The operative management of recurrent ureteropelvic junction obstruction

Purpose: Surgical repair of ureteropelvic junction obstruction is successful in 98% of cases. We evaluated children undergoing repeat pyeloplasty and discuss the etiology of recurrent ureteropelvic junction obstruction, surgical approach and outcome. Materials and Methods: Between 1982 and 1996, 366 children with ureteropelvic junction obstruction were surgically treated at our institution, including 16 who presented with recurrent ureteropelvic junction obstruction and required surgery. Results: Repeat repair was successful in all 16 patients, including ureterocalicostomy in 3 and dismembered pyeloplasty in the remainder. No nephrectomy was necessary. Anteriorly elongated flank incisions were made in all cases. Dense scar tissue around and obstructing the ureteropelvic junction was noted in the majority of cases. In 7 patients a redundant pelvis resulted in a kink at the ureteropelvic junction. A nephrostomy tube was placed in all cases and an additional transanastomotic stent was used in all but 2. Obstruction was relieved with 1 operation. Conclusions: A redundant pelvis resulting in a kink at the ureteropelvic junction may contribute to a higher chance of urinary leakage and subsequent obstructive scar formation in cases of failed pyeloplasty. Before repeat surgery anatomy should be precisely identified by antegrade and retrograde studies. The surgical approach usually involves identifying the ureter below the area of the previous surgery and then ensuring a tension-free anastomosis. If inadequate ureteral length or an intrarenal pelvis precludes direct anastomosis, ureterocalicostomy is an alternative. A nephrostomy tube and transanastomotic stent are advisable. Nephrectomy is rarely necessary and a good functional result can be anticipated.