Ureteropelvic Junction Obstruction: Difference between revisions

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*'''See [https://test.urologyschool.com/index.php/Pediatrics:_Surgery_of_the_Ureter#Ureteropelvic_Junction_Obstruction_(UJPO) Ureteropelvic Junction Obstruction Section] in [[Pediatrics: Surgery of the Ureter|Pediatrics Surgery of the Ureter Chapter Notes]]'''

==Etiology==

*'''~~Classified: congenital~~ vs. acquired or intrinsic vs. extrinsic'''

*'''Most cases are congenital,''' but may only become clinically apparent much later in life

=== Classification ===

**'''Congenital ureteropelvic junction obstruction (UPJO) usually results from intrinsic disease'''

*'''Congenital/primary vs. acquired/secondary or intrinsic vs. extrinsic'''

**'''Most cases are congenital''', but may only become clinically apparent much later in life

***'''UPJO in neonates is most frequently found as a result of maternal-fetal ultrasound'''

****Many newborns diagnosed with hydronephrosis on are subsequently found to have UPJO

****Many newborns diagnosed with hydronephrosis on ultrasound are subsequently found to have UPJO

*'''~~Congenital causes of UPJO~~ (5)~~: SHAVA~~'''

*#'''True ureteral Stricture'''

==== Congenital ====

*#'''High insertion found more frequently in the presence of renal ectopia or fusion anomalies'''

*#'''Aberrant vessels (controversy persists). Regardless, the presence of crossing vessels has a detrimental effect on the success rates of endopyelotomy'''

* '''SHAVA (5)'''

*#'''Kinks or Valves''' produced by infoldings of the ureteral mucosa and muscularis

#'''True ureteral Stricture'''

*#'''Aperistaltic segment'''

#'''High insertion found more frequently in the presence of renal ectopia or fusion anomalies'''

*'''~~Acquired causes of UJPO~~ (5)~~:~~ CRIIBS'''

#'''Aberrant vessels (controversy persists). Regardless, the presence of crossing vessels has a detrimental effect on the success rates of endopyelotomy'''

*#'''Cancer'''

#'''Kinks or Valves''' produced by infoldings of the ureteral mucosa and muscularis

*#'''Vesicoureteral Reflux;~~'''~~ can lead to upper tract dilation with subsequent elongation, tortuosity, and kinking of the ~~ureter~~

#'''Aperistaltic segment'''

*#'''Post-Inflammatory or postoperative scarring or Ischemia'''

*#'''Benign lesion (e.g. fibroepithelial polyps)'''

* '''UPJO in newborns and infants is most often caused by an ''intrinsic'' narrowing'''

*#'''Stones'''

** '''The ureteral segment has an interruption in the development of the circular musculature of the UPJ''' and an alteration in collagen fibers in and around the muscular cells. This results in a narrowed segment of the UPJ with '''functional discontinuity of the muscular contractions and ultimately to insufficient emptying of the renal pelvis'''

* '''UPJO in childhood and adolescence is often extrinsic narrowing caused by an accessory vessel to the lower pole of the kidney''' giving rise to flank pain, nausea, and vomiting.

**'''Extrinsic obstruction seen in association with a lower pole vessel''' (aberrant, accessory, or early branching) '''that passes anteriorly to the UPJ or proximal ureter and contributes to mechanical obstruction'''

* '''Congenital renal malformations commonly associated with UPJO (8):'''

*# '''Contralateral UPJO (most common anomaly)'''

*# '''Renal dysplasia'''

*# '''Multicystic dysplastic kidneys'''

*# '''Renal agenesis'''

*# '''Horseshoe kidneys'''

*# '''VUR'''

*# '''Ectopic kidney'''

*# '''Duplex kidney'''

==== Acquired ====

* '''CRIIBS (5)'''

#'''Cancer'''

#'''Vesicoureteral Reflux'''; can lead to upper tract dilation with subsequent elongation, tortuosity, and kinking or narrowing of the UPJ

#'''Post-Inflammatory or postoperative scarring or Ischemia'''

#'''Benign lesion (e.g. fibroepithelial polyps)'''

#'''Stones'''

=== Intermittent UPJO ===

* '''Dietl's crisis is intermittent abdominal pain associated with nausea and vomiting following an episode of high fluid intake.'''

*Although a renal scan with Lasix is used in an attempt to prompt the crisis, it may on occasion be falsely negative.

*In these patients, it is best to repeat a renal ultrasound at the time of pain and compare this to a baseline renal ultrasound taken when the patient was asymptomatic. If increased hydronephrosis at the time of symptoms is present, it is diagnostic and the pyeloplasty will be curative.

==Diagnosis and Evaluation==

===History and Physical Exam===

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===Imaging===

*Performed to determine the anatomic site and functional significance of an apparent obstruction

*'''~~Diuretic renography~~'''

* Performed to determine the anatomic site and functional significance of an apparent obstruction

**'''Commonly used''' for diagnosing both UPJ and ureteral obstruction

**'''Most commonly used agent in renogram studies is technetium 99m mercaptoacetyltriglycine (99m Tc-MAG3), especially in the pediatric population[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]'''

==== Contrast-enhanced axial imaging ====

***In the adult population, other agents can be used, such as diethylenetriamine pentaacetate (DTPA)

*'''CT/MR urography'''

**'''Provides quantitative data regarding differential renal function and obstruction''', even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''

***'''In general, kidneys with < 15% differential function are nonsalvageable in adults''' (Chapter 48 suggests <10%)'''.'''

==== Nuclear diuretic renography ====

****'''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''

*'''Commonly used''' for diagnosing both UPJ and ureteral obstruction

*'''Most commonly used agent in renogram studies is technetium 99m mercaptoacetyltriglycine (99m Tc-MAG3), especially in the pediatric population[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]'''

**In the adult population, other agents can be used, such as diethylenetriamine pentaacetate (DTPA)

*'''Provides quantitative data regarding differential renal function and obstruction''', even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''

**'''In general, kidneys with < 15% differential function are nonsalvageable in adults''' (Chapter 48 suggests <10%)'''.'''

***'''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''

==Management==

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#'''Causal hypertension'''

=== ~~'''~~Options~~'''~~ ===

=== Options ===

*'''Observation'''

**'''If patient is asymptomatic and the physiologic significance of the obstruction seems indeterminate, careful observation with serial follow-up renal scans is appropriate'''

*'''Intervention (4):'''

*#'''Decompression (stent or nephrostomy tube)'''

*#'''Decompression (ureteral stent or nephrostomy tube)'''

*#'''Endourological procedures (balloon dilation or endopyelotomy)'''

*#'''Pyeloplasty'''

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*#'''Reduced hospital stays and postoperative recovery'''

*'''Disadvantages (2):'''

*#'''Higher risk of failure than pyeloplasty'''.

*#'''Higher risk of failure than pyeloplasty'''

*#*'''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.

*#**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'''

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***'''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~~

*****'''Retrograde endopyelotomy'''

*****'''Percutaneous endopyelotomy ~~remains appropriate~~ for patients with UPJO and concomitant pyelocalyceal stones, which can be managed simultaneously'''.

******'''Advantage'''

*******No need for percutaneous access

*******Allows direct visualization of the UPJ and assurance of a properly situated, full-thickness endopyelotomy incision

*****'''Percutaneous endopyelotomy'''

******'''Advantage'''

*******'''Appropriate for patients with UPJO and concomitant pyelocalyceal stones, 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/]

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****'''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'''

***'''Postoperative care'''

*****Avoidance of strenuous activity for 8-10 days after the procedure

****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'''

****'''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'''

****'''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

*****Studies indicate that even at 36 months some late failures are identified, but relatively few are identified at 60 months

****'''~~Complications~~'''

***'''Adverse events'''

*****'''Early'''

****'''Early'''

*****#'''Bleeding requiring transfusion'''

****#'''Bleeding requiring transfusion'''

*****#'''Urinary leak'''

****#'''Urinary leak'''

*****#'''Drainage-related complications'''

****#'''Drainage-related complications'''

*****#'''Hydropneumothorax'''

****#'''Hydropneumothorax'''

*****#*'''Risk is increased if upper pole access is used'''

****#*'''Risk is increased if upper pole access is used'''

*****'''Late'''

****'''Late'''

*****#'''Recurrent obstruction'''

****#'''Recurrent obstruction'''

*****#*Options if percutaneous endopyelotomy fails:

****#*Options if percutaneous endopyelotomy fails:

*****#*#Retrograde endopyelotomy

****#*#Retrograde endopyelotomy

*****#*#Repeat percutaneous endopyelotomy

****#*#Repeat percutaneous endopyelotomy

*****#*#Laparoscopic, robotic, or open operative intervention

****#*#Laparoscopic, robotic, or open operative intervention

====Pyeloplasty====

*'''Principles of UPJ anastomosis (5):'''

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*#'''Uncorrected coagulopathy'''

*#'''Cardiopulmonary compromise unsuitable for surgery'''

*'''Before definitive surgical management, drainage of a kidney with UPJO is recommended only for infection associated with the obstruction or renal dysfunction resulting from obstruction in a solitary kidney or bilateral disease [suggesting no stent in renal dysfunction from single side obstruction if contralateral kidney fine]'''

*'''Technique'''

**'''Before definitive surgical management, drainage of a kidney with UPJO is recommended only for infection associated with the obstruction or renal dysfunction resulting from obstruction in a solitary kidney or bilateral disease [suggesting no stent in renal dysfunction from single side obstruction if contralateral kidney fine]'''

**'''Approaches: transperitoneal, retroperitoneal, or anterior extraperitoneal'''

***'''Transperitoneal laparoscopic approach is the most widely used method''' due to its associated large working space and familiar anatomy.

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*****'''The Foley Y-V-plasty is designed for repair of a UPJ obstruction secondary to a high ureteral insertion.'''

*****Flap procedures are not appropriate in the setting of crossing vessels and when reduction of redundant renal pelvis is desired

**'''The provision of external drainage from the site of surgical repair is absolutely necessary'''

***'''The provision of external drainage from the site of surgical repair is absolutely necessary'''

***'''Helps reduce risk of urinoma formation leading to possible disruption of the suture line, scarring, or sepsis'''

****'''Helps reduce risk of urinoma formation leading to possible disruption of the suture line, scarring, or sepsis'''

**'''Post-operative care'''

***'''The Foley catheter is usually removed 24 to 36 hours postoperatively, and the surgical drain is removed before hospital discharge if the drain output remains negligible.'''

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***'''Ureteral stent is typically removed 4-6 weeks later in an outpatient setting'''

***'''Follow-up including the use of imaging studies such as diuretic renal scan is performed'''

**'''~~Complications~~'''

**'''Adverse events'''

***'''Late'''

****'''Persistent urinary drainage'''

@@ Line 1: / Line 1: @@
 *'''See [https://test.urologyschool.com/index.php/Pediatrics:_Surgery_of_the_Ureter#Ureteropelvic_Junction_Obstruction_(UJPO) Ureteropelvic Junction Obstruction Section] in [[Pediatrics: Surgery of the Ureter|Pediatrics Surgery of the Ureter Chapter Notes]]'''
 ==Etiology==
-*'''<span style="color:#ff0000">Classified: congenital vs. acquired</span> or intrinsic vs. extrinsic'''
-*'''Most cases are congenital,''' but may only become clinically apparent much later in life
+=== Classification ===
-**'''Congenital ureteropelvic junction obstruction (UPJO) usually results from intrinsic disease'''
+*'''<span style="color:#ff0000">Congenital/primary vs. acquired/secondary</span> or intrinsic vs. extrinsic'''
+**'''<span style="color:#ff0000">Most cases are congenital</span>''', but may only become clinically apparent much later in life
 ***'''UPJO in neonates is most frequently found as a result of maternal-fetal ultrasound'''
-****Many newborns diagnosed with hydronephrosis on are subsequently found to have UPJO
+****Many newborns diagnosed with hydronephrosis on ultrasound are subsequently found to have UPJO
-*'''<span style="color:#ff0000">Congenital causes of UPJO (5):</span><span style="color:#0000ff"> SHAVA</span>'''
-*#'''<span style="color:#ff0000">True ureteral </span><span style="color:#0000ff">S</span><span style="color:#ff0000">tricture</span>'''
+==== Congenital ====
-*#'''<span style="color:#0000ff">H</span><span style="color:#ff0000">igh insertion</span> found more frequently in the presence of renal ectopia or fusion anomalies'''
-*#'''<span style="color:#0000ff">A</span><span style="color:#ff0000">berrant vessels</span> (controversy persists). Regardless, the presence of crossing vessels has a detrimental effect on the success rates of endopyelotomy'''
+* '''<span style="color:#0000ff">SHAVA (5)</span>'''
-*#'''<span style="color:#ff0000">Kinks or </span><span style="color:#0000ff">V</span><span style="color:#ff0000">alves</span>''' produced by infoldings of the ureteral mucosa and muscularis
+#'''<span style="color:#ff0000">True ureteral </span><span style="color:#0000ff">S</span><span style="color:#ff0000">tricture</span>'''
-*#'''<span style="color:#0000ff">A</span><span style="color:#ff0000">peristaltic segment</span>'''
+#'''<span style="color:#0000ff">H</span><span style="color:#ff0000">igh insertion</span> found more frequently in the presence of renal ectopia or fusion anomalies'''
-*'''<span style="color:#ff0000">Acquired causes of UJPO (5):</span><span style="color:#0000ff"> CRIIBS</span>'''
+#'''<span style="color:#0000ff">A</span><span style="color:#ff0000">berrant vessels</span> (controversy persists). Regardless, the presence of crossing vessels has a detrimental effect on the success rates of endopyelotomy'''
-*#'''<span style="color:#0000ff">C</span><span style="color:#ff0000">ancer</span>'''
+#'''<span style="color:#ff0000">Kinks or </span><span style="color:#0000ff">V</span><span style="color:#ff0000">alves</span>''' produced by infoldings of the ureteral mucosa and muscularis
-*#'''<span style="color:#ff0000">Vesicoureteral </span><span style="color:#0000ff">R</span><span style="color:#ff0000">eflux</span><span style="color:#0000ff">;</span>''' can lead to upper tract dilation with subsequent elongation, tortuosity, and kinking of the ureter
+#'''<span style="color:#0000ff">A</span><span style="color:#ff0000">peristaltic segment</span>'''
-*#'''<span style="color:#ff0000">Post-</span><span style="color:#0000ff">I</span><span style="color:#ff0000">nflammatory or postoperative scarring or <span style="color:#0000ff">I</span><span style="color:#ff0000">schemia</span>'''
-*#'''<span style="color:#0000ff">B</span><span style="color:#ff0000">enign lesion (e.g. fibroepithelial polyps)</span>'''
+* '''UPJO in newborns and infants is most often caused by an ''intrinsic'' narrowing'''
-*#'''<span style="color:#0000ff">S</span><span style="color:#ff0000">tones</span>'''
+** '''The ureteral segment has an interruption in the development of the circular musculature of the UPJ''' and an alteration in collagen fibers in and around the muscular cells. This results in a narrowed segment of the UPJ with '''functional discontinuity of the muscular contractions and ultimately to insufficient emptying of the renal pelvis'''
+* '''UPJO in childhood and adolescence is often extrinsic narrowing caused by an accessory vessel to the lower pole of the kidney''' giving rise to flank pain, nausea, and vomiting.
+**'''Extrinsic obstruction seen in association with a lower pole vessel''' (aberrant, accessory, or early branching) '''that passes anteriorly to the UPJ or proximal ureter and contributes to mechanical obstruction'''
+* '''Congenital renal malformations commonly associated with UPJO (8):'''
+*# '''Contralateral UPJO (most common anomaly)'''
+*# '''Renal dysplasia'''
+*# '''Multicystic dysplastic kidneys'''
+*# '''Renal agenesis'''
+*# '''Horseshoe kidneys'''
+*# '''VUR'''
+*# '''Ectopic kidney'''
+*# '''Duplex kidney'''
+==== Acquired ====
+* '''<span style="color:#0000ff">CRIIBS (5)</span>'''
+#'''<span style="color:#0000ff">C</span><span style="color:#ff0000">ancer</span>'''
+#'''<span style="color:#ff0000">Vesicoureteral </span><span style="color:#0000ff">R</span><span style="color:#ff0000">eflux</span>'''<span style="color:#0000ff">;</span> can lead to upper tract dilation with subsequent elongation, tortuosity, and kinking or narrowing of the UPJ
+#'''<span style="color:#ff0000">Post-</span><span style="color:#0000ff">I</span><span style="color:#ff0000">nflammatory or postoperative scarring or <span style="color:#0000ff">I</span><span style="color:#ff0000">schemia</span>'''
+#'''<span style="color:#0000ff">B</span><span style="color:#ff0000">enign lesion (e.g. fibroepithelial polyps)</span>'''
+#'''<span style="color:#0000ff">S</span><span style="color:#ff0000">tones</span>'''
+=== Intermittent UPJO ===
+* '''Dietl's crisis is intermittent abdominal pain associated with nausea and vomiting following an episode of high fluid intake.'''
+*Although a renal scan with Lasix is used in an attempt to prompt the crisis, it may on occasion be falsely negative.
+*In these patients, it is best to repeat a renal ultrasound at the time of pain and compare this to a baseline renal ultrasound taken when the patient was asymptomatic. If increased hydronephrosis at the time of symptoms is present, it is diagnostic and the pyeloplasty will be curative.
 ==Diagnosis and Evaluation==
 ===History and Physical Exam===
@@ Line 33: / Line 60: @@
 ===Imaging===
-*Performed to determine the anatomic site and functional significance of an apparent obstruction
-*'''Diuretic renography'''
+* Performed to determine the anatomic site and functional significance of an apparent obstruction
-**'''Commonly used''' for diagnosing both UPJ and ureteral obstruction
-**'''<span style="color:#ff0000">Most commonly used agent in renogram studies is technetium 99m mercaptoacetyltriglycine (99m Tc-MAG3), especially in the pediatric population[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]'''
+==== Contrast-enhanced axial imaging ====
-***In the adult population, other agents can be used, such as diethylenetriamine pentaacetate (DTPA)
+*'''CT/MR urography'''
-**'''<span style="color:#ff0000">Provides quantitative data regarding differential renal function and obstruction</span>''', even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''
-***'''<span style="color:#ff0000">In general, kidneys with < 15% differential function are nonsalvageable in adults</span>''' (Chapter 48 suggests <10%)'''.'''
+==== Nuclear diuretic renography ====
-****'''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''
+*'''Commonly used''' for diagnosing both UPJ and ureteral obstruction
+*'''<span style="color:#ff0000">Most commonly used agent in renogram studies is technetium 99m mercaptoacetyltriglycine (99m Tc-MAG3), especially in the pediatric population[https://www.ncbi.nlm.nih.gov/books/NBK560740/ §]'''
+**In the adult population, other agents can be used, such as diethylenetriamine pentaacetate (DTPA)
+*'''<span style="color:#ff0000">Provides quantitative data regarding differential renal function and obstruction</span>''', even in hydronephrotic renal units '''(see Pathophysiology of UUT Obstruction Chapter Notes for nuclear imaging details)'''
+**'''<span style="color:#ff0000">In general, kidneys with < 15% differential function are nonsalvageable in adults</span>''' (Chapter 48 suggests <10%)'''.'''
+***'''If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated'''
 ==Management==
@@ Line 52: / Line 84: @@
 #'''<span style="color:#ff0000">Causal hypertension</span>'''
-=== '''<span style="color:#ff0000">Options</span>''' ===
+=== <span style="color:#ff0000">Options</span> ===
 *'''<span style="color:#ff0000">Observation</span>'''
 **'''If patient is asymptomatic and the physiologic significance of the obstruction seems indeterminate, careful observation with serial follow-up renal scans is appropriate'''
 *'''<span style="color:#ff0000">Intervention (4):</span>'''
-*#'''<span style="color:#ff0000">Decompression (stent or nephrostomy tube)</span>'''
+*#'''<span style="color:#ff0000">Decompression (ureteral stent or nephrostomy tube)</span>'''
 *#'''<span style="color:#ff0000">Endourological procedures (balloon dilation or endopyelotomy)</span>'''
 *#'''<span style="color:#ff0000">Pyeloplasty</span>'''
@@ Line 68: / Line 100: @@
 *#'''<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>'''.
+*#'''<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.
+*#**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'''
@@ Line 84: / Line 116: @@
 ***'''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
+*****'''Retrograde endopyelotomy'''
-*****'''<span style="color:#ff0000">Percutaneous endopyelotomy remains appropriate for patients with UPJO and concomitant pyelocalyceal stones,</span> which can be managed simultaneously'''.
+******'''Advantage'''
+*******No need for percutaneous access
+*******Allows direct visualization of the UPJ and assurance of a properly situated, full-thickness endopyelotomy incision
+*****'''<span style="color:#ff0000">Percutaneous endopyelotomy</span>'''
+******'''<span style="color:#ff0000">Advantage</span>'''
+*******'''<span style="color:#ff0000">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/]
@@ Line 94: / Line 131: @@
 ****'''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'''
+***'''Postoperative care'''
-*****Avoidance of strenuous activity for 8-10 days after the procedure
+****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'''
+****'''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'''
+****'''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
+*****Studies indicate that even at 36 months some late failures are identified, but relatively few are identified at 60 months
-****'''Complications'''
+***'''Adverse events'''
-*****'''Early'''
+****'''Early'''
-*****#'''Bleeding requiring transfusion'''
+****#'''Bleeding requiring transfusion'''
-*****#'''Urinary leak'''
+****#'''Urinary leak'''
-*****#'''Drainage-related complications'''
+****#'''Drainage-related complications'''
-*****#'''Hydropneumothorax'''
+****#'''Hydropneumothorax'''
-*****#*'''Risk is increased if upper pole access is used'''
+****#*'''Risk is increased if upper pole access is used'''
-*****'''Late'''
+****'''Late'''
-*****#'''Recurrent obstruction'''
+****#'''Recurrent obstruction'''
-*****#*Options if percutaneous endopyelotomy fails:
+****#*Options if percutaneous endopyelotomy fails:
-*****#*#Retrograde endopyelotomy
+****#*#Retrograde endopyelotomy
-*****#*#Repeat percutaneous endopyelotomy
+****#*#Repeat percutaneous endopyelotomy
-*****#*#Laparoscopic, robotic, or open operative intervention
+****#*#Laparoscopic, robotic, or open operative intervention
 ====Pyeloplasty====
 *'''<span style="color:#ff0000">Principles of UPJ anastomosis (5):</span>'''
@@ Line 123: / Line 160: @@
 *#'''Uncorrected coagulopathy'''
 *#'''Cardiopulmonary compromise unsuitable for surgery'''
-*'''Before definitive surgical management, drainage of a kidney with UPJO is recommended only for infection associated with the obstruction or renal dysfunction resulting from obstruction in a solitary kidney or bilateral disease [suggesting no stent in renal dysfunction from single side obstruction if contralateral kidney fine]'''
 *'''Technique'''
+**'''Before definitive surgical management, drainage of a kidney with UPJO is recommended only for infection associated with the obstruction or renal dysfunction resulting from obstruction in a solitary kidney or bilateral disease [suggesting no stent in renal dysfunction from single side obstruction if contralateral kidney fine]'''
 **'''Approaches: transperitoneal, retroperitoneal, or anterior extraperitoneal'''
 ***'''Transperitoneal laparoscopic approach is the most widely used method''' due to its associated large working space and familiar anatomy.
@@ Line 146: / Line 183: @@
 *****'''The Foley Y-V-plasty is designed for repair of a UPJ obstruction secondary to a high ureteral insertion.'''
 *****Flap procedures are not appropriate in the setting of crossing vessels and when reduction of redundant renal pelvis is desired
-**'''<span style="color:#ff0000">The provision of external drainage from the site of surgical repair is absolutely necessary</span>'''
+***'''<span style="color:#ff0000">The provision of external drainage from the site of surgical repair is absolutely necessary</span>'''
-***'''Helps reduce risk of urinoma formation leading to possible disruption of the suture line, scarring, or sepsis'''
+****'''Helps reduce risk of urinoma formation leading to possible disruption of the suture line, scarring, or sepsis'''
 **'''<span style="color:#ff0000">Post-operative care</span>'''
 ***'''<span style="color:#ff0000">The Foley catheter is usually removed 24 to 36 hours postoperatively, and the surgical drain is removed before hospital discharge if the drain output remains negligible.</span>'''
@@ Line 153: / Line 190: @@
 ***'''<span style="color:#ff0000">Ureteral stent is typically removed 4-6 weeks later in an outpatient setting</span>'''
 ***'''<span style="color:#ff0000">Follow-up including the use of imaging studies such as diuretic renal scan is performed</span>'''
-**'''Complications'''
+**'''Adverse events'''
 ***'''Late'''
 ****'''Persistent urinary drainage'''