patients (71%) remained on surveillance with a mean followup of 48 months. Active surveillance seems to be a reasonable initial option for asymptomatic or mildly symptomatic adult patients with ureteropelvic junction obstruction because only approximately 30% have progression to surgical intervention within 4 years of diagnosis. This strategy offers the advantage of individualizing therapy according to symptoms and renographic findings.

Pediatric Robot-Assisted Laparoscopic Pyeloplasty Using a Transmesenteric Approach

Introduction: Robot-assisted laparoscopic pyeloplasty is an emerging minimally invasive option in the pediatric population for the treatment of ureteropelvic junction obstruction. Since the first description of minimally invasive pyeloplasty in 1993,1 the robot-assisted technique has been applied to both primary and reoperative procedures in the pediatric population, achieving results comparable to open surgery.2–4 We describe our transmesenteric approach for robot-assisted laparoscopic pyeloplasties, which provides direct access to the pelvis without mobilization of the colon. Materials and Methods: After induction of anesthesia and insertion of a Foley catheter, the patient is secured with tape in the supine position with the ipsilateral side raised on a gel roll such that the patient is at a 45° angle to the bed. Initial access is performed using an open peritoneal (Hasson) technique. One 8.5- or 12-mm camera port, two robotic arm ports (5 or 8 mm), and one 5-mm accessory port are used for the procedure. The bed is then rotated to elevate the ipsilateral side. The Da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, CA) is docked over the ipsilateral side to the ports. A small window is made in the mesentery overlying the dilated renal pelvis while taking care to avoid major vasculature and the renal pelvis is dissected free. A “hitch stitch” is placed through the abdominal wall, through the renal pelvis, and then through the abdominal wall to provide exposure and traction during subsequent dissection and reconstruction. The ureteropelvic junction is transected proximal to the obstruction and the ureter is spatulated until a healthy lumen is visible. The ureteropelvic junction is then reconstructed with running 5-0 Monocryl sutures, using the strictured portion temporarily as a handle until excision just before completion of the anastamosis. Finally, the mesenteric window is closed with a running 4-0 Vicryl suture. Results and Conclusions: Robot-assisted laparoscopic pyeloplasty using a transmesenteric approach provides rapid identification of as well as easy access to the ureteropelvic junction obstruction in children. Observation of the dilated renal pelvis through the mesentery allows for exposure through avascular planes, obviating colon mobilization. Complete reconstruction can be performed without extensive colonic mobilization, preserving the retro-colic space. Transmesenteric robot-assisted laparoscopic pyeloplasty is an attractive alternative to previously described robotic pyeloplasty techniques for the treatment of ureteropelvic junction obstruction in children. No competing financial interests exist. Runtime of video: 7 mins 11 secs.

Operative treatment for ureteropelvic junction obstruction

Objective To analyze the clinical features and summarize diagnosis and therapeutic efficacy for ureteropelvic junction obstruction(UPJO). Methods Two hundred and twenty-two patients with UPJO were treated from 2000 to 2008,including 155 males and 67 females:the age rangeed from 13 to 75 and mean age was 29 years.One hundred and seventy-three cases presented with back pain;19 cases with urine infection;12 cases with abdomen bump;7 cases with macroscopic hematuria;11 cases found by B-ultrasound examine.Etiological factors included 185 patients of ureteropelvic junction stenosis;18 cases of high location of the junction;19 cases which were diagnosed UPJO due to benign oppression,including fiber cords and peculiar vessels.A total of 222 cases of surgical procedures were conducted,of them Anderson-Hynes dismembered pyeloplasty was conducted for 191 cases,fiber cords and peculiar vessels were relieved for 19,nephrectomy for 12 cases because of nonfunction. Results One hundred and ninety-one cases who underwent Anderson-Hynes dismembered pyeloplasty were all succeeded with operation.They were followed up for 6 months to 8years with a mean of 38 months.B-ultrasound and IVU showed that hydronephrosis was obviously relieved.The clinical symptoms disappeared in all cases.The levels of serum creatinine of 7 cases who had higher ereatinine recovered. Conclusion Anderson-Hynes dismembered pyeloplasty could be a good choice and effective method for the treatment of UPJO. Key words: Ureteropelvic junction obstruction; Hydronephrosis; Pyeloplasty

Retroperitoneal laparoscopic dismembered pyeloplasty in pediatric ureteropelvic junction obstruction

Objective To discuss the efficacy of retroperitoneal laparoscopic dismembered pyeloplasty for pediatric ureteropelvic junction obstruction(UPJO). Methods Retroperitoneal laparoscopic dismembered pyeloplasty was performed on 24 patients with UPJO.The age of the patients ranged from 3 to 14 years(mean,7 years).The diagnosis was set up by ultrasonography,IVU,CT or magnetic resonance urography.All the patients had hydronephrosis,with 4 cases mild,10 cases moderate and 10 severe ones. Results All operations were completed laparoscopieally,without conversions to open surgery during operation.The mean operative time was 180 min(range 150 to 200).The mean blood loss was 60 ml(range 40 to 100)and the mean postoperative hospital stay was 7 d (range 5 to 9).All 24 patients were followed-up for 6 to 24 months(mean,1 4 months).There was no stricture at UPJ.Eighteen patients had complete resolution of hydronephrosis and 6 patients showed obvious alleviation in hydronephrosis. Conclusion Retroperitoneal laparoseopie dismembered pyeloplasty could be a mini-invasive,safe,and effective procedure for the treatment of UPJO in pediatric patients. Key words: Laparoscopes; Pyeloplasty; Child

Laparoscopic dismembered pyeloplasty for the treatment of ureteropelvic junction obstruction

Objective To discuss the treatment of ureteropelvic junction obstruction by laparoscopic pyeloplasty. Methods A retrospective review of consecutive laparoscopic pyeloplasty in 102 patients between September 2001 and December 2007 was performed. The ureterpelvic junction was dissected and the obstruction portion was excised. Anastomosis was then performed through the ureter and the renal pelvis walls with a stent. Results The mean operating time was 120 min and the average blood loss was 80ml. No major complication occurred intraoperative. The drainage was removed in 3-10 days. The average hospital stay was 8.5 days. The stent was kept for 30-60 days. IVU and B ultrasound examination revealed that the hydronephrosis alleviated during the follow-up and no anastomosis stricture occurred. Conclusions Laparoscopic dismembered pyeloplasty could provide lower morbidity, shorter hospital stay, and faster convalescence. It could be an effective treatment for ureteropelvic junction obstruction. Key words: Laparoscopes; Ureteropelvic junction obstruction

Laparoscopic pyeloplasty: an analysis of first 100 cases and important lessons learned

Laparoscopic pyeloplasty (LP) is a minimally invasive approach that is becoming a standard treatment of ureteropelvic junction obstruction (UPJO). It is providing similar results when compared with open surgery. We here present our technique and analyses of experience of our first 100 cases. We retrospectively reviewed and analyzed the records of first 100 cases of LP performed for UPJO with dilatation of renal pelvis at our centre. Patients' profile; perioperative, intraoperative and postoperative parameters like time of surgery, blood loss, complications, duration of hospital stay, outcome of procedure were analyzed. The mean operative time, need for an extra-port, conversions to open, estimated blood loss, complications and recurrences all significantly decreased after first 50 cases. One patient developed shock due to bleeding from inferior epigastric vessels near port-site, and had to be explored. Overall success rate was 96%. Lesser incidence of fourth-port insertion, conversions to open, and thus decreased operative time was attributed to introduction of additional techniques to reduce the learning curve. LP is a technically difficult procedure. Sticking to the basic steps of LP, and trying and thus incorporating additional tactics are useful to reduce the learning curve.

Doppelniere mit Nierenbeckenabgangsstenose im Kindesalter

Laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction (UPJO) in children is still one of the most demanding operations in urology. We report on a 12-year-old boy with UPJO in a duplicated collecting system with high ureter fissus. He was admitted with a 1-year history of recurrent flank pain and dilation of the lower duplicated collecting system. We performed a retroperitoneoscopic Anderson-Hynes pyeloplasty.

The minimally invasive management of ureteropelvic junction obstruction in horseshoe kidneys

Data regarding the treatment of ureteropelvic junction obstruction (UPJO) in horseshoe kidneys are limited. We performed a retrospective analysis of our experience with minimally invasive treatment of UPJO in patients with this anomaly. Between March of 1996 and March 2008, 9 patients with horseshoe kidneys were treated for UPJO at our institution. Of these patients, 6 were managed with retrograde endopyelotomy, 2 with laparoscopic pyeloplasty, and one by robotic pyeloplasty. Outcomes of these procedures were retrospectively reviewed. A total of nine patients were available for analysis. Four of six patients who underwent endopyelotomy had available follow-up, with a mean of 56months. The success rate for these patients was 75%. Two of three patients (67%) in the laparoscopic/robotic cohort were successfully treated with a mean follow-up of 21months. UPJO in horseshoe kidneys can pose a therapeutic dilemma. The minimally invasive treatment of these patients is feasible with good success rates for both endopyelotomy and laparoscopic/robotic pyeloplasty.

Preliminary Experience with Laparoscopic Ureteropelvic Junction Release in the Treatment of Ureteropelvic Junction Obstruction

To review our experience with laparoscopic ureteropelvic junction (UPJ) release in the treatment of UPJ obstruction (UPJO) in adults. We retrospectively reviewed 44 consecutive patients who underwent laparoscopic treatment of UPJO at our institution between December 2000 and April 2008. Patient characteristics, perioperative data, intraoperative findings leading to a decision to perform UPJ release, and outcomes were recorded. Mean patient age was 47.4 years (range 20-60 years). UPJ release was performed as definitive treatment in 9 of 47 laparoscopic procedures for UPJO. The obstruction was right-sided in five and left-sided in four patients. Three (33%) patients were previously treated with either balloon dilation or endopyelotomy, or both. Intraoperative findings included (1) significant scarring, inflammation, or fibrosis, (2) adherent bands between a crossing vessel and the UPJ, or (3) obvious constricting periureteral bands. A crossing vessel was observed in seven patients (78%). Mean operative time, estimated blood loss, and length of stay were 370.1 +/- 76.9 minutes, 24.4 +/- 31.3 mL, and 1.4 +/- 0.5 days, respectively. At a mean follow-up of 25.1 +/- 17.3 months, a 78% overall success rate was achieved. UPJ release was most successful in the patients in the "significant scarring, inflammation, or fibrosis" category (100%). Although pyeloplasty remains the preferred treatment for UPJO, UPJ release can be successful in certain circumstances, particularly when significant scarring, inflammation, or fibrosis appears to be the primary etiology of the obstruction. Further investigation is warranted to help define the specific clinical situations in which UPJ release may be beneficial.

Prospective analysis of completely stentless robot-assisted pyeloplasty in children.

Robot-assisted pyeloplasty (RAP) is emerging as an effective tool for treatment of ureteropelvic junction obstruction (UPJO) in the pediatric population. Typically stents are utilized for RAP and removed four weeks after the procedure. We present our prospective experience with stentless RAP. Twenty children between the ages of 12 and 113months (mean age 56months) underwent transperitoneal RAP for UPJO utilizing the DaVinci surgical system. Outcome measures included operative time, length of hospital stay, and resolution of obstruction by ultrasonography, magnetic resonance urography (MRU), and/or diuretic radionuclide imaging (DRI). All patients successfully underwent robot-assisted laparoscopic pyeloplasty without conversion to pure laparoscopy or open procedure. Mean operative time was 124.7min with a mean console time of 82.3min. The mean hospital stay was 18h. Of the 20 patients, 13/20 (65%) had resolution or improvement in the degree of hydronephrosis. The other patients had no evidence of obstruction based upon follow-up MRU or DRI. Stentless RAP is a safe and effective option for surgical treatment of UPJO. A larger prospective long-term cohort is needed to confirm the safety and efficacy of the stentless approach.

Functional outcome after laparoscopic dismembered pyeloplasty in children

Laparoscopic or retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction in children has become a routine procedure. The aim of this study was to evaluate functional outcome for patients who had undergone a laparoscopic dismembered pyeloplasty. Seventy children underwent a laparoscopic dismembered pyeloplasty. Median follow up was 24 months (1-48). We reviewed differential renal function (DRF) and tracer clearance with diuretic renography before as well as 3 and 12 months after operation. Ultrasound was used to determine the grade of hydronephrosis pre- and postoperatively. Median age at operation was 20 months (1-178). Median operating time was 140 min (95-220). Mean DRF could be preserved with no significant difference (P>0.05). All patients showed a significant improvement in tracer clearance on diuretic renography postoperatively (P<0.0001). Ultrasound examinations postoperatively showed a diminished grade of hydronephrosis without significance (P=0.657). In terms of preservation of DRF the laparoscopic approach is as effective as open surgery. Tracer clearance is significantly improving. Operating times for laparoscopic pyeloplasty are competitive. We conclude that laparoscopic pyeloplasty requires extensive experience in laparoscopic pediatric urology but might replace the open surgical procedure as gold standard in the operative treatment of ureteropelvic junction obstruction.

Editorial Comment

This large single center series confirms the now established excellent and reproducible success rates of laparoscopic extraperitoneal dismembered pyeloplasty. We congratulate the authors for their skill in performing this technically difficult surgery with impressive operating times, low morbidity, and a 98% early success rate. The apparent long length of postoperative stay relates to cultural differences and belies the clear advantages of this technique over open surgery. Retroperitoneal Laparoscopic Dismembered Anderson-Hynes Pyeloplasty in Treatment of Ureteropelvic Junction Obstruction (Report of 150 cases)UrologyVol. 74Issue 5PreviewTo assess the feasibility and efficacy of retroperitoneal laparoscopic dismembered Anderson-Hynes pyeloplasty in the treatment of ureteropelvic junction obstruction (UPJO). Full-Text PDF ReplyUrologyVol. 74Issue 5PreviewWith the development of laparoscopic technique, laparoscopy has been used in all kinds of surgeries in the field of urology, such as adrenalectomy, nephrectomy, cystectomy, and prostatectomy. However, laparoscopic technique has been also accepted and perfectly mastered by urologists in China. Full-Text PDF

What Is the Best Treatment for Ureteropelvic Junction Obstruction? In response to: Ureteropelvic Junction Obstruction: Which Is the Best Treatment Today?

What Is the Best Treatment for Ureteropelvic Junction Obstruction? In response to: Ureteropelvic Junction Obstruction: Which Is the Best Treatment Today?

Ureteropelvic Junction Obstruction: Which Is the Best Treatment Today?

The aim of this review is to critically compare the different procedures performed for the treatment of ureteropelvic junction obstruction (UPJO) in order to identify, currently, the best treatment that a urologist should propose to patients with this condition. Three different types of procedures were assessed: open pyeloplasty (OP), endopyelotomy, and laparoscopic pyeloplasty (LP). Regarding efficacy, success rates of 94.1, 62-83, and 95.9-97.2% were reported for OP, endopyelotomy, and LP, respectively. Concerning operative time and length of hospital stay, no extensive data are available in the literature, although endopyelotomy seems to provide shorter times with respect to those reported after OP and LP. Regarding the complication rate, it was very similar after the different techniques and due to the respective approaches. Overall, our data support the conclusion that LP provided a balance between the highly successful technique reported by OP and the quick postoperative recovery provided by the endoscopic approach. Anyway, in spite of these clear advantages, the reproducibility of LP is still strongly limited by the challenge of the learning curve. The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA), providing an extraordinary vision and precision of surgical movement, appears to be changing this scenario, allowing naïve surgeons to achieve very good results after few procedures. In this setting, robot-assisted pyeloplasty seems to be emerging as the new standard of care in the patients with UPJO, which will further take place over the other techniques once its costs decrease.

Does Renal Function Remain Stable After Puberty in Children With Prenatal Hydronephrosis and Improved Renal Function After Pyeloplasty?

We evaluated whether improved renal function after pyeloplasty for prenatal ureteropelvic junction obstruction persisted through puberty. A total of 441 males and 137 females with a prenatal diagnosis of hydronephrosis that led to the postnatal diagnosis of ureteropelvic junction obstruction were followed at our department from 1989 to 2008. Of the patients we reviewed the records of 49 who underwent surgery between 1989 and 1992, and completed puberty. Hydronephrosis was on the right side in 18 children (36.7%) and on the left side in 31 (63.3%). According to Society for Fetal Urology classification at first presentation postnatal hydronephrosis was grades 2 to 4 in 18 (36.7%), 23 (46.9%) and 8 children (16.3%), respectively. Initially relative renal function was more than 40% in 18 children (36.7%), between 30% and 40% in 24 (49%), and less than 30% in 7 (14.3%). Preoperatively mean +/- SEM relative renal function was 36.6% +/- 7.8% in all reviewed patients. Improvement in hydronephrosis was confirmed in all patients. This remained stable during and after puberty in all except 2 patients, who required endopyelotomy 8 and 10 years following pyeloplasty, respectively, due to deterioration in hydronephrosis without a decrease in relative renal function. They showed improvement in the washout curve pattern after the procedure. Pyeloplasty led to increased relative renal function in the short term from 36.7% +/- 1.2% before surgery to 41.2% +/- 0.91% in all patients (p <0.001). It remained stable at 43.2% +/- 0.75% after puberty in all reviewed patients. To our knowledge our data show for the first time that successful pyeloplasty after the prenatal diagnosis of ureteropelvic junction obstruction is associated with improved renal function throughout puberty.

Retroperitoneal Laparoscopic Dismembered Anderson-Hynes Pyeloplasty in Treatment of Ureteropelvic Junction Obstruction (Report of 150 cases)

To assess the feasibility and efficacy of retroperitoneal laparoscopic dismembered Anderson-Hynes pyeloplasty in the treatment of ureteropelvic junction obstruction (UPJO). Between August 2003 and June 2007, retroperitoneal laparoscopic dismembered Anderson-Hynes pyeloplasty was performed in 150 patients diagnosed with UPJO. All patients were assessed preoperatively by imaging examinations (ultrasonography, computerized tomography, and intravenous or retrograde urography) and isotope diuretic renography. Additionally, of the 150 cases, 16 patients with renal calculi underwent concomitant pyelolithotomy. All surgeries were successful. No conversion to open surgery was observed. The average operating time, blood loss, and postoperative hospital stay was 105 minutes (range 95-190), 35 mL (range 20-80), and 7.4 days (range 6-12), respectively. A crossing vessel was encountered in 70 (46.7%) patients. Concomitant renal calculi were successfully removed in 11 patients. Two cases presented with urinary leakage that disappeared on the 11th and 12th postoperative day, respectively. Success rate was 98% at a mean follow-up of 16 months (range 12-24). Retroperitoneal laparoscopic pyeloplasty provides a minimal invasive treatment modality with low morbidity, short hospital stay, and quick postoperative recovery for patients with UPJO. In experienced hands, laparoscopic pyeloplasty is an effective alternative treatment for UPJO.

Ureteropelvic Junction Obstruction: Which Surgical Approach?

Abstract Context Open pyeloplasty has been considered the referral standard of treatment for ureteropelvic junction obstruction (UPJO). Minimally invasive procedures, however, have evolved and have gradually replaced open surgery, with various success and complication rates. The ideal universal treatment for UPJO is still elusive and controversial. Objectives The current status of three surgical approaches to the treatment of UPJO are reviewed: laparoscopic pyeloplasty (LP), robotic-assisted pyeloplasty, and endopyelotomy. Evidence acquisition The interactive discussion among the expert presenters and urologists participating at the Second Congress on Controversies in Urology in Lisbon, Portugal, is summarized. Evidence synthesis A review of the relevant literature and the experts' opinions seem to indicate that LP, either conventional or robotic, should be considered as the treatment of choice for UPJO, because it achieves the highest success rates (90%) while still offering the patient the advantages of minimally invasive surgery. The conventional laparoscopic approach demands a high level of surgical expertise and dedicated training that can be partially obviated by the robotic system. Evidence proving clear advantages of robotic pyeloplasty over conventional laparoscopy, however, is lacking due to short follow-up. Additionally, in its current version, the robotic system is financially prohibitive for many centers worldwide. In experienced hands, endopyelotomy performed either percutaneously or by the retrograde ureteroscopic approach can achieve long-standing satisfactory results in carefully selected patients (short strictures, minimal hydronephrosis, no crossing vessel). Additionally, endopyelotomy is the procedure of choice for failed pyeloplasty, with success rates of up to 80%. Conclusions It can be concluded from the presented data that, given the surgical expertise, LP should be considered the current standard of care for UPJO, with high success rates comparable to the open procedure. The advantages of the robotic system for the patient remain to be proved by scientific data. Endopyelotomy is still indicated in selected cases as a primary therapeutic option and should be considered the procedure of choice for pyeloplasty failures.