Editing Management of Upper Urinary Tract Obstruction (section)

==== Endourologic procedures ====
* '''<span style="color:#ff0000">Options (2):</span>''' 
*#'''<span style="color:#ff0000">Balloon dilation</span>'''
*#'''<span style="color:#ff0000">Endopyelotomy</span>'''
*'''<span style="color:#ff0000">Advantages:</span>''' 
*#'''<span style="color:#ff0000">Less invasive</span>'''
*#'''<span style="color:#ff0000">Reduced hospital stays and postoperative recovery</span>'''
* '''<span style="color:#ff0000">Disadvantages (2):</span>''' 
*#'''<span style="color:#ff0000">Higher risk of failure than pyeloplasty</span>'''. 
*#*'''Patients should be counseled that the success rate of any endourologic approach may be less than that of formal reconstruction.'''
*#** Success rates approach 85-90% for percutaneous endopyelotomy.
*#'''Requires taking into account the degree of hydronephrosis, ipsilateral renal function, concomitant calculi, and possibly the presence of crossing vessels,''' whereas pyeloplasty (open, laparoscopic, or robotic) can be applied to almost any anatomic variation of UPJO
*#* '''Moderate to severe hydronephrosis is most predictive of failure after percutaneous endopyelotomy'''
* '''<span style="color:#ff0000">Transplantation complications are particularly suited to endoscopic (antegrade or retrograde) management</span>'''
* '''<span style="color:#ff0000">Approaches:</span>'''
** '''<span style="color:#ff0000">Retrograde balloon dilation alone</span>'''
*** '''Long-term follow-up studies have shown a diminishing success rate over time'''
** '''<span style="color:#ff0000">Endopyelotomy</span>'''
*** '''<span style="color:#ff0000">Contraindications (3):</span>'''
***# '''<span style="color:#ff0000">>2 cm of obstruction</span>'''
***# '''<span style="color:#ff0000">Untreated UTI</span>'''
***# '''<span style="color:#ff0000">Untreated coagulopathy</span>'''
*** '''Technique'''
****'''Approaches: percutaneous antegrade or retrograde ureteroscopic''' 
***** The main advantage of retrograde ureteroscopic endopyelotomy is that it allows direct visualization of the UPJ and assurance of a properly situated, full-thickness endopyelotomy incision without the need for percutaneous access
*****'''<span style="color:#ff0000">Percutaneous endopyelotomy remains appropriate for patients with UPJO and concomitant pyelocalyceal stones,</span> which can be managed simultaneously'''.
****'''Methods: can be done with an endopyelotome, holmium laser or cutting balloon catheter'''
***** Cutting balloon catheters have the potential to better dilate ischemic and fibrotic lesions resistant to conventional balloon catheter dilation[https://pubmed.ncbi.nlm.nih.gov/19959311/]
*****'''Little evidence for significant differences in success among endopyelotomy techniques.''' 
******Differences lie in technical considerations and complications.
*****'''<span style="color:#ff0000">If using an endopyelotome or laser, a full-thickness lateral incision</span> is made through the obstructing proximal ureter, from the ureteral lumen out to the peripelvic and periureteral fat'''
****** '''Incision should usually be made laterally because this is the location devoid of crossing vessels'''
**** '''A stent is placed across the incision and is left to heal.''' 
*****No consensus as to the optimal stent size or duration after endopyelotomy
****'''Postoperative care'''
*****Avoidance of strenuous activity for 8-10 days after the procedure
*****'''Once the stent is removed, that patient returns 1 month later for history and physical exam, urinalysis, and diuretic renography'''
*****'''For most adults, 2-3 year follow-up is justified''' 
******Studies indicate that even at 36 months some late failures are identified, but relatively few are identified at 60 months
****'''Complications'''
*****'''Early'''
*****#'''Bleeding requiring transfusion'''
*****#'''Urinary leak'''
*****#'''Drainage-related complications'''
*****#'''Hydropneumothorax'''
*****#*'''Risk is increased if upper pole access is used'''
*****'''Late'''
*****#'''Recurrent obstruction'''
*****#*Options if percutaneous endopyelotomy fails:
*****#*#Retrograde endopyelotomy
*****#*#Repeat percutaneous endopyelotomy
*****#*#Laparoscopic, robotic, or open operative intervention