0022-5347/90/1442 0246302 OO/O

THEJOURNAL OF UROLOGI Copyright C 1990 by AMERICAN CROLOGICAL ASSOCIATION,I N C

Vol. 144, August Printed in IL S.A.

URETERBNEPHROSCOPIC ENDOPUELOTOMU RALPH V. CLAYMAN, JOSEPH W. BASLER, LOUIS KAVOUSSI

AND

DANIEL D. PICUS

From the Division of Urologic Surgery, Departments of Surgery and Radiology, Washington University School of Medicine, St. Louis, Missouri

ABSTRACT

The percutaneous nephrostomy tract has provided urologists with antegrade access to the upper urinary tract. Via this approach ureteropelvic junction obstruction has been treated with an endoscopically controlled incision with a cold knife. While less invasive than an open operation, we have noted significant discomfort from the 24 to 32F percutaneous tract. Accordingly, we sought to achieve the same results by using a less invasive approach, that is retrograde ureteronephroscopic endopyelotomy. A total of 10 patients (9 women and 1man) with 5 primary and 5 secondary ureteropelvic junction obstructions underwent ureteroscopic endopyelotomy with a 3 or 5F Greenwald cutting electrode passed through a 12F rigid, 10.8F flexible or 9.8F flexible deflectable ureteronephroscope. Preoperatively, ureteropelvic junction obstruction was documented by a furosemide washout renal scan and/or a Whitaker test in 8 of 10 patients. In 2 patients an excretory urograln or retrograde pyelography was diagnostic. Duration of the procedure averaged 180 minutes (245 minutes with a concurrent Whitaker test). At the conclusion of the procedure a 71148' indwelling ureteral stent was placed. The nephrostomy tube was removed after 3 days and average hospital stay was 5 days. The ureteral stents were routinely left i n place for 6 weeks. Followup in 10 patients averaged 12 months. Flank pain was largely resolved in all patients. A followup Whitaker test, excretory urogram or renal scan ultimately has demonstrated decreased or no obstruction in 9 of 10 patients. In summary, early results with retrograde ureteronephroscopic endopyelotomy, specifically in female patients, appear to be promising. Morbidity is minimal and efficacy is satisfactory given the favorable objective response noted in 90% of the patients. (J.Urol., 144: 246-252, 1990) Advances in the endosurgical approach to upper urinary tract disease have led to the development of an endourological treatment for ureteropelvic junction obstruction, that is pyelolysis Initially, the endourological approach was or end~pyelotomy.',~ through a nephrostomy tract with a cold knife urethrotome. More recently, there have been reports of either placing a guide wire retrograde in the ureter and then dilating the ureteropelvic junction with a balloon under fluoroscopic control or actually using the ureteronephroscope to incise the ureteropelvic juncour method to accomplish retrograde endot i ~ n .We ~ . report ~ pyelotomy completely through the rigid or flexible ureteroscope using an electrosurgical probe, thereby obviating the need for a large nephrostomy tract or use of the nephroscope. MATERIALS AND METHODS

Ten patients (9 women and 1 man) between 20 and 80 years old with 5 primary and 5 secondary ureteropelvic junction obstructions were entered into the study. Table 1 shows the demographics and preoperative evaluation of the symptoms. Preoperative symptoms included pain (8 of 10 patients) and urinary tract infection (I of 10). Two patients had undergone preoperative ureteral stinting and 3 had percutaneous nephrostomy tubes placed to relieve the symptoms. Before endopyelotomy all patients underwent an excretory urogram (IVP) or retrograde pyelogram. A furosemide washout renal scan and/or a Whitaker test" (with the patient under local anesthesia) was also obtained routinely. The latter test was performed on the same day of the planned endopyelotomy. When the Whitaker test was positive an 8F nephrostomy tube was left in place. The nephrostomy tube allowed for continuous flow through the ureteroscope during the subsequent procedure. The patients were placed on the urology fluoroscopy table in a modified dorsal lithotomy position with the contralateral leg raised and maximally abducted, and the ipsilateral leg level was Accepted for publication February 5, 1990.

abducted almost to the midline. A perineal urethrostomy was performed in the man to afford easier access to the upper tract. A flexible cystoscope was introduced and a 0.035-inch Bentson guide wire was advanced up the ureter with the tip coiled in the renal pelvis. At times it was necessary to pass a 5F angiographic catheter over the Bentson guide wire to manipulate the guide wire beyond the ureteropelvic junction. Alternatively, a Terumo @ide wire with a lubricious coating was used to bypass the obstruction. Next, a 5F angiographic catheter was placed over the initial guide wire and advanced into the renal pelvis. The initial guide wire was exchanged for a 0.035-inch Amplatz super stiff guide wire (fig. 1,A ) . The super stiff guide wire helped to straighten the ureter, thereby facilitating the subsequent incision. The 5F angiographic catheter was removed and an 8 cm. long, 6 mm. in diameter, 7F ureteral dilating balloon was advanced over the super stiff guide wire to a point just beyond the ureterovesical junction. The distal ureter was dilated slowly (0.5 cc per minute) under fluoroscopic control and the balloon was left fully inflated for 2 to 10 minutes. Uuon deflation and removal of the balloon a 5F angiographic catheter was again passed over the Amplatz super stiff guide wire, and the catheter and guide wire were sutured to the urethral meatus or a labia majorum with 2-zero silk suture. A long rigid ureteronephroscope (12F) or a flexible deflectable ureteroscope (9.8F or 10.8F) was advanced alongside, not over, the 5F angiographic catheter. The Amplatz super stiff guide wire was used to straighten the ureter, thereby facilitating access to the ureteropelvic junction. The ureteropelvic junction area was visualized retrograde and appeared as an iris-like constriction around the 5F angiographic catheter (fig, 1, A, inset). The irrigant then was changed from normal saline to sorbitol. The electrocautery unit was set to the same cutting setting as for transurethral resection of the prostate (cutting current 50, coagulation current- 0). A 3F or 5F angled tip Greenwald electrode was used with cutting current to incise -

T A B L E1. R e t r o ~ r a d eendopyelotomy: patient po,uulation Preop. Srudies Pt.-Age-Sex

Symptoms

Ureteropelvic Junction TYT~

Affected Side

IVP

1-67-F

Pain

Primary

Rt.

Pos.

2-59-F

Pain

Primary

Rt.

Pos.

3-56-F

Primary

Rt.

Secondary

5-20-M

Weakness, urinary tract infection Pain, nausea and vomiting Pain

Secondary

6-80-F 7-65-F 8-58-F

Pain Pain Pain

9-70-F

4-71-F

10-50-F

" Retrograde

Diuretic Renogram

Whitaker Test Differential Pressure (cm, water)

30

Pos.

No data available No data available Pos., rt.

Rt.

Pos.

Neg., rt.

56

Lt.

Pos.

Primary Secondary Secondary

Lt. Rt. Rt.

Hypertension

Secondary

Lr.

Pos. Pos. No data available" Pos.

No data available 21 18 No data available 40

Pain

Primary

Rt.

No data available Pos., lr. Neg., rt. No data available KO data available No data available

hTo data available*

15

1'7

9

pyelogram

the ureteropelvic junction along its posterior and lateral surface until periureteral fat was seen clearly. The incision was then extended into the renal pelvis for 1 to 2 cm. Any significant bleeding sites then were coagulated. The electrosurgery unit was always set up so that either the cutting or coagulating current, never both, could be used at a given moment. Upon completion of the incision the irrigant was changed back to normal saline (fig. 1, B ) . Then, a nephrostogram was performed through the ureteroscope. Marked extravasation from the ureteropelvic junction was an indication that the pyelotomy was done deeply enough. A 260 cm. long, 0.035-inch exchange guide wire was passed via the nephrostomy tube and retrieved with a grasping forceps through the ureteroscope (fig. 1, C), thereby establishing a through-and-through guide wire. The angiographic catheter and Amplatz super stiff guide wire were removed. An 8 mm. ureteral balloon dilating catheter was passed from below the lesion over the exchange guide wire. Inflation of the balloon to 1 to 2 atmospheres of pressure in the area of incision allowed for adequate separation of the cut edges and identification of any inadequately incised areas (fig. 1,D). In the latter lnstance the ureteroscope and cutting electrode were reintroduced to incise the ureteropelvic junction area more deeply. After removal of the balloon a tapered 7/14F stent was advanced over the exchange guide wire, such that the 14F portion was overlying the incised ureteropelvic junction. A metal tipped pusher catheter was used to steady the distal end of the endopyelotomy stent. The distal curl of the stent was allowed to form in the bladder (fig. 1, E to G). If the stent did not pass easily a 6 mm. ureteral balloon dilator was used to dilate the distal ureter and thereby facilitate Dassape of the stent. A urethral catheter and nephrosiomy were placed at the end of the procedure. 8F A nephrostogram was performed 2 mornings postoperatively. If there was no extravasation the nephrostorny tube and urethral catheter were removed, and the patient was discharged from the hospital. If extravasation was present the nephrostomy tube was left in place, the patient was discharged from the hospital and a nephrostogram was repeated in 1 week. At this time the nephrostomy tube was removed provided there was no extravasation and free flow of contrast medium down the stent (1patient). All patients were given an oral antibiotic to take for 6 weeks postoperatively. After 6 weeks the stent was removed with the patient under

intravenously assisted local anesthesia on an outpatient basis in the cystoscopy suite. At the time the stent was removed flexible ureteroscopy was performed to assess the patency of the ureteropelvic junction and rule out any obstructing tissue. Six weeks after stent removal (3 months after the initial procedure) a furosemide washout renal scan was obtained. This study and/or an IVP also usually was repeated a t 6 months (fig. 2). At 1 year a repeat furosemide washout renal scan and, when possible, a Whitaker test were performed. RESULTS

Nine women and 1man with documented ureteropelvic junction obstruction underwent retrograde transurethral endopyelotomy (table 1). Average duration of the procedure was 180 minutes (245 minutes with a concurrent Whitaker test performed in the operating room). However, it is of note that as we gained more experience with the retrograde approach the operative time decreased. Indeed, the procedural time for patient 9 was 140 minutes and for patient 10 it was 90 minutes. Blood loss was minimal (table 2). The average postoperative hemoglobin change was 1.2 mg./dl. (decrease). No patient had a postoperative fever greater than 37,8@. Followup averaged 12 months (range 5 to 24 months, table 3). Stents were routinely left in place for 6 to 8 weeks. Postoperative Whitaker tests were performed in 4 patients and all 4 had pressures either below preoperative values and/or within the normal range.' Radionuclide renography was performed on 7 patients 3 months after the procedure. The results were improved function with no obstruction in I patient, unchanged function with no obstruction in 3, improved function with elevated T1h in 2 and decreased relative function without obstruction in 1. Of the 2 patients with persistent elevation of Tlh 1 had a distal ureteral stricture but had radiographic evidence of an open ureteropelvic junction. The distal ureteral stricture has since been incised and the patient presently is asymptomatic. One patient had an immediate postoperative complication of congestive heart failure and oliguria requiring a brief stay in the intensive care unit. This patient underwent simultaneous antegrade right endopyelotomy as well as the retrograde left endopyelotomy. A subsequent renal scan demonstrated an 8% increase in function in the treated kidney over preoperative values despite the prolonged T1/2. In summary, the objective response rate for retrograde endopyelotomy is 90%.

248

CLAYMAN A N D ASSOCIATES

FIG. 1. A, 5F catheter a n d guide wire have been advanced through site of ureteropelvic junction ( U P J ) obstruction. 8F nephrostomy tube is in place. B, ureteropelvic junction obstruction is incised with electrode (cutting, not coagulating, current) through wall of ureter out to retroperitoneal fat. Incision is continued for 1 cm. above and below site of narrowing. C, through-and-through exchange guide wire has been established. D, 8 mm. balloon has been passed to ureteropelvic junction and inflated to 1 to 2 atmospheres of pressure. Lack of any waste indicates that incision has been made sufficiently deep. Also, nephrostogram can be performed. There should be extravasation from ureteropelvic junction. E, 7/14F stent h a s been properly positioned over exchange guide wire and guide wire has been removed. F, radiograph shows stent in position with 14F portion lying proximally. G, upper arrow emphasizes additional drainage hole placed at start of 14F portion of stent. There are no other drainage holes in 14F part of stent. Lower arrow shows where stent tapers to 7F. 7F portion and both pigtail ends of stent have drainage

249

URETERONEPHROSCOPIC ENDOPUELOTOMY

percutaneous nephrostomy and sharply incised with a cold knife under endoscopic vision using a direct vision urethrotome.' A 12F external nephroureterostomy stent was left indwelling for 4 weeks. In 7 patients in whom a nephrostomy tract could be established the over-all success rate was 71%.' The 2 failures were attributed to too small a stent or an insufficiently deep ureterotomy. Badlani and associates initiated this same procedure in the United States, which they Endopyelotomy is perhaps a more apt termed endopyelot~my.~ term, since the ureteropelvic junction is being incised (Greek tome: cutting) not lysed (Greek: to dissolve or set free as by a specific chemical compound). These investigators rapidly developed a large series (31 patients) in which the success rate was 87% for congenital and acquired ureteropelvic junction 7/87 2/87 obstruction^.^ With this procedure hospital stay was decreased (25 m~nutes) (25minutes) (4 days) and postoperative convalescence was markedly shortFIG. 2. Preoperative ( A ) and postoperative ( B ) IVPs (25 minutes) ened. of patient who underwent retrograde endopyelotomy. Paralleling the developments with endopyelotomy were developments in ureteroscopy. Indeed, the first purpose built All 10 patients were interviewed a t an average of 12 months ureteroscopes were not reported until 1980 by Perez-Castro postoperatively. All patients reported marked improvement in Ellendt and Martinez-Pineiro.' Surgical procedures through the preoperative symptoms. Eight individuals were completely these endoscopes were extremely few. The experience of free of pain and 2 had only occasional mild flank discomfort. Huffman and associates on use of a rigid ureteroscope to excise low grade ureteral tumors first appeared in 1983." Then, Bagley DISCUSSION and associates reported use of a combined percutaneous neThe surgical treatment of ureteropelvic junction obstruction phrostomy and ureteroscopy approach to incise an obliterated began in 1886 with the report by Trendelenburg of a plastic ureteropelvic junction in 2 patients." However, the incision was performed through the nephrostomy tract under the visual .~ procedure to relieve ureteropelvic junction o b s t r ~ c t i o nSince then a variety of operations have been developed: U-V plasty, guidance of the ureteroscope. In both cases an indwelling stent The was left permanently in place. pelvic flap procedures and the dismembered pyelopla~ty.~ The first report of a completely ureteronephroscopic apover-all success rate for the surgical approach is Complications of surgical pyeloplasty include nephrectomy (3.2%), proach to the obstructed ureteropelvic junction was by Inglis fistula (2.6%) and ureteropelvic junction stricture (2.4%).' A and Tolley in 1986.4 The nephrostomy was eliminated and the approach was completely from beneath the ureteropelvic juncrepeat pyeloplasty is necessary in 2.2% of the patients.' The basis for a n endourological approach to ureteropelvic tion using a rigid ureteroscope and a diathermy hook to make junction obstruction harkens back to the description by the ureterotomy. Both patients were women with a secondary Albarran in 1909 of a ureterotome externe, in which he made a ureteropelvic junction obstruction, and the procedure was suclongitudinal incision into a stenotic ureter; the author stated cessful in both (followup was 4 months and 1 year). Our method, although developed independently, is similar to that no sutures were necessary as long as the catheter was left in place for 6 weeks.6 In 1915 Keyes accomplished possibly the that of Inglis and Tolley, and is the first report of the use of a first successful ureterotome externe in the United States in a retrograde approach in patients with a primary ureteropelvic patient with a solitary kidney.' In 1948 Davis and associates junction obstruction and of using the flexible as well as the reported their experience of treating ureteral strictures by direct rigid ureteroscope to complete the incision. As with the Inglis incision, placement of a T-tube (later a stent) and use of sutures and Tolley procedure the entire endopyelotomy is performed to wrap the urothelium around the stent at least partially in transureterally. The immediate benefits of this approach are hopes that the urothelium would then grow over the exposed its less invasive nature and the elimination of a large, longarea of the stent.' Their method relieved symptoms in 85% of term (6 to 8 weeks) nephrostomy tube. Also, our impression is the patients and resulted in a radiographically acceptable result that it is easier to incise the ureteropelvic junction from below the lesion upward, since in our experience the starting point in 70%. In 1983 Wickham reported the first series of pyelolysis in (the narrowing in the ureter) and the ending point (the capawhich the ureteropelvic junction was approached through a cious renal pelvis) are better defined then when one proceeds T A B L E2. Retrograde endopyelotomy: results P t . No

Operating room time (mins.) Method of incision: Electrode Cold knife Balloon Fat seen Estimated blood loss (cc) Postop. hemoglob~n change (gm./dl.) Duration of nephrostomy tube (days) Duration of stent (wks.) Hospital days

135 3F Yes Yes Yes 0 -1.3

5F No No Yes 100 -0.6

5F No No Yes 0 0

3F KO No Yes 100 -1.7

5F No No No 100 -1.5

5F No Yes Yes 0 -3.2

3F No Yes Yes 100 -1.3

3F No Yes Equivocal 0 -0.1

2F No Yes Yes 100 -1.8

2F No Yes Yes 100 -1.2

8 4

5 12t

6 2

2'h 1

7 3

4

3 7 5

6 6

6 3

4

5

*Patient did not return for removal of nephrostomy tube as directed. t Postoperative course complicated by congestive heart failure requiring prolonged management

5

250

CLAYMAN A N D ASSOCIATES

TABLE3. Retrograde endopyelotomy: follow u p evaluation Preop. Studies Pt. No.

F;;~

IVP

Renogram: Obstruction T1/2

No data available Improved No data available Same Same No data available Improved

Functional Change

(n)

Whitaker Test Differential Pressure (em. water)

Change in Whitaker Test (cm. water)

+19

No data available No data available Pos. (25 mins.) Ko data available Pos (17 mins.)

No data available No data available +12

No data available 4

No data available +8

0

0:

No data available No data available No data available No data available No data available

No data available No data available No data available No data available No data available

Improved

Neg.

No data available Ko data available

Neg. Neg.

-9

No data available No data available Ko data available

Complications

-21

-6

Neg.

Neg.

% Symptom Relief

12

No data available -13 -44

* Distal ureteral stricture developed 7 months postoperatively. t No preoperative Whitaker test. $ Immediately postoperatively congestive heart failure and oliguria resolved with aggressive management

from an antegrade approach. However, presently there is not The size requirements for the indwelling ureteral stent still sufficient experience to permit comparison of long-term effi- are unsettled. From an anatomical standpoint the normal adult cacy of the ureteroscopic approach with standard pyeloplasty ureteropelvic junction is 5 mm. (15F in diameter). While the or antegrade endopyelotomy. Also, our experience is predomi- practice of placing an 8 or 10F stent after incision of the nantly limited to female patients. T o be sure, rigid and flexible ureteropelvic junction can be justified by the dilation usually ureteroscopy is easier in female than in male patients. In seen in the area of the ureter undergoing ureterotomy, we addition, the more direct route to the ureteropelvic junction in believe that placement of a larger stent might be b e n e f i ~ i a l . ~ ~ ~ ~ the female patients makes it easier to perform the procedure An earlier study claiming increased ureteral scarring from through a rigid ureteroscope with its superior optics and greater larger stents involved the use of T-tubes or stents in which the degree of control. However, in this regard it is important to use distal tip of the stent resided in the ureter. Under these circumthe operating ureteroscope with its insulated sheath to preclude stances strictures developed a t the point where the tip of the propagation of the electrocautery current and possible damage stent was rubbing on the ureteral mucosa.13 By being certain to the distal ureter. that the distal end of the stent is in the bladder these stentThere are 3 areas of variability regarding the endoscopic related ureteral strictures can be avoided.14 incision of the ureteropelvic junction: type of cutting element Also, much data support the contention that the ureter can used, size of the indwelling stent and duration of stent placeAs such, we are now using be safely dilated to 21F or ment. Regarding the type of cutting element used, we prefer an indwelling endopyelotomy stent, which is 14F along the the 3F Greenwald electrode with an angled tip, which is easily portion that spans the incised ureteropelvic junction and then maneuvered. The angled tip enhances the placement of the tapers to 7F a t its distal tip. These indwelling stents are made incision and allows the incision to be extended laterally enough to enter the periureteral fat easily. These electrodes are avail- of silicone and are reasonably well tolerated. To date, in this able in a 2F shaft; the cutting element is only 300 p. While a patient population we have had no problems removing the stent cold knife might well result in a more confined area of periure- from the bladder with a standard cystoscope and grasping teral damage, it is difficult to extend the incision laterally forceps. However, among more than 30 patients in whom these enough to open the ureter and enter the retroperitoneal fat due stents have been placed for other reasons there have been 2 to the limited mobility of the rigid ureteroscope within the cases of incrustation that precluded cystoscopic removal. In 1 ureter. Indeed, Inglis and Tolley had 1 case in which attempts patient the stent was removed via a percutaneous nephrostomy to incise the ureteropelvic junction with a cold knife failed; a and in 1 extracorporeal shock wave lithotripsy was used to subsequent attempt with the diathermy hook was s u c ~ e s s f u l . ~fragment the incrustations, following which the stent could be Alternatively, the contact neodymium:YAG laser with a laser removed cystoscopically. The duration of stent placement also is controversial. While tip (smallest size 5F) or the K T P laser probe could be used to incise the ureter. The advantage of the latter device is its 400 the urothelium has been shown to cover an incision within 7 to 10 days, the muscle fibers are believed to take up to 8 weeks to p. fiber size, which would easily pass through the 3F working port of the 10F flexible deflectable ureteronephroscope. How- bridge a ~reterotomy.~',"Others have shown that within 2 to ever, there are no data o n this form of incision of the uretero- 4 months peristaltic waves will traverse a previously incised area of the ureter.lg As such, it seems reasonable to leave the pelvic junction.

URETERONEPWROSCOPIC ENDOPYELOTOMY s t e n t i n place for 6 t o 8 weeks t o allow for complete healing. T h i s i s o u r c u r r e n t policy. CONCLUSION

The concept of retrograde endopyelotomy is attractive a n d o u r early results a p p e a r t o b e promising. In t h i s s m a l l series t h e presence of ureteropelvic junction obstruction w a s docum e n t e d b y r e n o g r a p h y a n d pressure/flow studies before t r e a t m e n t . N o p a t i e n t w i t h a concomitant s t o n e a n d ureteropelvic junction w a s included in t h i s series. Postoperatively, interviews and objective s t u d i e s h a v e been repeated in a n effort t o evaluate t h e efficacy of t e c h n i q u e . Over-all, 90% of t h e p a t i e n t s a r e improved; results s i m i l a r t o t h o s e reported for pyeloplasty o r antegrade endopyelotomy. However, o u r experience t o date h a s been limited p r i m a r i l y t o female patients. I n addition, retrograde endopyelotomy is minimally invasive, eliminates t h e n e e d for a long-term n e p h r o s t o m y t u b e a n d provides f o r a brief hospital stay. However, o u r length of followup is t o o brief for a n y f i r m conclusions t o b e d r a w n regarding t h e role of t h i s a p p r o a c h w i t h respect t o surgical pyeloplasty o r even a n t e g r a d e endopyelotomy. ADDENDUM

S i n c e t h i s m a n u s c r i p t w a s w r i t t e n o u r experience w i t h r e t rograde endopyelotomy h a s been e x t e n d e d t o 16 patients. A m o n g t h i s g r o u p t h e r e have been 2 p a t i e n t s w h o required a transfusion secondary to a n incised retroperitoneal vessel. Also, t h e r e have been 2 failures in t h i s group requiring o p e n repair. Therefore, o u r over-all success r a t e c u r r e n t l y i s 81%. REFERENCES

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Experimental extensive balloon dilation of the distal ureter: immediate and long-term effects. J. Endourol., 1: 19, 1987. 17. Oppenheimer, R. and Hinman, F., Jr.: Ureteral regeneration: contracture vs. hyperplasia of smooth muscle. J. Urol., 74: 476, 1955. 18. McDonald, J. H. and Calams, J. A.: Experimental ureteral stricture: ureteral regrowth following ureterotomy with and without intubation. J. Urol., 84:52, 1960. 19. Rohrmann, D., Hannappel, J., Schafer, W. and Lutzeyer, W.: Myogenic excitation conduction after microsurgical anastomosis of the ureter. J. Urol., part 2, 135:170A, abstract 265, 1986.

EDITORIAL COMMENTS

I congratulate the authors on an excellent and well documented small series. Conceptually, it is preferable to perform an endopyelotomy ureteroscopically, and it is even more desirable to be able to do this without a nephrostomy tube, whether it is 8F as the authors describe or 14F as I have advocated. The authors had a 90% success rate initially with 10 cases, which decreased to 81% with the addition of 6 patients. Our success rate with 150 patients treated antegrade is 86%, which is essentially the same. My major concern with this study is the technical problems associated with ureteroscopic incision. The field of vision of a nephroscope is markedly superior to that of a flexible ureteroscope. Even with a nephroscope it often is difficult to assess the degree of obstruction at the ureteropelvic junction, and the length and depth of the incision. It cannot be easier with a ureteroscope when the small field of vision can easily be obscured by even slight bleedine. certainly, the antegrade approach has-the disadvantage of requiring dilation of the nephrostomy tract. Among its advantages are the ability to use a nephroscope rather than a ureteroscope. One can also look for abnormal pulsation at the ureteropelvic junction and avoid incising in that area. The obstruction to flow is from proximal to distal. Therefore, it is easier to evaluate a high insertion, a flap valve effect of the length of functional ureteral narrowing from above. The procedure is safer, more rapid and, I believe, more effective from above. Ureteroscopic incision of the ureteropelvic junction as advocated by the authors is advantageous because it avoids dilation of t h e nephrostomy tract from 8 to 26F. However, the disadvantages of the technique are considerable. It is technically more difficult to perform ureteroscopy in the upper third of the ureter and the ureteropelvic junction, particularly in muscular male patients. This problem is aggravated by having to perform the procedure adjacent to a 5F catheter, which may explain why the authors, who are skilled ureteroscopists, require 3 to 4 hours to perform this procedure. Although smaller flexible endoscopes may avoid this problem, they bring their own problems of reduced visibility, which possibly explains the inadvertent retroperitoneal bleeding created in 2 patients and the need for repeat ureteroscopy t o locate any inadequately incised areas as in figure 1, D. Moreover, it often is difficult to be certain of the actual site of the ureteropelvic junction from below, since kinking of the ureter where it crosses over the psoas muscle may resemble the ureteropelvic junction, which in turn may cause inadvertent ureterotomy. To date, the authors have had only 1 distal ureteral stricture, which is a surprisingly good record. The technique described for insertion of the double pigtail stent at the termination of the procedure could lead to problems. I t is difficult to achieve a curl in the upper end of a double pigtail catheter and a pigtail nephrostomy tube when they are unfolded over 1 guide wire extending from the nephrostomy site to the bladder. In less skilled hands 1 of the curls could slip out through the endopyelotomy incision or down the ureter. Placing the same stent under nephroscopic control is technically easier and more exact. I agree that this exciting new development in endopyelotomy should be assessed further by those highly skilled in upper ureteroscopic surgery. While this is being done endopyelotomy from above can be performed by urologists who have some experience in percutaneous stone surgery. Arthur D. Smith Division of Urology Long Island Jewish-Hillside Medical Center New Hyde Park, New York Endoscopic repair of ureteropelvic junction obstruction has attracted many proponents, even though conventional open pyeloplasty has become a successful surgical endeavor in patients who do not have

Ureteronephroscopic endopyelotomy.

The percutaneous nephrostomy tract has provided urologists with antegrade access to the upper urinary tract. Via this approach ureteropelvic junction ...
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