Patient Selection Indications And Contraindications

Indications for surgical intervention in patients with ureteropelvic junction obstruction include functionally significant obstruction, as defined by the presence of flank pain or other symptoms associated with the obstruction, impairment, or deterioration in renal function.

In addition, upper urinary tract infection or renal calculi formation secondary to inadequate urinary drainage can also prompt surgical intervention. Asymptomatic individuals, in whom the physiologic significance of obstruction is indeterminate based on radiologic imaging studies, may reasonably be observed and followed with routine monitoring.

The majority of patients with ureteropelvic junction obstruction will benefit from surgical intervention with the primary goal of relieving symptoms and preserving renal function. The gold standard for achieving unobstructed urinary flow has been open operative repair and reconstruction of the ureteropelvic junction in the form of pyeloplasty. Antegrade and retrograde endoscopic approaches have since become popular as initial procedures of choice due to their minimal invasive nature and patient preference. However, success rates with these alternative techniques have not proved comparable with those of open pyeloplasty, especially in cases of

The presence of a crossing vessel is not a contraindication for laparoscopic- or robotic-assisted repair.

The principal contraindication to any minimally invasive approach is a long segment of obstruction, precluding the performance of a tension-free anastomosis between normal ureter and the renal pelvis. Age, body mass, prior operations, and/or side of involvement are other possible exclusion criteria.

long strictures, crossing vessels, or a large redundant renal pelvis. The indications for open and endoscopic management of ureteropelvic junction obstruction are still evolving, and careful patient selection for each approach may yield improved success rates (24).

The principal contraindication to any minimally invasive approach is a long segment of obstruction, precluding the performance of a tension-free anastomosis between normal ureter and the renal pelvis. Age, body mass, prior operations, and/or side of involvement are other possible exclusion criteria.

The presence of a large struvite stone may present a relative contraindication to robotic-assisted pyeloplasty repair. However, several series of laparoscopic- and robotic-assisted pyeloplasty repairs with concomitant pyelolithotomy have been performed without difficulty. Smaller stones were simply grasped and removed under direct vision or entrapped using a flexible cystoscope. Larger stones were taken out with an EndoCatch® bagb (19,20,25-29). However, in the setting of struvite renal calculi that cannot be easily accessed via a laparoscopic procedure, an alternative approach may be more appropriate.

The presence of a crossing vessel is not a contraindication for laparoscopic- or robotic-assisted repair. In such instance, a dismembered Anderson-Hynes type repair is recommended. Indeed, some authors do not obtain preoperative studies to detect crossing vessels, believing that intraoperative recognition is readily apparent and addressed at the time of surgery (19).

Nephrectomy is often the preferred option for kidneys with no function or poor function and minimal potential for salvage. When repeated attempts at repair have failed and further intervention would be complicated with a low yield for success, nephrectomy may be considered as well. Additionally in patients with significant medical comorbidities, advanced age, or limited life expectancy, nephrectomy may be a suitable option. In any situation warranting surgical removal of the kidney over a reconstructive procedure, it is of extreme importance to verify the presence of an essentially normal contralateral kidney on the basis of radiographic or radionuclide studies.

The patient should be counseled as to the risks and benefits of the procedure, including the fact that the success rate of any robotic-assisted approach may be less than that of a standard open operative intervention.

A bowel preparation is usually recommended especially when robotic surgery is performed by the novice practitioner.

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