title: Percutaneous endopyeloplasty: a novel technique.
abstract: OBJECTIVE
  Despite a 10% to 15% failure rate, endopyelotomy remains the treatment of choice for most patients with ureteropelvic junction (UPJ) obstruction. We present a novel technique of percutaneous endopyeloplasty, wherein a precise, full-thickness approximation of a standard longitudinal endopyelotomy incision is performed in a horizontal Heineke-Mikulicz fashion through the conventional solitary percutaneous tract via a nephroscope. We assess the feasibility and efficacy of percutaneous endopyeloplasty in a chronic porcine bilateral UPJ obstruction model and compare outcome data with those#10; of conventional endopyelotomy and laparoscopic pyeloplasty.
  
  
  METHODS
  Partial UPJ obstruction was created in 20 kidneys (11 pigs) by laparoscopic ligation of the upper ureter over a 5F ureteral catheter. After development of hydronephrosis over a period of 4 to 6 weeks, percutaneous endopyeloplasty (N = 10), conventional percutaneous endopyelotomy (N = 5), or laparoscopic pyeloplasty (N = 5) was performed. The essential steps of percutaneous endopyeloplasty include retrograde ureteral catheterization, standard percutaneous endopyelotomy incision, mobilization of the distal ureteral lip, horizontal suturing of the endopyelotomy incision through the nephroscope, and nephrostomy drainage and ureteral stenting. Suturing was performed using a modified 5-mm laparoscopic device (Sew Right 5 SR; LSI Solutions, Rochester, NY), which was passed through the nephroscope.
  
  
  RESULTS
  Percutaneous endopyeloplasty was technically successful in all 10 kidneys with a mean total operative time of 81.4 minutes (range 51-117 minutes). The mean endopyeloplasty suturing time was 29.4 minutes (range 20-64 minutes). Three kidneys required two sutures, while seven kidneys required three sutures to complete the endopyeloplasty. The solitary complication was a lower-pole infundibular stenosis. Over a mean follow-up of 7.7 weeks, all renal units showed relief of obstruction, as evidenced by regression of hydronephrosis,#10; improvement in T(1/2) and glomerular filtration rate on renogram, and a low intrapelvic pressure on Whitaker test. At autopsy, the endopyeloplasty site showed a fine, well-healed transverse scar with no evidence of residual suture on the mucosal surface. The mean caliber of the UPJ following endopyeloplasty (13.8F +/- 2.2F) was significantly greater (P = 0.01) than that following endopyelotomy (7.5F +/- 1.9F). Intraoperative extravasation on completion of endopyeloplasty was absent (N = 6) or mild (N = 4) compared with that seen in all five kidneys following endopyelotomy.
  
  
  CONCLUSIONS
  Percutaneous endopyeloplasty is feasible, simple, reproducible, and effective. Its advantages over conventional endopyelotomy include transrenal performance of a Fenger-plasty, wider caliber of the UPJ, absence of extravasation, and shorter duration of ureteral stenting.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Eduardo F
authors.initials: EF
authors.lastname: Carvalhal
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Kevin
authors.initials: K
authors.lastname: Banks
authors.forename: Rajeeva
authors.initials: R
authors.lastname: Raju
authors.forename: Shanker S
authors.initials: SS
authors.lastname: Raja
authors.forename: Anoop M
authors.initials: AM
authors.lastname: Meraney
authors.forename: Gyung Tak
authors.initials: GT
authors.lastname: Sung
authors.forename: Jude
authors.initials: J
authors.lastname: Sauer
mesh_terms: D000818:Animals; D005240:Feasibility Studies; D005260:Female; D006869:Hydronephrosis / Q000601:surgery*; D007682:Kidney Pelvis / Q000473:pathology / Q000601:surgery*; D020706:Laparoscopes; D010535:Laparoscopy / Q000379:methods*; D023421:Models, Animal; D015203:Reproducibility of Results; D015607:Stents; D013536:Suture Techniques / Q000295:instrumentation; D013552:Swine; D016896:Treatment Outcome; D014513:Ureter / Q000473:pathology / Q000601:surgery*; D014517:Ureteral Obstruction / Q000601:surgery*; D014546:Urinary Catheterization / Q000379:methods; D013520:Urologic Surgical Procedures / Q000379:methods*; D014945:Wound Healing