Management of secondary ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty

Laparoscopic pyeloplasty has been established as a minimally invasive alternative to open pyeloplasty. However, little is known about the treatment of patients in whom this technique fails. We present our experience with treating ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty.

From August 1993 to September of 2003, 227 patients underwent laparoscopic pyeloplasty for primary ureteropelvic junction obstruction. Of these patients 10 (4.4%), including 6 females and 4 males 24 to 62 years old (mean age 42.1), underwent secondary treatment after laparoscopic pyeloplasty failed. The type of secondary intervention varied by anatomical factors, and patient and surgeon preference. Success was defined as symptomatic relief and improved radiographic imaging at latest followup.

Secondary interventions were repeat laparoscopic pyeloplasty in 1 patient, retrograde endoscopic balloon dilation in 2 and endopyelotomy in 7 (laser, cold knife and cutting balloon endopyelotomy in 3, 2, and 2, respectively). No postoperative complications were seen. Patients were followed for a mean of 25.5 months (range 3 to 96) after the second procedure. Seven of 10 secondary interventions (70%) were successful with no obstruction on followup imaging. Three of 10 interventions (30%) failed, namely 1 laparoscopic pyeloplasty, 1 endoscopic balloon dilation and 1 laser endopyelotomy. Failure of the second procedure occurred at a mean of 9.3 months.

When given the choice, most patients select endoscopic management after failed primary laparoscopic pyeloplasty due to its minimally invasive nature and low complication rate. Success rates are 70% with repeat intervention. Some patients require a third intervention.