Endopyelotomy

Endopyelotomy Surgery

Endopyelotomy is minimally invasive surgery that is applied to cure an obstruction (or blockage) of the ureteropelvic junction (UPJO) - the point where the kidney joins the ureter.

This method is in contrast to open or laparoscopic pyeloplasty, in which the obstruction is cut externally.

What Is Endopyelotomy?

Endopyelotomy is a form of endoscopic surgery in order to enlarge the constricted UPJ and enhance drainage of the urine.

It can be performed through:

Retrograde (through ureter) Approach

• A beta-scope is made through the urethra bladder- ureter- UPJ.

Antegrade Approach (through kidney)

• The kidney is punctured on the back and the UPJ is accessed via the renal pelvis.
• It is a decision of the anatomy, severity and preference of the surgeon.

Endopyelotomy Indications

The surgery is indicated in case of:

• The main UPJ obstruction in the chosen patients.
• Previous upjo cases that had failed (redo UPJO cases)
• Short strictures (<2 cm)
• Lack of diabolical crossing ships.
• In cases where the kidney functioning is sufficient (>20 -25%).
• Patients who are not fit to undergo major surgery.

Benefits of Endopyelotomy

• Minimally invasive
• No large incisions
• Shorter operative time
• Shorter hospital stay
• Faster recovery
• May be employed in the cases of non-pyeloplasty.

Endopyelotomy surgery procedure

Endopyelotomy is a least invasive endoscopic surgery to treat ureteropelvic junction obstruction (UPJO) by incising the constricted segment intraoperatively and re-establishing the flow of urine out of the kidney into the ureter.

The procedure may be done using retrograde (through ureter) or antegrade (through kidney) method.

Preoperative Preparation

• Ultrasound, CT urogram, diuretic renogram assessment of the patient.
• Urine culture and blood tests.
• Fasting for 6–8 hours
• Prophylactic antibiotics
• Regional or general anaesthesia is administered.

Positioning

• In the case of retrograde endopyelotomy: lithotomy position.
• In the case of antegrade endopyelotomy: prone or supine and supported on the flank.

Access to the Urinary Tract

Retrograde Approach (through ureter):

• To examine the bladder a cystoscope is slipped into the urethra to the bladder.
• A guidewire is inserted into the ureter and as far as in the renal pelvis.
• The ureteroscope is pushed after the guidewire to the UPJ.

Antegrade Approach (through kidney):

• In a small puncture (percutaneous access), the flank is percuted.
• A nephroscope is placed in the renal pelvis.
• The kidney visualization of the UPJ is seen.

Determination of the UPJ Stricture

• The hindered, constricted channel is seen.
• Fluoroscopy, also known as contrast imaging, is frequently employed.
• The surgeon identifies the precise place of blockage.
• Efforts are made not to cross sail as there may be.

Stricture (Endopyelotomy) Incision

An incision is made completely through the narrowed UPJ with one of the tools following:

Cold Knife Endopyelotomy

• The stricture is cut with a small cutting blade.

Electrocautery Endopyelotomy

• The tight segment is burnt open using an electrocautery electrode.

Laser Endopyelotomy (Holmium: YAG)

• The scar tissue is precise cutting with a laser fiber.
• It is the most widespread and popular method in the modern world.

The incision is made as a rule:

• On the atera-medial wall of the UPJ.
• To the full thickness until periureteral fat is in sight.
• It will guarantee that the obstruction is widened properly.

Balloon Dilatation (Optional)

• In most instances, a high pressure balloon is blown up in the point of incision to further open the UPJ.

Placing Stents (Critical Process)

A Double-J (DJ) stent is placed to:

• Hold the newly opened UPJ open.
• Allow proper healing
• Prevent re-stricture
• The stent remains for 4–6 weeks.

Completion of Procedure

• Endoscope is removed
• Kidney drainage is checked
• Patient transferred to recover area.

Hospital Stay

• Usually 1–2 days
• Pain is minimal
• There is the administration of IV fluids and antibiotics.

Postoperative Care

• A course of oral antibiotics in a few days.
• Pain medicines
• Avoid heavy lifting
• Hydration encouraged
• Symptoms of stents can appear (frequency, urgency, aching in the flank)

Stent Removal

• Performed following 4-6 weeks with a flexible cystoscope.
• Typically outpatient surgery.

Follow-up

• Ultrasound 4 -6 weeks post-stent removal
• 3-month diuretic renogram to ensure improved drainage.
• Monitoring upon recurrence.

Endopyelotomy success rate

Endopyelotomy rates of success rely on patient selection, stricture features and presence of cross vessels.

Overall Success Rate

• 60-80 percent in cases of correctly chosen patients.
• It is less than laparoscopic or robotic pyeloplasty (with 90-95 percent success).

Success Rate by Patient Categories

UPJ Obstruction (first-time surgery)

• 70–80% success

Best results occur when:

• The stricture is short (<2 cm)
• No important crossing ships.
• Kidney function is >25%
• Hydronephrosis is not severe.

Secondary / Redo UPJO (following failed pyeloplasty)

• 40–60% success

Lower success because:

• Scar tissue is thicker
• Longer strictures
• Often distorted anatomy

Poor Candidates

Success rate decreases to <40% if:

• Severe hydronephrosis
• Crossing vessels present
• Stricture >2 cm
• Kidney function <20%
• Pyeloplasty is highly desirable in such situations.

Endopyelotomy complications

Endopyelotomy is a relatively safe procedure, and like any other operation, it may result in complications. These can be short term, short term or long term.

Bleeding

• Minimal amounts are prevalent and tend to be self-restrictive.
• There can also be a major bleeding, and this is particularly possible in cases of an antegrade technique in which a puncture in the kidney is made.
• In extreme situations, embolization or intervention might be necessary.

Infection / Fever / UTI

• As a result of UTI manipulation of the urinary tract.
• Normally managed through antibiotics.
• Infrequently can cause urosepsis and admission to the hospital is necessary.

Urinary Leakage

• Peripheral leakage of the incision in the UPJ.
• The DJ stent normally stops and controls it.

Stent-Related Symptoms

More usual with the Double-J stent, as:

• Urinary frequency
• Burning sensation
• Flank pain
• Blood in urine
• Urgency
• These are resolved following the removal of stents.

Chronic Surgery Obstruction (Failure of Surgery)

Among the most critical complications:

• It happens in 20-40 percent of patients based on anatomy.
• May needs repeat endopyelotomy/pyeloplasty.

Ureteral Injury

• Perforation may result through over-incision or deep cuts.
• Uncommon, but can be in need of repair or temporary drainage.

Stricture Recurrence

• Reduction in returns as a result of a scar.

More common in:

• Long strictures
• Crossing vessels patients.
• Severe hydronephrosis

Perirenal Hematoma

• Around kidney (particularly in antegrade approach) blood collection.
• Often resolves on its own
• Rarely needs drainage

Urine or Contrast Extravasation

• Outside leakage of the collecting system.
• The stent normally controls them.
• Very seldom needs to be intervened in.

Pain or Discomfort

• Mild flank pain is common
• Typically treated using painkillers.
• Recurrent pain may be a sign of stent irritation or failure of obstruction.

Rare Complications

• Stent migration
• Hypersensitivity to contrast.
• Damage to tissues around the injury.
• Development of false passage during instrumentation.

Endopyelotomy recovery time

Endopyelotomy recovery has been noted to be fast, as the surgery is typically minimally invasive and internal with no significant cuttings.

Hospital Stay

• 1–2 days
• The patients are discharged the day after observation and hydration.

Return to Daily Activities

• 3–5 days
• There is permission of light activities.
• The first thing is not to tax oneself with heavy work and hard exercise.

Full Physical Recovery

• 2–3 weeks

By this time:

• Pain has reduced
• Urine flow improves
• Routine lifestyle is normal

Stent Duration

A Double-J (DJ) stent is inserted during the operation and retained:

• 4–6 weeks

Patients may feel:

• Urgency
• Frequency
• Mild flank discomfort
• Burning during urination
• These conditions get better upon removal of the stent.

Stent Removal

• Performed 4-6 weeks after a cystoscope.
• Quick, outpatient procedure
• No major downtime

Follow-Up Tests

To measure the success of an operation:

Ultrasound

• At 4–6 weeks after stent removal

Diuretic Renogram (DTPA/MAG3 scan)

• At 3 months
• Verifies the enhancement of drainage and kidney functioning.

At What Stage to Start Heavy Activity?

• 4–6 weeks after surgery
• (This is a prerequisite on comfort and doctor recommendation.)

When to Resume Work?

• Desk job: 3–5 days
• Physical labour: 2–4 weeks

When Symptoms Improve?

• Improvement of pain and stent discomfort occurs in 1- 2 weeks.
• The urinary flow gradually becomes better in weeks or months.

Conclusion

Endopyelotomy is a less invasive, safe surgery, with limited indications to be used in patients who have ureteropelvic junction obstruction (UPJO). It is fast healing, short hospitalization, and it does not involve any significant cuts. But it is most successful in short and simple strictures not crossing blood vessels and in patients with well-functioning kidneys. Although effective in most instances, endopyelotomy had low long-term success rates as compared to laparoscopic or robotic pyeloplasty which is the gold standard. The correct choice of the patient, exact surgical procedure and follow-up of the patient are very important in making the best results.

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FAQ

1. Is endopyelotomy painful?

• It is generally painless as a result of anaesthesia. There is slight discomfort that can be caused by the stent although it can be dealt with through medication.

2. What happens if an endopyelotomy fails?

• Repeat endopyelotomy or further definitive laparoscopic/robotic pyeloplasty can be performed on the patient in cases of persistent/recurrent obstruction.

3. Does endopyelotomy offer greater advantages over pyeloplasty?

• Not always.

The success rate of pyeloplasty is greater (90-95) and is the gold standard. The selected patients that require a fast and less invasive surgery are better served with endopyelotomy.

4. Should I undergo post-surgery follow-up tests?

• Yes. Ultrasound at 4 -6 weeks and a diuretic renogram at approximately 3 months to ensure there has been improved drainage.