ENDOUROLOGY & LAPAROSCOPY

Ureteropelvic junction obstruction: determining durability of endourological intervention
Albani JM, Yost AJ, Streem SB
From the Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
J Urol.; 171: 579-82

• Purpose: We evaluated the durability of endourological intervention for ureteropelvic junction obstruction and established guidelines for postoperative surveillance.
• Materials and Methods: Since 1989, 150 patients have undergone endourological intervention for ureteropelvic junction obstruction, of whom 127 (53 men and 74 women) 13 to 79 years old (mean age 40.4) underwent postoperative evaluation at our center. These 127 patients are the study group reported. Endourological management consisted of hot wire balloon endopyelotomy in 25 patients, percutaneous endopyelotomy in 67 and ureteroscopic laser endopyelotomy in 35. Success in this study was strictly defined as symptomatic relief plus radiographic resolution on excretory urogram and/or diuretic renogram. Statistical analysis was performed to assess mean time to failure and develop Kaplan-Meier re-stenosis-free survival estimates.
• Results: Followup was 1 to 128 months (mean 22). Time to failure was 0.9 to 32.4 months (mean ± SD 10.3 ± 9.4). Kaplan-Meier estimates of time to re-stenosis (failure) were 6 months in 12% of patients, 12 in 22%, 18 in 24%, 24 in 27%, 30 in 32% and 36 in 37%. After 3 years no further failures were observed and Kaplan-Meier estimates remained unchanged.
• Conclusions: The long-term probability of success, which is estimated to be 63.3% in this series, is somewhat lower than that reported in the literature. It likely is a result of longer followup and a more strict definition of success that includes functional and symptomatic relief. Our data suggest that while most failures become evident within the first 12 months, failure can develop as late as 3 years after intervention. As such, patients should be followed at least that long to ensure a durable result.
  
  
• Editorial Comment
  Data such as this has been presented at meetings for a few years, and many in the academic community have started to lose favor for endopyelotomy and move towards laparoscopic pyeloplasty because of these findings. Although the mean time to failure was 10 months in this study, patients continued to fail up to 3 years post-operatively. A procedure with a 63% success rate long-term is just not a good choice for a young, active patient. On the basis of data such as this, I continue to offer endopyelotomy but encourage my patients towards pyeloplasty (if they are medically fit) because of my perception (although there are few data) that pyeloplasty will have better durability.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA