ENDOPYELOTOMY

An endopyelotomy begins with direct visualization of the obstruction from either from a retrograde approach (ureteroscopy, see page 10-33) or anterograde approach (nephroscopy, see Plates 10-13 and 10-14). A safety wire is advanced across the stricture, which is then incised using a knife, laser, or other device. The incision is created in a lateral direction, so as to minimize injury to crossing vessels, and should extend through the ureteral mucosa and muscle until periureteral fat is seen. In the case of a high insertion of the ureter into the renal pelvis, an anterior or posterior incision may be required to allow proper marsupialization of the proximal ureter into the renal pelvis.

A ureteral stent or percutaneous nephroureteral stent is placed to facilitate postoperative drainage and can be removed after 4 to 6 weeks. If injury to a crossing vessel is suggested by intraoperative hemorrhage or post operative hemodynamic instability, the patient should undergo emergent angiographic evaluation and possible embolization.

FOLLOW-UP

One month after the procedure, an ultrasound of the kidneys and bladder should be performed. Three months after the procedure, after the stents have been removed, diuretic renography should be performed to confirm the production and unobstructed flow of urine through the affected upper tract.

Open pyeloplasty has a long-term success rate of 95%, with comparable rates reported in the laparoscopic and nascent robotic literature. Endoscopic repair appears to be less successful, with failure occurring in up to one third of cases.