Salvage laparoscopic pyeloplasty in the worst case scenario: After both failed open repair and endoscopic salvage

Background and Purpose: Historically, open pyeloplasty has been the gold-standard treatment for primary ureteropelvic junction (UPJ) obstruction, with success rates > 90 %. Over the past decade, laparoscopic pyeloplasty has emerged as a highly successful alternative for primary UPJ and secondary obstruction. For patients failing open pyeloplasty, endoscopic procedures such as antegrade and retrograde endopyelotomy have been used as salvage therapies with success rates as high as 87.5 %. Persistent obstruction after an initial open pyeloplasty and a subsequent unsuccessful salvage endoscopic procedure presents a difficult scenario, often necessitating complex and challenging repairs. We reviewed our experience with salvage laparoscopic pyeloplasty as a reconstructive option for this difficult group of patients. Patients and Methods: Between January 2002 and April 2005, 66 laparoscopic pyeloplasties were performed. Four patients, who had persistent obstruction after both open pyeloplasty and subsequent salvage endoscopic procedures, were the subject of this analysis. Operative time, length of stay (LOS), pain score resolution, and physiologic success rates were evaluated. Success was defined as resolution of obstruction on physiologic testing (renal scan). Results: The mean operative time was 310 minutes and the mean LOS 1.2 days. Three patients experienced resolution of obstruction by nuclear scan. The remaining patient, who has persistent obstruction but stable function on nuclear scan and resolution of pain, has refused evaluation with Whitaker testing. All patients have experienced at least 50% reduction of pain. Utilizing our strict physiologic criteria for success, including a diuretic T-1/2 of < 10 minutes, a success rate of 75% was obtained. Conclusion: Our series of laparoscopic reconstructions of the UPJ in patients failing both an initial open pyeloplasty and subsequent salvage endoscopic procedures is the largest in the literature at present. As in open surgery, the ability to respond to intraoperative findings with techniques such as flap repair and renal mobilization are essential. Although time consuming, these repairs can be successful and maintain the advantages of laparoscopy.