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COMMENTARY

Department of Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York, U.S.A.

Minimally invasive therapies for the management of ureteropelvic junction obstruction currently challenge the standard open surgical approach to this entity with an ever-changing armamentarium of laparoscopic skill and technology. An endopyelotomy, laparoscopic pyeloplasty, or even a combination of the two techniques (1) may be employed with the confidence that outcomes will be highly successful and repairs will be durable. Presently we

most often choose between an endopyelotomy or laparoscopic pyeloplasty for definitive treatment of ureteropelvic junction obstruction rather than even consider an open approach primarily.

Laparoscopy, in particular, is playing an increasing role in ureteropelvic junction management and has proven to be a viable alternative for patients with ureteropelvic junction obstruction. As in the open technique, a tension-free mucosa-to-mucosa watertight anastomosis will dictate operative success. In turn, such success is contingent on proficiency with laparoscopic suturing, a skill that has become easier to acquire with the aid of robotics (2), handassisted laparoscopy (3), and newly described laparoscopic instrumentation and techniques (4,5).

In the last decade, approximately 16 series have reported on laparoscopic pyeloplasty for the treatment of primary ureteropelvic junction obstruction. Anderson-Hynes dismembered pyeloplasty, Y-V plasty, and Fengerplasty, which have all been described utilizing either a transperitoneal or retroperitoneal approach. Most impressive are the overwhelming success rates (>95%) in the large majority of these patients with operative times ranging from two to four hours. Few series, however, have compared data on the open versus laparoscopic approach at their respective institutions. Bauer et al. (6), for example, represent the minority to do so demonstrating comparable outcomes between open and laparoscopic groups with regard to relief of obstruction, relief of symptoms, and improved activity. Future efforts in follow-up studies must focus on defining "success rates" prospectively in a stratified and uniform manner. Outcomes, for example, in terms of pre and postoperative renal function (i.e, T^ emptying time) and objective pain scales will give us the agency to truly compare minimally invasive techniques and determine which method is arguably most successful.

Comparisons between minimally invasive treatments for ureteropelvic junction obstruction have been made. In a multivariate analysis, Gill et al. (7) demonstrated that laparoscopic pyeloplasty was more successful (95.5%) than percutaneous endopyelotomy (86%), ureteroscopic endopyelotomy (85%), or electrocautery balloon endopyelotomy (76.7%). Why was laparoscopy superior? Were the preoperative parameters capable of foretelling such success? Massive hydronephrosis, poor renal function, stenotic segments greater than 1 cm, and a large renal pelvis draped over a renal vessel, for example, may be predictors of such success if a laparoscopic approach is used. It is important to note that it is still debatable as to whether or not "crossing vessel(s)" are truly significant in the etiology of ureteropelvic junction obstruction (8). Until the significance of this anatomic entity is better elucidated, treatment should not necessarily be dictated based on its presence.

Conversely, absence of the aforementioned anatomical variants suggests that there is more of an indication to utilize an endopyelotomy as the primary treatment modality. To this end, Pardalidis et al. (9) reported a success rate of 95% when patients were well selected for either endopyelotomy or laparoscopy based on such anatomical differences. Currently, this appears to be the general practice trend among academic endourologists in North America (10). It is evident that success in approaching a ureteropelvic junction obstruction may not necessarily rely on which minimally invasive technique is used but rather which procedure is utilized on an individual basis.

The pediatric population may be the most important group to focus on when analyzing the benefits of new technology for the treatment of uretero-pelvic junction obstruction. Similar to adult cohorts, laparoscopic pyeloplas-ties in three pediatric series have demonstrated success rates from 87% to 100%. The dismembered pyeloplasty has been deemed the ultimate challenge in pediatric urological laparoscopy, as fine suturing with small instrumentation is required (11). Robotics may aid the pediatric urologist in this demanding operation, serving as a model for the adult urologist wishing to acquire better laparoscopic suturing skills. Future prospective and well-stratified studies in the pediatric population will especially give us a clearer view of the effect of laparoscopy on renal development and functionality over time. Results with pediatric endopyelotomy have yielded poor results that have been attributed to the difficulties encountered with ureteral stenting. Further development in pediatric endopyelotomy is needed. There is no doubt, however, that laparoscopic approaches to ureteropelvic junction obstruction in the pediatric population will soon challenge the open technique as the standard of care.

A secondary ureteropelvic junction repair poses a challenge for the laparoscopist. Adhesions and fibrosis may limit exposure and prolong operative times. Despite this, minimally invasive salvage procedures yield a greater than 80% success rate. Salvage procedures for failed primary laparoscopic pyeloplasties are best served with an endopyelotomy. Conversely, failed primary endopyelotomies are best served with a laparoscopic pyeloplasty.

Laparoscopic pyeloplasty with concomitant pyelolithotomy has also emerged as a primary mode of treatment for instances of nephrolithiasis with a ureteropelvic junction obstruction. Although series reporting on this approach are few and demonstrate prolonged operative times, the feasibility of this technique has been demonstrated. It is our practice to evaluate the extent of edema at the ureteropelvic junction if repair is anticipated at the time of percutaneous nephrolithotomy. If there is no edema, endopyelotomy is performed. Conversely, the presence of edema calls for re-evaluation of the ureteropelvic junction with a functional study once all stones have been cleared and the edema has subsided. A ureteropelvic junction "obstruction" in the presence of nephrolithiasis may be a function of inflammation, precluding repair. Immediate laparoscopic pyeloplasty with concomitant pyelolithotomy may run the risk of unnecessary ureteropelvic junction "repair." Perhaps better technology fusing endoscopic technique during laparoscopy will further facilitate the employment of this procedure. Along the same line, laparoscopic pyelo-plasties performed for ureteropelvic junction obstructions in the presence of upper tract anomalies in horseshoe kidneys or ectopic kidneys have yielded equivalent results to the open approach. Although comparable success rates have been reported, such anomalies may present technical challenges (i.e., anomalous blood supply) requiring cases to be individualized only in highly skilled hands.

A minimally invasive approach for the treatment of primary uretero-pelvic junction obstruction has certainly emerged as perhaps a "new gold standard." Laparoscopic pyeloplasty, in particular, is more widely utilized and has proven to be efficacious. It is specifically geared toward cases in which known anatomical variables preclude the likelihood of endoscopic success. In the very near future, it will be exciting to see how accelerations in endoscopic and laparoscopic refinements, "raise the bar" even higher for what we will consider or demand as standard of care in both the adult and pediatric populations with ureteropelvic junction obstructions. Operator experience coupled with ultimate advancements in laparoscopic suturing techniques and instrumentation will certainly decrease operative times, former minimize morbidity, and assure that patients undergoing laparoscopic pyeloplasties will be in near perfect stead. On the horizon, urinary markers such as tumor growth factor (12) and nuclear factor-kappa B (13) hold great promise as predictive markers for what might translate into a ureteropelvic junction obstruction repair success or failure, further aiding in our minimally invasive treatment decisions.

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