eMedicine Specialties > Urology > Surgery

Pyeloplasty: Follow-up

Author: Thomas MT Turk, MD, Associate Professor, Department of Urology, Loyola University Medical Center
Coauthor(s): Anthony J Polcari, MD, Staff Physician, Department of Urology, Loyola University Medical Center; Sameer K Sharma, MD, Staff Physician, Department of Urology, Loyola University Medical Center; Brant R Fulmer, MD, Consulting Staff, Department of Urology, Geisinger Medical Center Urology
Contributor Information and Disclosures

Updated: Jul 20, 2009

Outcome and Prognosis

Success rates for the different treatments for ureteropelvic junction (UPJ) obstruction vary depending on a number of factors, including, but not limited, to the degree of obstruction; whether it is a primary or secondary obstruction; the function of the affected kidney; anatomic considerations, such as the presence of crossing vessels; and the expertise of the treating surgeon.

Open pyeloplasty

Often considered the criterion standard for the treatment of UPJ obstruction, open pyeloplasty has success rates consistently greater than 90% based on subjective patient symptoms and objective radiographic evidence.

Laparoscopic pyeloplasty

Although technically more difficult than open pyeloplasty, this technique shares similar success rates with its open counterpart. Success rates range from 88%-100%, with most series citing rates well over 90%. In the largest series to date of 170 patients undergoing dismembered pyeloplasty, Moon and colleagues (2006) report a symptomatic success rate of 96%.8

Robotic pyeloplasty

The enthusiasm for robotic pyeloplasty is supported by a mounting body of evidence documenting its efficacy. Several single-center series report symptomatic and radiographic success rates of 94%-100%, and, recently, a multi-institutional review reported that 96% of patients undergoing robotic dismembered pyeloplasty at 3 centers demonstrated resolution of obstruction on imaging studies.9 In addition, most series report significantly shorter operative times for robotic compared with laparoscopic pyeloplasty.

Antegrade endopyelotomy

The success rates of antegrade endopyelotomy are 75-95%. Different factors contributing to the success or failure include whether the obstruction is primary or secondary, whether high insertion of the ureter into the renal pelvis occurred, the degree of hydronephrosis and the function of the affected kidney, and the presence of a crossing vessel near the UPJ.

Retrograde endopyelotomy

Although this approach is typically considered to have lower success rates compared to an antegrade approach and open or laparoscopic pyeloplasty, it can usually be performed with minimal morbidity and, perhaps, at a lower cost compared to alternative treatments. Success rates are reported to be 70-85%. As with an antegrade approach, anatomic and functional factors affect the overall success rates.

Acucise endopyelotomy

The overall success rate of 75% for Acucise retrograde endopyelotomy is similar to that of the antegrade and retrograde approach. Similar anatomic and functional factors can also affect the success rate of this procedure.

Future and Controversies

The optimal treatment for patients with ureteropelvic junction (UPJ) obstruction is a continuing source of controversy among urologic surgeons. While open pyeloplasty has traditionally yielded the highest success rates, this must be balanced against greater patient discomfort and longer recovery times. Conversely, endopyelotomy is a less morbid approach, with generally lower but potentially acceptable success rates. Standard laparoscopic pyeloplasty combines the minimally invasive aspects while maintaining the effectiveness of open pyeloplasty; however, its technical challenges have limited its use to centers with considerable laparoscopic expertise. The da Vinci robot holds promise as a tool that will allow more surgeons to offer a minimally invasive approach to pyeloplasty.

As evidenced by the development of the laparoscopic pyeloplasty, a trend toward less-invasive approaches for the treatment of UPJ obstruction is certainly occurring. Other methods are being explored that may work as adjuncts to the currently available surgical treatments. The primary reason for failure of the current procedures is the formation of scar tissue composed of collagen at the site of the anastomosis or the site of endopyelotomy. Some investigators are examining the role of collagen inhibitors in animal models to reduce the amount of collagen in an attempt to reduce scarring after treatment.

Other investigators are examining the role of adenovirus to transfect genes to reduce scarring in the ureters of animals with ureteral strictures. While these studies explore adjuncts to the currently available treatments, the ultimate outcome may be the development of less-invasive or noninvasive treatments for UPJ obstruction.

 


More on Pyeloplasty

Overview: Pyeloplasty
Workup: Pyeloplasty
Treatment: Pyeloplasty
Follow-up: Pyeloplasty
References
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Further Reading

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Keywords

pyeloplasty, congenital hydronephrosis, ureteropelvic junction obstruction, UPJ obstruction, open pyeloplasty, laparoscopic pyeloplasty, robotic pyeloplasty, robot-assisted pyeloplasty, robot-assisted laparoscopic pyeloplasty, Acucise endopyelotomy, hematuria, urinary tract infection, UTI, dismembered pyeloplasty, antegrade endopyelotomy, antegrade endopyeloplasty, retrograde endopyelotomy, laparoscopic dismembered pyeloplasty, urologic abnormality, horseshoe kidney, ectopic kidney, nephrolithiasis, vesicoureteral reflux, stones, stone passage, pyelonephritis, ipsilateral nephrolithiasis, renal function deterioration, recurrent flank pain

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Contributor Information and Disclosures

Author

Thomas MT Turk, MD, Associate Professor, Department of Urology, Loyola University Medical Center
Thomas MT Turk, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Anthony J Polcari, MD, Staff Physician, Department of Urology, Loyola University Medical Center
Disclosure: Nothing to disclose.

Sameer K Sharma, MD, Staff Physician, Department of Urology, Loyola University Medical Center
Disclosure: Nothing to disclose.

Brant R Fulmer, MD, Consulting Staff, Department of Urology, Geisinger Medical Center Urology
Brant R Fulmer, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association
Disclosure: Intuitive Surgical Honoraria Speaking and teaching

Medical Editor

Peter Langenstroer, MD, Associate Professor, Department of Urology, Medical College of Wisconsin
Peter Langenstroer, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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