ADULT ENDOPYELOTOMY - IMPACT OF ETIOLOGY AND ANTEGRADE VERSUS RETROGRADE APPROACH ON OUTCOME

Purpose: We evaluate our experience with endopyelotomy for ureteropelv ic junction obstruction by stratifying the results of an antegrade ver sus a retrograde approach for primary, secondary, calculi related, hig h insertion and impaired renal function related obstruction, individua lly. Materials and Methods: We retrospectively reviewed results of 149 nonrandomized patients treated for ureteropelvic junction obstruction , of whom 83 underwent antegrade percutaneous endopyelotomy using a ri ght angle Greenwald electrode and 66 underwent retrograde endopyelotom y using a cutting balloon device. Subjective results were based on an analog pain scale, objective results on renal scan, excretory urograph y or Whitaker test and cost-effectiveness analysis on total treatment cost. Results: In both primary and secondary ureteropelvic junction ob struction, retrograde endopyelotomy was related to a significantly sho rter operating room time and hospital stay (p < 0.05). When treating n oncalculous primary ureteropelvic junction obstruction (92 patients) t here was a better objective, albeit not statistically significant, suc cess rate with antegrade endopyelotomy (89 versus 71%) but retrograde endopyelotomy was 20% more cost-effective. When treating secondary ure teropelvic junction obstruction (37 patients) there was a better objec tive, albeit not statistically significant, success rate (83 versus 77 %) with retrograde endopyelotomy, which was 37% more cost-effective. C omplication rates were higher with antegrade compared to retrograde en dopyelotomy for primary and secondary ureteropelvic junction obstructi on (25 versus 14% and 26 versus 0%). In 20 patients with concomitant s tones endopyelotomy results were better (93 to 100% success) than for any other categories of ureteropelvic junction obstruction. Of note, e ndopyelotomy also provided a reasonable outcome among patients with a high insertion primary ureteropelvic junction obstruction (70% success ). Conclusions: Antegrade endopyelotomy is the preferred approach in p atients with primary ureteropelvic junction obstruction and concomitan t renal calculi (13.4% of cases), and may also be preferable in patien ts with high insertion obstruction (6.7%). For all other primary and a ll secondary ureteropelvic junction obstruction, antegrade and retrogr ade endopyelotomy is effective therapy yet retrograde endopyelotomy re sults in less operating room time, shorter hospital stay, fewer compli cations and significantly less expense to achieve the desired outcome.