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com/article/450785-print

emedicine.medscape.com

Ureteropelvic Junction
Obstruction
Updated: Mar 09, 2018
Author: Michael Grasso, III, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS

Overview

Background
Ureteropelvic junction (UPJ) obstruction is defined as an obstruction of the flow of urine from the renal pelvis to the proximal
ureter. The condition is frequently encountered by both adult and pediatric urologists. Congenital abnormalities may be observed
in both adults and children, but adults may also present with UPJ obstruction secondary to surgery or other disorders that can
cause inflammation of the upper urinary tract.

The critical decision to be made in dealing with suspected UPJ obstruction is whether the radiologic findings correlate with the
physiologic picture. In other words, severely dilated hydronephrotic kidneys may, in fact, be found to be draining well when
studied appropriately. Defining the exact anatomy and function of these kidneys is crucial when evaluating and treating these
patients.

The treatment strategies for UPJ obstruction have shifted significantly in the last several years. The gamut of current surgical
treatments for UPJ obstruction includes the following:

Laparoscopic pyeloplasty
Open pyeloplasty
Endopyelotomy
Endopyeloplasty
Robotic-assisted laparoscopic pyeloplasty

While open pyeloplasty is still considered the criterion standard for treatment of UPJ obstruction in infants, laparoscopic
pyeloplasty, with or without robotic assistance, is the treatment of choice in older children and in most adults.[1]

History of the Procedure


UPJ obstruction is the most common cause of neonatal and antenatal hydronephrosis, occurring in one per 1500 live births.
Prior to the use of prenatal ultrasonography, most patients with UPJ obstruction presented with pain, hematuria, urosepsis,
failure to thrive, or a palpable mass. With the enhanced ability and availability of prenatal ultrasonography, urologic
abnormalities are being diagnosed earlier and more frequently. Fifty percent of patients diagnosed with antenatal
hydronephrosis are eventually diagnosed with UPJ obstruction upon further workup.

Initially, most children are treated conservatively and monitored closely. Intervention is indicated in the event of significantly
impaired renal drainage or poor renal growth.

Problem
UPJ obstruction is defined as an obstruction of the flow of urine from the renal pelvis to the proximal ureter. The resultant back
pressure within the renal pelvis may lead to progressive renal damage and deterioration.

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UPJ obstruction presents most frequently in childhood, but adult and elderly individuals can also present with a primary
obstructive lesion. In adults, other etiologies for ureteral obstruction must be considered, including stones, ureteral compression
due to extrinsic processes, retroperitoneal fibrosis, and other inflammatory processes.

Epidemiology
Frequency

Epidemiologic features of UPJ obstruction are as follows:

Ultrasonography reveals fetal upper urinary tract dilatation in approximately one in 100 pregnancies; however, only one in
500 of those infants are later diagnosed with significant urologic problems

UPJ obstruction is found in approximately 50% of patients diagnosed with antenatal hydronephrosis

The male-to-female ratio of UPJ obstruction is 3-4:1

In general, the left kidney is more commonly affected than the right kidney

UPJ obstruction is less common in adults than in children but is not rare in either population

UPJ obstruction is bilateral in 10% of cases

Etiology
Possible etiologies for UPJ obstruction include the following:

Intrinsic obstruction may result from stenosis due to scarring of ureteral valves.

Ureteral hypoplasia may result in abnormal peristalsis through the UPJ. Asymmetry of ureteral wall musculature may
inhibit the natural peristaltic emptying of the renal pelvis into the ureter.

An abnormal or high insertion of the ureter into the renal pelvis may alter the configuration and impair drainage of urine.
This may be an effect rather than a cause because the two etiologies mentioned above may manifest as a high-insertion
variant seen on imaging studies.

Crossing lower-pole renal vessel(s) or entrapment of the ureter by a vessel can block urinary flow down the ureter.
Vessels that wrap around the UPJ may be associated with obstruction or may be a product of renal dilatation and
hydronephrosis that distorts renal vascular architecture.

Rotation of the kidney (eg, renal ectopy) and renal hypermobility can cause intermittent obstruction that is solely
dependent on the position of the kidney relative to the ureter. This was once a very popular diagnosis; however, the other
etiologies mentioned above are more prevalent today, and this cause is particularly rare.

Secondary UPJ obstruction can be caused by prior surgical intervention to treat other disorders (eg, renal stone disease)
or failed repair of a primary UPJ obstruction. This obstructive lesion is usually secondary to ureteral-wall and periureteral
scar formation.

All of the above abnormalities impair drainage of urine from the kidney into the ureter, resulting in elevated intrarenal back
pressure, dilatation of the collecting system, and hydronephrosis.

Scanning electron microscopy studies using 3-dimensional techniques have shown that normal elasticity and distension of the
renal pelvis are impaired secondary to rigid collagen bundling. Increased collagen deposition between smooth muscle cells
results in wider cell-to-cell and nerve-to-cell distances. Neural depletion has also been reported. In addition,
immunohistochemical studies have shown decreased neuronal markers and nerve growth factors within the smooth muscle
layer, thus impeding peristalsis.

In the rat model, acute obstruction resulted in increased levels of angiotensin 11 and increased transforming growth factor–β
expression, resulting in pathological deposition of extracellular matrix, which may be one mechanism that leads to obstruction.

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Presentation
Neonates may present with hydronephrosis. Older children may present with urinary tract infection (UTI), a flank mass, or
intermittent flank pain secondary to a primary UPJ obstruction. Hematuria may also be a presenting sign if obstruction is
associated with infection.

Adults with UPJ obstruction can present with various symptoms, including back and flank pain, UTI, and/or pyelonephritis. A
detailed history may reveal that the pain correlates with periods of increased fluid intake or ingestion of a food with diuretic
properties (ie, Dietl crisis).

Indications
The goals in treating patients with ureteropelvic junction (UPJ) obstruction are to improve renal drainage and to maintain or
improve renal function.

As mentioned above, dilatation of the intrarenal collecting system or hydronephrosis does not necessarily imply obstruction.
Specifically in children, renal pelvic dilatation should be monitored with serial imaging to assess for changes in dilatation, renal
parenchymal thickness and/or the presence of scarring, and function. Surgical repair is indicated upon a significant differential
on serial imaging or progressive deterioration of renal function.

Using this algorithm, patients with hydronephrosis are monitored closely with renal ultrasonography and nuclear medicine
renography every 3-6 months. Similarly, in adults, repair is recommended if nuclear medicine renal scan or intravenous
pyelography (IVP) reveals ureteral obstruction.

Relevant Anatomy
The evaluation of an obstructed ureteropelvic junction (UPJ) requires information about ureteral and surrounding anatomy, renal
position and ectopy, associated vasculature, and renal function. Prior to surgical intervention, the surgeon frequently evaluates
for renal position/ectopy, mobility, and UPJ anatomy, such as high-insertion variants versus annular stricture variants.

The major vascular supply of the UPJ comes from branches of the renal artery. These vessels usually lie in an anteromedial
location in relation to the proximal ureter. Aberrant polar vessels may also be associated with the renal pelvis, causing
compression and obstruction of the collecting system. These vessels arise from either the renal artery from a position proximal
to the main intrarenal branching site or directly from the aorta. They can surround the UPJ and can be associated with
obstruction, or they may be aberrantly positioned secondary to increasing hydronephrosis.

Intraluminal sonogram demonstrating the renal vein surrounding the ureteropelvic junction and causing extrinsic compression
and obstruction.

An endopyelotomy refers to an endoscopic incision of the UPJ, performed to create a more funneled drainage system and to
bring the UPJ more dependent or caudad below areas of pathology.

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The vascular anatomy at the UPJ becomes crucial during an endopyelotomy. The renal collecting system may be accessed
percutaneously (antegrade) or in a retrograde fashion via passage of a ureteroscope through the urethra, bladder, and ureter in
order to access the obstruction and to perform an incision. While most associated UPJ vessels lie in the anteromedial plane,
accessory vessels may lie posteriorly or laterally. If all endoscopic incisions are made in the posterior-lateral plane,
intraoperative hemorrhage may occur. For this reason, a comprehensive vascular evaluation with intraoperative endoluminal
ultrasonography, preoperative CT scanning, or MRI with vascular reconstruction is recommended prior to this form of treatment.

CT scan without contrast demonstrating severe left-sided hydronephrosis secondary to ureteropelvic junction obstruction.

CT scan with intravenous contrast demonstrating pooling of contrast and delayed excretion of contrast from a left-sided
ureteropelvic junction obstruction.

Multidetector CT scanning with 3-dimensional reconstruction can be particularly helpful in establishing the anatomy of UPJ
obstruction, revealing an intrinsic or high-insertion UPJ. Crossing vessels and their relationship to the ureter of the UPJ can also
be evaluated. The location of these vessels and their possible contribution to renal obstruction can help the surgeon decide
whether endopyelotomy, open pyeloplasty, or laparoscopic pyeloplasty would be the most effective treatment modality.

When an open or laparoscopic pyeloplasty is performed, an accurate understanding of the vascular anatomy allows the surgeon
to preserve the accessory renal vessels and to redirect them if the surgeon feels that they contribute to the obstruction. If an
endopyelotomy is planned, this information can guide the surgeon in directing the endopyelotomy incision away from crossing
vessels. CT scanning in combination with 3-phase and 3-dimensional contrast imaging yields a reported sensitivity of 75%-97%
in revealing crossing vessels. El-Nahas et al reported that CT scanning yielded a sensitivity of 97%, specificity of 92%, and
accuracy of 96% in detecting crossing vessels associated with UPJ obstruction.[2]

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Retrograde pyelography at the time of surgery is often used to estimate the length of the stricture and the amount of
pelvis/ureter that needs to be excised at the time of the pyeloplasty to create a dependent funnel.

Workup

Laboratory Studies
All patients with possible ureteropelvic junction (UPJ) obstruction should be evaluated with the following laboratory studies:

Complete blood cell count (CBC)


Coagulation profile
Electrolyte levels
Renal function assessment - Blood urea nitrogen (BUN) and serum creatinine levels
Urine culture

Imaging Studies
Neonates who present with hydronephrosis should be fully evaluated with voiding cystourethrography (VCUG; to rule out
vesicoureteral reflux) and renal ultrasonography (see image below) soon after birth. These patients should also be placed on
prophylactic antibiotics (amoxicillin 15 mg/kg) to prevent urinary tract infections (UTIs), especially while diagnostic imaging is
being performed.

Intraluminal sonogram of ureteropelvic junction obstruction demonstrating multiple crossing vessels.

If renal ultrasonography demonstrates hydronephrosis without reflux on VCUG, a diuretic renal scan (mercaptotriglycylglycine
[MAG-3], diethylenetriamine [DTPA], or dimercaptosuccinic acid [DMSA]) should be performed to quantify relative renal function
and to define the extent of obstruction. Renal ultrasonography and VCUG are performed in children with suspected UPJ
obstruction.

Historically, intravenous pyelography (IVP) was used to evaluate patients with possible UPJ obstruction. However, in the
evaluation of a child with a hydronephrotic kidney, diuretic renography has taken the place of IVP. The benefits of diuretic
renography are that iodine-based intravenous contrast is not used, radiation exposure is minimal, and renal function can be
better quantified. The disadvantage of the nuclear medicine scan is that insight into renal anatomy is not obtained.

In 1992, the Society for Fetal Urology and the Pediatric Nuclear Medicine Council published guidelines for the "Well-Tempered
Diuresis Renogram."[3] Standardized protocols for hydration, radiopharmaceuticals, bladder catheterization, diuretic dose,
timing of diuretic, and determination of clearance half-time (T1/2) have been established.

Functionally significant obstruction is often diagnosed with diuretic renal scanning. The conventional renographic criteria include
a flat or rising washout curve after diuretic with T1/2 of greater than 20 minutes and differential function of less than 40. Recent
studies suggest that measurement of P40 (Percent tracer clearance at 40 minutes) may be more sensitive in assessing clinically

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significant renal obstruction.[4] This particular assessment has the benefit of using an existing diagnostic study. The differential
function is important in determining the need for intervention, especially in asymptomatic patients, and in selecting the
appropriate treatment (pyeloplasty vs nephrectomy). Poorly functioning kidneys (< 10%) are often best treated with
nephrectomy, however, studies by Nishi (2016) and Singla (2016) have demonstrated evidence of good functional outcomes
despite age and low pre-operative renal split functions (less than 25%).[5, 6] Additionally, retrospective review by Li et al,
utilized multivariate analysis comparing factors of age, renal pelvis type, and renal resistive index, concluding that preoperative
differential function cannot independently recoverability postoperatively.[7] Nuclear medicine scanning is also used to assess
outcomes after surgical intervention.

The evaluation of ureteral anatomy is difficult with nuclear medicine renal scanning. In adult patients, IVP is more commonly
used to outline this anatomy and can often replace nuclear medicine scanning altogether. See the images below.

Intravenous pyelogram demonstrating ureteropelvic junction obstruction with dilatation of the collecting system and non-
visualization of the ureter on delayed imaging.

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Retrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to annular stricture.

Retrograde pyelogram demonstrating ureteropelvic junction obstruction secondary to crossing vessels.

Multidetector computed tomography (CT) scanning with three-dimensional reconstruction may be used to help establish the
anatomy of UPJ obstruction and associated vessels. In children, retrograde ureteropyelography is sometimes performed to
define the entire ureter just prior to surgical repair. Contrast-enhanced color Doppler imaging is recommended by some as a
useful imaging modality for the detection of crossing vessels in patients with UPJ obstruction.

Dynamic contrast-enhanced magnetic resonance urography (MRU) is the latest imaging modality used in assessing UPJ
obstruction. In children, this study offers the advantages of no radiation exposure and excellent anatomical and functional details

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with a single study. The study also provides details of renal vasculature, renal pelvis anatomy, location of crossing vessels, renal
cortical scarring, and ureteral fetal folds in the proximal ureter.

Recent criteria for diagnosis of UPJ obstruction on MRU include fluid levels on delayed contrast-enhanced scans and the
presence of swirling contrast material on the dynamic images. MRU using a time-resolved, data-sharing three-dimensional
contrast-enhanced technique can demonstrate ureteral peristalsis and permits quantification of ureteral peristaltic frequency.[8]

Contrast-enhanced magnetic resonance angiography (MRA) had a sensitivity of 85%, a specificity of 80%, and a positive
predictive value of 0.8 for the diagnosis of aberrant and obstructing renal arteries in a retrospective study of 19 pediatric patients
with UPJ obstruction.[9]

Diagnostic Procedures
When the workup results are equivocal, a Whitaker antegrade pressure-flow study may be performed to further evaluate for UPJ
obstruction. This test begins with the placement of a small-diameter nephrostomy tube through the back and directly into the
kidney. Dilute contrast medium is instilled, and the intrarenal collecting system is pressure-monitored. Under fluoroscopy, the
UPJ is assessed and drainage through this segment is defined.

While function cannot be assessed, relative resistance and pressure within the renal pelvis can be measured. High intrarenal
pressures define obstruction, while low pressures in the presence of hydronephrosis are consistent with normal variance. This is
particularly useful in large dilated systems in which the renal pelvis must be completely full prior to drainage assessment. In this
setting, nuclear medicine scanning can yield false-positive results.

Treatment

Medical Therapy
In children with ureteropelvic junction (UPJ) obstruction, medical therapy is focused on maintaining sterile urine and assessing
renal function and the degree of hydronephrosis. Typically, when imaging studies reveal an incomplete obstruction, the patient is
monitored with routine renal ultrasonography and nuclear medicine renography. Currently, no available medical therapy is
capable of reversing UPJ obstruction in either adults or children.

Initially, most children are treated conservatively and monitored closely. Intervention is indicated in the event of significantly
impaired renal drainage or poor renal growth. The accepted criteria for intervention in infants and children include clearance
half-time (T 1/2) greater than 20 minutes, differential function less than 40%, and ongoing parenchymal thinning with or without
contralateral compensatory hypertrophy. Other indications for intervention are as follows:

Pain
Hypertension
Hematuria
Secondary renal calculi
Recurrent urinary tract infections

Surgical Therapy
Surgical intervention to treat an obstructed UPJ is warranted, especially upon deterioration of renal function. The principles of
surgical repair, as initially described by Foley, include the following:

Formation of a funnel
Dependent drainage
Watertight anastomosis
Tension-free anastomosis

In children, the procedure of choice is an Anderson-Hynes dismembered pyeloplasty. The approach may be performed through
a flank, dorsal lumbotomy, or anterior extraperitoneal technique. Laparoscopy has gained increasing acceptance in pediatric
surgery and is often used to perform pyeloplasties in children. In many cases, laparoscopic pyeloplasty is technically unfeasible
in very small children and infants because of space constraints.
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Using this method, the obstructed segment is completely resected, with reanastomosis of the renal pelvis and ureter in a
dependent funneled fashion. The decision of whether to use a ureteral stent transiently during the initial healing process is
based on the personal preference of the surgeon. The success rate of dismembered pyeloplasty for treating an obstructed UPJ
exceeds 95%.

Laparoscopic pyeloplasty offers a minimally invasive treatment option that may be used in patients with either primary or
secondary UPJ obstruction and is emerging as a new criterion standard in the treatment of UPJ obstruction.[1, 10] Success
rates are comparable with those of open pyeloplasty procedures, and some studies have shown that laparoscopy offers the
advantages of decreased morbidity, shorter hospital stay, and quicker recovery.

Laparoscopic pyeloplasty is a technically demanding procedure that generally requires significant laparoscopic experience. The
recent introduction of unidirectional barbed suture material (V-Loc) has led to positive results, including decreased operative
time (up to 35.8 min in one study), equal tension on the anastomosis, and decreased learning curve in less experienced
surgeons.[11] Robotic-assisted laparoscopic pyeloplasty has become increasingly popular as the robots have become more
prevalent. A small intrarenal pelvis is a relative contraindication to laparoscopic pyeloplasty.

Endoscopic treatment alternatives include an antegrade or retrograde endopyelotomy, which is an endoscopic incision
performed through the obstructing segment.

An outcome study of surgical procedures for UPJ obstruction found that for minimally invasive pyeloplasty (n=1125) the failure
rate was 7%, the rate for open pyeloplasty (n=775) was 9%, and that for endopyelotomy (n=1315) was 15%. The average
length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P <0.001).<ref>12</ref>

Prior to incising a UPJ obstruction, intraluminal ultrasonography or another imaging study is recommended to evaluate adjacent
ureteral vasculature. Endoluminal ultrasonography is particularly useful in evaluating an obstructed UPJ because it allows for
complete real-time evaluation with specific attention to the presence or proximity of blood vessels prior to an endoscopic
incision. It is also useful in defining the ureteral anatomy and in directing the incision technique in order to maximize the surgical
outcome.

An endopyelotomy incision is performed through the area of obstruction with a laser, electrocautery, or endoscopic scalpel. Most
surgeons dilate the newly incised area with a balloon catheter to help ensure a complete incision. This is followed by prolonged
ureteral stenting, for a period of 4-8 weeks. The stent acts as internal scaffolding during healing and maintains renal drainage.
Success rates with the percutaneous and ureteroscopic endopyelotomy are 80-90%.

When open pyeloplasty fails, endopyelotomy is particularly useful, even in the pediatric population.[13]

In patients who have a suboptimal result from endopyelotomy, repeat incision can be performed with success. Traditional open
or laparoscopic pyeloplasty is also indicated after failed endopyelotomy.

Of the open surgical repairs used to treat UPJ obstruction, the Anderson-Hynes dismembered pyeloplasty is particularly useful
for the high-insertion variant. The benefit of this procedure is complete excision of the diseased segment of ureter and
reconstruction with healthy viable tissue.

The Foley Y-V plasty is also useful for the high-insertion variant but cannot be used if transposition of a lower-pole vessel is
needed.

Endopyelotomy for high-insertion UPJ obstruction is patterned after this open surgical procedure but is contraindicated in the
presence of a crossing posterior or lateral vessel.

Spiral and vertical flaps (eg, Culp and DeWeerd, Scardino and Prince) are useful when a long-strictured segment of diseased
ureter is encountered. With these procedures, the proximal ureter is re-created with redundant renal pelvis that is tubularized.

Ureterocalicostomy (ie, anastomosis of the ureter to a lower-pole renal calyx) is usually reserved for failed open pyeloplasty
when no extrarenal pelvis scarring and significant hilar scarring are present. With this procedure, the ureter is sutured directly to
a lower pole calyx after a modest partial nephrectomy is performed to remove parenchyma in the area of anastomosis.

Success Rates of Treatment Options


Endopyelotomy

Endopyelotomy is a reasonable option in patients with mild-to-moderate hydronephrosis and reasonably good renal function.
The stricture should be short (< 1.5 cm), and no crossing vessels should be defined on preoperative or intraoperative imaging
(ie, intraluminal ultrasonography). Endopyelotomy may be the preferred option in patients in whom prior pyeloplasty has failed.
Antegrade and retrograde approaches are equally efficacious.

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Endopyeloplasty

Reported by Gill et al from the Cleveland clinic in 2002, endopyeloplasty essentially consists of horizontal suturing of a standard
vertical endopyelotomy incision performed through a percutaneous tract via a 26F nephroscope.[14] Indications for
endopyeloplasty include short-segment UPJ obstruction, an absence of crossing vessels, and an absence of prior surgery in the
UPJ. Endopyeloplasty yields results comparable to those of endopyelotomy, but additional studies are needed for validation.

Laparoscopic pyeloplasty

This procedure is replacing open pyeloplasty as the criterion standard.[1] Most large series report 95% success rates. Unlike
endopyelotomy, laparoscopic pyeloplasty can be offered to patients with severe hydronephrosis, crossing vessels, and long-
segment strictures. However, the significant learning curve associated with laparoscopic suturing has limited its widespread use.
In skilled hands, the indications for laparoscopic pyeloplasty may be extended to secondary UPJ obstruction, concomitant renal
calculi, and anomalous and solitary kidneys. Salvage laparoscopic pyeloplasty is an excellent option with durable long-term
outcomes in patients in whom open pyeloplasty has previously failed.[15]

The success rates of transperitoneal laparoscopic pyeloplasty and retroperitoneoscopic laparoscopic pyeloplasty were
comparable (96.4% versus 96.6%) during a mean follow-up of approximately 30 months in a prospective study of 112 patients
with primary UPJ obstruction, but transperitoneal laparoscopic pyeloplasty was associated with significantly greater
postoperative pain and a higher tramadol dose, a higher rate of temporary ileus, and a longer hospital stay. Total operative time
was significantly higher for retroperitoneoscopic laparoscopic pyeloplasty.[16]

Robotic-assisted laparoscopic pyeloplasty


Robotic assistance is useful for surgeons who are obtaining experience with laparoscopic technique or for rare, complex cases
for which suturing is challenging because of prior surgery or anatomic variants. The da Vinci robotic surgical system has been
used successfully for laparoscopic reconstruction of the collecting system. The advantages of this system include degrees of
suturing freedom in a tight surgical field, stereoscopic vision, tremor filtration, and scaling. The results are similar to those of
conventional laparoscopic pyeloplasty. In the pediatric population, although only a few published series have addressed long-
term outcomes, the short-term data suggest similar success in both traditional open and laparoscopic pyeloplasty, including
treatment of the youngest children.[17, 18]

Single-site pyeloplasty

Recently, reports have described early experiences with laparoscopic single-site pyeloplasty, during which pyeloplasty is
performed via a single port placed at the umbilicus. Conventional laparoendoscopic single-site (C-LESS) pyeloplasty is
technically challenging owing to instrument clashing, loss of triangulation, and difficulty sewing. Adaption of the da Vinci Si
robotic surgical platform to laparoendoscopic single-site pyeloplasty appears to reduce the learning curve for this complex
procedure. Long-term follow-up with single-site laparoscopic pyeloplasty is not yet available. Improved cosmesis and one large
access port scar versus three 5-mm port sites are theoretical advantages with this approach.[19, 20, 21]

Preoperative Details
The preoperative workup includes the following:

History and physical examination

Evaluation of complete blood cell count, electrolyte levels, renal function, and coagulation profile

Radiographic and functional studies of the affected kidney

Evaluation of the normal contralateral kidney

Evaluation of peri-UPJ vascular anatomy

Anesthesia evaluation

Intraoperative Details
Techniques of surgical repair of an obstructed ureteropelvic junction
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One of the goals of laparoscopy is to mirror open techniques, so most of the principles of surgical repair apply to both. In
addition to creating a funnel with dependent drainage, care must be taken to minimize tissue handling and tension on the
reconstructed UPJ. Whether to use ureteral stents or nephrostomy tubes after open or laparoscopic repair is based on personal
preference.

Principles of endopyelotomy

Endopyelotomy may be performed either antegrade or retrograde, ureteroscopically. A safety guidewire must be placed within
the ureter prior to endoscopic incision. Intraluminal ultrasonography or preoperative imaging is essential to define peri-UPJ
vascular anatomy.

The endoscopic incision should be performed full-thickness through the UPJ and into perirenal fat with laser energy,
electrocautery, or an endoscopic scalpel. To ensure a proper incision, extravasation of contrast should be seen on pyelography
during the procedure. The incision is most commonly performed posterolaterally.

Balloon dilation is often performed after the incision is made to ensure completeness. Ureteral stenting for 4-8 weeks after the
endoscopic procedure is common, although no consensus exists regarding size and duration of stents.

Postoperative Details
Risk factors for failure after endopyelotomy include the following:

Greater length of UPJ obstruction


Diminished renal function (< 25%)
Massive hydronephrosis with a redundant renal pelvis
Crossing vessels
Crossing vessels with massive hydronephrosis (worst outcome)

Follow-up
Prophylactic antibiotic therapy should be given postoperatively. Remove the endopyelotomy stent after 4-8 weeks.

Follow up with renal ultrasonography 1-3 months after surgery. In addition, follow up with intravenous pyelography or nuclear
medicine renal scan 3-6 months after surgery, as varying degrees of hydronephrosis may persist beyond a year postoperatively,
[22] and some evidence suggests that diuretic response may not improve despite successful surgical repair.[23, 24] In these
cases, evaluation of parenchymal transit time may be more useful in assessing function and durability of the repair.

Serial renal imaging is recommended for the first year after surgery and should be continued less frequently thereafter if results
have normalized.

For patient education information, see Intravenous Pyelogram and Adhesions, General and After Surgery.

Complications
Potential complications from open surgical pyeloplasty include urinary tract infection and pyelonephritis, urinary extravasation
and leakage, recurrent ureteropelvic junction (UPJ) obstruction, or stricture formation. Treatment of urinary leakage centers
around catheter drainage, such as nephrostomy, ureteral stent, or perianastomotic drain, to direct urine away from the
perianastomotic tissues and to decrease the risk of postoperative stricture disease.

Specific complications from endopyelotomy include significant intraoperative bleeding if the endoscopic incision is made
inadvertently into a major polar vessel, postoperative infection, and recurrence of obstruction. If significant intraoperative
bleeding results in hypotension, emergency arteriography and embolization are indicated.

Outcome and Prognosis

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Open and laparoscopic pyeloplasty yield long-term success rates that exceed 95%. The success rate for endopyelotomy
approaches 80-90%.

Future and Controversies


The future of treatment of ureteropelvic junction (UPJ) obstruction will certainly include a broadening of the application of
laparoscopic techniques. As laparoscopic pyeloplasty has gained acceptance and the surgical experience has increased, the
procedure time has become shorter. The use of robotic assistance may broaden the application of laparoscopy.

Contributor Information and Disclosures

Author

Michael Grasso, III, MD Professor and Vice Chairman, Department of Urology, New York Medical College; Director, Living
Related Kidney Transplantation, Westchester Medical Center; Director of Endourology, Lenox Hill Hospital

Michael Grasso, III, MD is a member of the following medical societies: American Medical Association, American Urological
Association, Endourological Society, International Society of Urology, Medical Society of the State of New York, National Kidney
Foundation, Society of Laparoendoscopic Surgeons

Disclosure: Received consulting fee from Karl Storz Endoscopy for consulting.

Coauthor(s)

Jacob H Cohen, MD, MPH Fellow in Endourology, Lenox Hill Hospital

Disclosure: Nothing to disclose.

Srinivas Rajamahanty, MD, MCh Staff Physician, Department of Urology, Westchester Medical Center, Valhalla, New York

Disclosure: Nothing to disclose.

Jordan S Gitlin, MD Assistant Professor, Department of Urology, Albert Einstein College of Medicine-Yeshiva University;
Consulting Staff, Pediatric Urology Associates PC

Jordan S Gitlin, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association

Disclosure: Nothing to disclose.

G Blake Johnson, MD Consulting Staff, Middleton Urology Associates

G Blake Johnson, MD is a member of the following medical societies: American College of Surgeons, American Medical
Association, American Urological Association

Disclosure: Nothing to disclose.

Wayne L DeBeatham, MD Fellow in Endourology, Department of Surgery, Phelps Memorial Hospital

Wayne L DeBeatham, MD is a member of the following medical societies: American College of Surgeons, National Medical
Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Shlomo Raz, MD Professor, Department of Surgery, Division of Urology, University of California, Los Angeles, David Geffen
School of Medicine

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Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association,
American Urological Association, California Medical Association

Disclosure: Nothing to disclose.

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, Society of University Urologists

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical; Olympus.

Additional Contributors

Allen Donald Seftel, MD Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson
Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Allen Donald Seftel, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received
consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal
of urology for board membership; Received consulting fee from endo for consulting.

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