Current Management Of Ureteropelvic Junction Obstruction And Indications For Laparoscopic Pyeloplasty

The treatment of adult ureteropelvic junction obstruction has undergone significant changes during the past two decades, with the advent of laparoscopic pyeloplasty being one of them. Despite its advantages, this procedure requires both laparoscopic experience and considerable skill with laparoscopic suturing. Laparoscopic approaches are performed in selected centers and only recently have been integrated into almost all residency programs. As a consequence, laparoscopic pyeloplasty is still not widely performed. The familiarity of most urologists with endoscopic techniques makes endopyelotomy feasible without the need for any further training after residency. As a

In the presence of a crossing vessel or a huge pelvis, laparoscopic dismembered pyeloplasty is preferred due to its low morbidity and the capability of transposing the crossing vessel or reducing the renal pelvis similar to open pyeloplasty.

consequence, endopyelotomy still continues to be more commonly performed, even in tertiary referral centers (17). However, endopyelotomy frequently fails in the presence of a crossing vessel or a very dilated renal pelvis. Current imaging with three-dimensional helical computing tomography or contrast-enhanced color Doppler can identify accurately abnormal renal vessels. Therefore preoperative knowledge of the existence of a crossing vessel or a huge pelvis allows urologists to avoid endoscopic management.

In the presence of a crossing vessel or a huge pelvis, laparoscopic dismembered pyeloplasty is preferred due to its low morbidity and the capability of transposing the crossing vessel or reducing the renal pelvis similar to open pyeloplasty.

Patients with anatomic variations such as a horseshoe or pelvic kidney are also good candidates for laparoscopic surgery. Failed prior procedures do not preclude laparoscopy (18,19). The presence of ipsilateral renal calculi is not a contraindication for the procedure (20). However, laparoscopic pyeloplasty for small intrarenal pelvis would be technically challenging, similar to open surgery.

The transperitoneal approach, which provides more anatomic landmarks than the retroperitoneal approach, has been used in most pyeloplasty series and is considered easier for the beginner.

Morbidity of transperitoneal laparoscopic pyeloplasty has been shown to be considerably less than that of open pyeloplasty. Complications have decreased with experience and range between 11% and 20% in latest series.

In all studies comparing laparoscopic versus open pyeloplasty, the laparoscopic approach provides less postoperative pain, shorter hospital stay, and faster recovery. Success rates in most recent series are above 90% and similar to those obtained with the open approach.

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