Failure after laparoscopic pyeloplasty: prevention and management

Because of the high success of laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction, strategies for managing failures are less well described. We report our experience with persistent or recurrent obstruction after LP.

We reviewed 128 patients who were treated with LP at our institution from 1996 through 2008. Success was defined as objective resolution of obstruction by renal scintigraphy, Whitaker testing, or direct visualization. We extracted data by chart review regarding patient demographics, medical history, operative technique, and salvage treatments. We then assessed for association between patient characteristics and treatment failure.

Overall, 102 patients had sufficient follow-up, of which 84 (82%) were successes. Of 18 failures, median time to failure was 2.5 months (0.5-88 mos). Of 10 failures managed endoscopically, 7 were salvaged. One of two patients treated conservatively ultimately had resolution while six patients needed simple nephrectomy. Overall, 8 (44%) were salvageable with median follow-up of 19 months (4-58 mos). Patients with failure were more likely to have diabetes mellitus, longer length of stay, higher American Society of Anesthesiologists (ASA) score, a stent placed at the time of pyeloplasty, or ureteral stent malfunction (P<0.05). Patients with failure despite salvage were more likely to have stent malfunction or body mass index >30 kg/m(2) (P<0.05). Adjusting for the above factors, stent placement at time of surgery and ASA score >2 were associated with failure (P<0.05) while periureteral fibrosis trended toward a significant association (P=0.061).

Nearly half of failures after LP are salvageable, many with endoscopic management.