Techniques

Laser endopyelotomy

Endopyelotomy is an endoscopic operation performed entirely through the urethra. A holmium laser is used to cut the narrow segment of the ureteropelvic junction from the inside and a stent is left in place while the incision heals open. Success rates are lower than reconstruction, but there is no abdominal incision.

When endopyelotomy is considered

  • A shorter narrowing at the UPJ, without a large crossing vessel in the way.
  • Patients who have had a previous reconstruction that has scarred down again.
  • Patients who want to avoid any abdominal surgery, accepting the lower success rate.
  • Patients on long-term anticoagulation where a full reconstruction is less attractive - although anticoagulation still needs careful discussion because bleeding risk is not zero.

How it is done

  1. General or spinal anaesthetic.
  2. A flexible or semi-rigid telescope is passed through the urethra, the bladder, and up the ureter to the UPJ.
  3. A holmium laser fibre is used to cut through the narrowed segment from inside the lumen, through the full thickness of the wall.
  4. A balloon is passed across the incision and inflated to open the cut area.
  5. A double-J ureteric stent is left in place for six weeks so the cut edges heal open.
  6. The stent is removed in a short day-case cystoscopy at six weeks.

What the evidence shows

A systematic review by Elmussareh, Traxer, and Somani (2018) pooled adult endopyelotomy results and reported success around 75%, with higher success for shorter segments and lower success where a crossing vessel was present. A larger comparative-effectiveness study by Jacobs and colleagues (Urology 2018) also found that patients treated with endopyelotomy were more likely to need a further procedure than those treated with pyeloplasty. Dr Kooner has presented his own endopyelotomy outcomes, which have been in line with the published literature.

Risks and considerations

  • Bleeding, particularly if a crossing vessel is present next to the UPJ. Pre-operative imaging is reviewed carefully to minimise this.
  • Stent-related symptoms (frequency, urgency, blood in urine, mild flank ache) for the six weeks the stent is in place.
  • Urinary tract infection while the stent is in place.
  • Recurrence of narrowing at the treated segment - the main reason for a lower success rate than reconstructive surgery.
  • Need for a subsequent pyeloplasty if endopyelotomy fails.

How it compares with pyeloplasty

Pyeloplasty has a higher first-attempt success rate and a lower rate of needing further procedures, and is the preferred option for most adults with confirmed UPJ obstruction. Endopyelotomy's main appeal is that it involves no abdominal incision and a short recovery. Whether that trade-off is worth the lower success depends on the individual's anatomy, goals, and previous treatments.

Alternatives

Discuss your UPJ obstruction pathway

The rooms can arrange a consultation to review imaging, confirm obstruction with a drainage study, and outline which pyeloplasty approach fits your situation.

Contact the rooms Second opinion