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The case for percutaneous endopyeloplasty.

in the treatment algorithm for UPJ obstruction. Factors that define the optimal choice of surgical approach in the individual patient include ipsilateral renal function, degree of hydronephrosis, length of stricture, previous surgical intervention on the UPJ, presence of ipsilateral renal calculi, presence of a crossing vessel at the UPJ, and individual surgeon comfort level and experience. Management Relevant facts in the case scenario include a history of open pyeloplasty and presence of a 1.5-cm lower-pole calculus. Additional variables that need to be assessed before deciding the optimal management include length of stricture, anatomy of the UPJ and proximal ureter, and ipsilateral renal function. Therefore, the initial step in management would be to quantify differential renal function via a radionuclear renal scan and obtain anatomic evaluation via excretory urography. Anatomic delineation of the UPJ and proximal ureter is further defined by performing retrograde pyelography. Because the length of stricture and anatomy of the UPJ play a significant role in determining type of therapy, we typically perform the retrograde pyelography as a separate procedure in patients who have undergone pyeloplasty previously, especially if the anatomic delineation is suboptimal on excretory urography. This approach helps plan the appropriate procedure and enables us to counsel patients appropriately. This is an important issue, because many patients in whom an open pyeloplasty has failed may need a complex salvage reconstructive procedure. We assume in this debate that the segment of obstruction is short and there is no significant tortuosity of the proximal ureter. In general, endopyelotomy is a reasonable alternative for patients in whom pyeloplasty has failed, and pyeloplasty is the preferred approach for patients in whom endopyelotomy has failed. Because this patient also has a 1.5 cm calculus, the percutaneous approach would be preferred. We believe endopyeloplasty to be functionally superior to endopyelotomy, and it would therefore be our procedure of choice for this patient. This approach would effectively remove the calculus and simultaneously manage the UPJ obstruction. A crucial factor in this case is that the pyeloplasty was performed 13 years ago. We believe that the periureteral scarring is less dense if the surgical intervention was performed in the remote past as opposed to recently. It therefore would not technically prohibit performance of an endopyeloplasty.