Urolithiasis, Endourology and Laparoscopy

Urological Survey UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Long-Term Success of Antegrade Endopyelotomy Compared With Pyeloplasty at a Single Institution D. S. Dimarco, M. T. Gettman, S. M. McGee, G. K. Chow, A. J. Leroy, J. Slezak, D. E. Patterson and J. W. Segura, Department of Urology, Mayo Clinic, Rochester, Minnesota J Endourol 2006; 20: 707–712. Background and Purpose: The classic standard for surgical repair of ureteropelvic junction (UPJ) obstruction has been open pyeloplasty, with a 95% success rate. Antegrade endopyelotomy is a less-invasive option with a slightly lower success rate. However, recent data call into question the long-term durability of UPJ repair. We present the long-term success of treatment of UPJ obstruction comparing these two modalities. Patients and Methods: We reviewed the medical records of patients undergoing percutaneous antegrade endopyelotomy or open and laparoscopic pyeloplasty for UPJ repair in our practice from 1988 to 2004. Success was defined as both radiographic and symptomatic improvement. We evaluated the impact of preoperative factors, including prior surgical repair, crossing vessels, renal function, and calculi, on success. Results: The estimated 3-, 5-, and 10-year recurrence-free survival rates for the endopyelotomy group (N ⫽ 182) were 63%, 55%, and 41%, respectively, compared with 85%, 80%, and 75% for the pyeloplasty group (N ⫽ 175; P ⬍ 0.001). Of the failed endopyelotomies undergoing salvage open repair, 8 of 26 (31%) had crossing vessels. Poor renal function and previous failed pyeloplasty decreased success in the pyeloplasty group. Variation from standard cold-knife incision adversely affected endopyelotomy success. Conclusions: Long-term success rates after both endopyelotomy and pyeloplasty are worse than previously reported. Although most failures in both groups occurred within 2 years, failures continue to appear after 5 and 10 years, and patients should be followed accordingly. In view of these results of endopyelotomy, laparoscopic pyeloplasty may prove to be the preferred minimally invasive approach to repair UPJ obstruction. Editorial Comment: This article received the first place prize in clinical research at the 24th World Congress of Endourology, and rightfully so. It is an honest assessment of the true success of procedures designed to correct UPJ obstruction. Success in this series was defined as “complete resolution of symptoms and resolution or improvement of radiographic obstruction.” The latter suggests that results would have been even “worse” if the authors had strictly adhered to a policy of “success” requiring a return to a normal renal scan (ie no change or improvement in percent renal function and a normal t½). Be that as it may, it is most impressive, and depressingly so, that results with endopyelotomy and open pyeloplasty are, in fact, far inferior to the rates often cited to our patients. It bears repeating that in this article the 3, 5 and 10-year “success” rates for antegrade percutaneous endopyelotomy were 64%, 55% and 41%, respectively, while the respective rates for open pyeloplasty were 85%, 80% and 75%. Among the failed endopyelotomies the authors noted that only 31% involved crossing vessels, although it was not reported what percentage of the failures were associated with renal function less than 25% or high grade hydronephrosis. Perhaps all patients after any reconstructive effort are going to need followup for at least 5 years, and possibly 10 years. What does this mean? To my mind, we as a group have often not been strict enough in our definitions of “success” and “failure.” To me, “success” means a 2 or less on an analogue pain scale (of 1 to 10, with 1 being a headache) and a t½ that is 10 minutes or less with preservation or improvement in percent function. While “failure” is clearer, there is a third category, which is that of “improvement,” in which the patient may have an analogue pain scale in the 3 to 4 range or a renal scan in the 10 to 20-minute range with preserved or improved function. These patients do not require any further therapy, but they do deserve to be placed in a different category. The bottom line is that endopyelotomy is not all it is cracked up to be— early success is no indication of future performance. Is endopyelotomy dead? I do not think it is. However, I do believe that its use needs to be limited to those patients most likely to benefit. At our hospital endopyelotomy is reserved for the few patients meeting 3 specific criteria—more than 25% function on the renal scan, low grade hydronephrosis and no crossing vessels. Ralph Clayman, M.D.

0022-5347/08/1793-0985/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION

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Vol. 179, 985, March 2008 Printed in U.S.A. DOI:10.1016/j.juro.2007.11.016