Laparoscopic pyeloplasty: the standard of care for ureteropelvic junction obstruction

Open pyeloplasty has been the gold standard treatment for ureteropelvic junction obstruction (UPJO). Endopyelotomy, in spite of its inferior effectiveness, was sometimes preferred in select patients owing to its less invasive nature. Fortunately, over the past 2 decades a superior minimally invasive treatment has emerged with success rates equivalent to open pyeloplasty and complication rates equivalent to endopyelotomy. It is for good reason that laparoscopic pyeloplasty has become the new standard of care for the treatment of UPJO.

Ureteropelvic junction obstruction is marked by renal outflow obstruction and may be asymptomatic or result in pain and complications, such as renal failure, pyelonephritis and calculus formation. Surgical management of UPJO aims to provide symptomatic relief and preserve remaining renal function. Today, treatment usually consists of either laparoscopic pyeloplasty or endopyelotomy. Its effectiveness, versatility and safety make laparoscopic pyeloplasty the optimal treatment for UPJO in virtually all circumstances.

Short-term effectiveness

Most studies define treatment “success” as resolution of both symptoms and hydronephrosis. Laparoscopic pyeloplasty, performed via transperitoneal or retroperitoneal approaches, yields success rates of 93% to 100%,^1–7 equivalent to those of open pyeloplasty.^8,9 Endopyelotomy is significantly less effective, with success rates varying according to the particular approach employed; 67% to 86% for antegrade endopyelotomy,^10–14 32% to 77% for Acucise endopyelotomy^15–17 and 73% to 85% for retrograde endopyelotomy.^18–21

Three studies directly comparing the 2 treatments report success rates of 98%, 95.3% and 94.4% for laparoscopic pyeloplasty compared with 84%, 55.4%, and 72.6% for endopyelotomy, respectively.^22–24 By any approach, endopyelotomy is consistently less effective than pyeloplasty.

Long-term effectiveness

The superior effectiveness of laparoscopic pyeloplasty over endopyelotomy becomes even more pronounced in the long-term. Dimarco and colleagues followed patients after laparoscopic pyeloplasty or endopyelotomy for a mean 16 years.²⁵ Treatment failures occurred in both groups as late as 10 years after the procedure. The 3-, 5-, and 10-year recurrence-free survival rates were 85%, 80% and 75% for laparoscopic pyeloplasty and only 63%, 55% and 41% for endopyelotomy, respectively.

Versatility

Several factors decrease the effectiveness of endopyelotomy, including long strictures, severe hydronephrosis, poor renal function, presence of a crossing vessel and previous failed endopyelotomy.^{11,13–15,18,24,26–29} Furthermore, anatomic variants, such as pelvic, horseshoe and solitary kidney, are contraindications to endopyelotomy. Conversely, laparoscopic pyeloplasty can be effectively employed in any of these variants.

The significance of crossing vessels, which occur in 38% to 44% of patients with UPJO,^25,29 is the subject of ongoing debate. The 5-year mean success rate of antegrade endopyelotomy is only 42% in the presence of a crossing vessel.¹¹ Laparoscopic pyeloplasty, unlike endopyelotomy, allows for the transposition of crossing vessels from anterior to posterior or vice versa. Furthermore, concurrent renal stones can be effectively treated by pyelolithotomy with a 90% success rate.¹

Safety

Endopyelotomy previously filled a niche as a safer, less invasive treatment option than open pyeloplasty. Since it was first described in 1993,³⁰ laparoscopic pyeloplasty has developed into a procedure that is as safe as endopyelotomy and safer than open pyeloplasty, due to its lack of a substantial incision.^1,23 Complications of laparoscopic pyeloplasty include urine leak, urinary tract infection, stent migration and hemorrhage requiring transfusion. Reported complication rates are 0 to 18%, with most series citing about 10%.^1–7

Complications of endopyelotomy include hemorrhage requiring transfusion, ureteral avulsion, stricture, ureteral intussusception and Page kidney. Complication rates range from 0 to 42%. Comparable to laparoscopic pyeloplasty, endopyelotomy has complication rates of about 10%.^{12,13,18,31,32} Dimarco and colleagues found that complications occurred in 8.1% of patients undergoing laparoscopic pyeloplasty and 11.1% of patients undergoing endopyelotomy with 1.0% and 1.3% requiring transfusion respectively.²⁵

Conclusion

The old argument for endopyelotomy as a potentially safer, albeit less effective, treatment for UPJO is now obsolete. Its superior effectiveness in the short-, and particularly the long-term, combined with its remarkable versatility and low complication rates make laparsocopic pyeloplasty the clear standard of care for the treatment of UPJO. Endopyelotomy should be relegated to a salvage procedure after failed pyeloplasty.²⁵ The steep learning curve for laparoscopic pyeloplasty may be smoothed by the adoption of robotic-assisted pyeloplasty, which appears to be as effective as open and laparoscopic approaches.^33–36 Other exciting developments, such as single-port pyeloplasty, are on the horizon.³⁷ In the meantime, laparoscopic pyeloplasty will remain the far superior treatment option for virtually all patients undergoing treatment of ureteropelvic junction obstruction.