Percutaneous Antegrade Endoscopic Pyelotomy: Review of 50 Consecutive Cases

Between 1988 and 1993, 50 percutaneous antegrade endoscopic pyelotomies were performed for ureteropelvic junction obstruction at this institution. The success of the procedure was based on radiological parameters as well as patient symptomatology. The overall success rate of the procedure was 88%. Endoscopic pyelotomy was successful in 9 of 11 patients (82%) who presented after failing previous renal procedures. When endoscopic pyelotomy was used as the initial treatment modality the success rate was 90%. These results support the argument that endoscopic pyelotomy should be considered as first line therapy for most adults with ureteropelvic junction obstructions. The use of percutaneous endoscopic pyelotomy as a treatment modality for obstruction of the ureteropelvic junction is not a new concept. Indeed, the current operative technique of percutaneous endoscopic pyelotomy has its roots dating back to the performance of intubated ureterotomies by Davis et al.'f2 Not until the work of Wickham and Kellet did the idea of performing an intubated ureterotomy via a percutaneous nephrostomy tract become a viable alternative to open pyelopla~ty.~ Later, the technique was further refined and the term endo-pyelotomy was coined by Badlani et al.4 Since that time, further refinements in surgical instrumentation have allowed endoscopic pyelotomy to gain more popularity gradually. We analyze retrospectively the results of 50 consecutive percutaneous antegrade endoscopic pyelotomies performed at our clinic. The starting date and number of cases presented are not arbitrary since the date approximates the point at which surgical equipment and general surgical technique became standardized at this institution. All patients referred to us (J. W. S. and D. E. P.) for management of ureteropelvic junction obstruction were offered endoscopic pyelotomy or open surgery. Three patients elected open surgery and in 1 the distortion of the collecting system was judged too great for endoscopic pyelotomy. METHODS Between January 1988 and May 1993, 50 percutaneous antegrade endoscopic pyelotomies were performed at our institution as the treatment for patients with ureteropelvic junction obstruction. Mean age of the 29 female and 21 male patients was 42 years (range 4 to 87 years). Of the patients 33 (66%) presented with chronic episodic flank pain and 10 (20%) with single incapacitating bouts of flank pain. An incidental finding was noted in an asymptomatic patient (2%). One patient (2%) had an iatrogenic injury and the condition was noted during medical evaluation of pyelonephritis in 2% or recurrent nephrolithiasis in 8%. Indeed, 16 patients (32%) had a medical history that included nephrolithiasis. Ureteropelvic junction obstruction was noted on the right side in 27 patients and on the left side in 23. The diagnosis of ureteropelvic junction obstruction was based upon patient symptomatology and radiological findings. Excretory urography (IVP) was the initial test of choice in the majority of patients (part A of figure). Diuretic renography is usually reserved for patients with equivocal findings on Ivp. Retrograde pyelography typically was performed as the initial test of choice in those with allergies to contrast medium or renal insufficiency, or as a confirmatory test before treatment. Postoperative IVPs were obtained at 3 and 6 months, and then at 12 to 18-month intervals (part B of figure). Subsequent IVPs were not obtained routinely. Diuretic renography in the postoperative period was only used in the same fashion as it had been during the preoperative period. Pressure-flow studies as described by Whitaker were not routinely performed as part of either the diagnostic evaluation or postoperative followup. Endoscopic pyelotomy was considered successful only when the patient was completely free of any symptomatology and had improved radiological findings, such as significantly increased emptying of the renal pelvis on IVP. Followup ranged from 3 months to 4 years (mean 12 months). Endoscopic pyelotomy was initiated by performing a percutaneous nephrostomy through an upper or middle pole calk with the patient in the prone position. The tract was then dilated to 24F and nephroscopic examination of the renal pelvis was performed. After the stenotic area was identifled, a guide wire was placed across the area and well into the ureter. The cold-cut knife was passed over the guide wire with the endo-pyelotomy being performed in the posterolatera1 position, making a full thickness cut into the peri