Surgical Options in the Management of Ureteropelvic Junction Obstruction

Introduction

Treatments for uretero-pelvic junction obstruction (UPJO) have been well established and are highly efficacious. Historically, open pyeloplasty (OP) has been the treatment of choice with success rates exceeding 90%. Recent developments in instrumentation have allowed the development of more minimally invasive treatment options in the management of UPJO, which have comparable efficacy but with significantly less morbidity and shorter convalescence. Indeed, while OP is still largely considered the criterion standard for UPJO in infants, laparoscopic pyeloplasty (LP), with or without robotic assistance, is the treatment of choice in older children and in most adults. Pathogenesis and diagnostic workup will be briefly touched upon in this review; however, the focus will be on surgical options in the management of UPJO. The surgical principles of repair, initially described by Foley, are still applicable today and include formation of a funnel, dependent drainage, and a watertight and tension-free anastomosis. Current treatment options reviewed in this article include antegrade and retrograde endopyelotomy, endopyeloplasty, LP, robotic-assisted pyeloplasty (RAP), and conventional and robotic laparoendoscopic single-site surgery (LESS).

Abstract

A variety of surgical management options to treat ureteropelvic junction obstruction (UPJO) exist. Most of these techniques have been well established, are highly efficacious, and have low morbidity. Historically, open pyeloplasty (OP) has been the treatment of choice with success rates exceeding 90%. Advancements in instrumentation have allowed more minimally invasive treatment options in the management of UPJO. There is a wide spectrum of minimally invasive options, each with specific indications, advantages, and compromises. Despite a variety of minimally invasive techniques, the least invasive generally has slightly decreased efficacy than other options but the benefits of decreased pain and shorter convalescence. Other minimally invasive techniques have comparable efficacy to, but significantly less morbidity and shorter convalescence than OP. Although OP is still largely considered the criterion standard for UPJO in infants, laparoscopic pyeloplasty (LP), with or without robotic assistance, is currently the treatment of choice in older children and in most adults. This review will briefly touch upon the pathogenesis and diagnostic workup; however, the focus will be on surgical options in the management of UPJO. Current treatment options reviewed in this article include antegrade and retrograde endopyelotomy, endopyeloplasty, LP, robotic-assisted pyeloplasty, and conventional and robotic laparoendoscopic single-site surgery.

Keywords

pyeloplasty, ureteropelvic junction, reconstructive urology, minimally invasive surgery, endoscopy/ureteroscopy, laparoscopy, robotic-assisted surgery