Surveys reveal shift in treatment of UPJ obstruction


Mumbai, India—Since the introduction of percutaneous endopyelotomy in the mid 1980s, the treatment of adult ureteropelvic junction obstruction has undergone a tremendous change. In addition, with the increasing use of laparoscopy to treat urologic diseases, various endoscopic and laparoscopic techniques now offer success rates comparable to those of the traditional open surgery while minimizing patient morbidity.

Results of two independent surveys show how these trends have affected clinical practice in the United States and abroad, with laparoscopic pyeloplasty emerging as a standard of care at academic centers. Demonstration of a crossing vessel remains an important factor in determining the course of management of UPJ obstruction, according to the surveys, both of which were presented at the World Congress on Endourology.

Open pyeloplasty was the procedure of choice among more than three-fourths (77.6%) of community urologists, whereas academic urologists tended to prefer laparoscopic pyeloplasty (66.9%).

In academic centers, laparoscopic pyeloplasty is currently the preferred surgical treatment option for most patients with UPJ obstruction, but it is still in its early stages among urologists in community practice, the Cedars-Sinai survey found. Laparoscopic pyeloplasty was routinely offered by 88% of academic urologists and 47% of private-practice urologists in the United States, compared with 74% of both academic and private-practice urologists practicing outside the United States. Open pyeloplasty is still performed by a significant number of community urologists.

"Fellowship training in endourology, involvement in resident teaching, and the number of cases of UPJ obstruction encountered in one's practice correlated with the overall likelihood of offering laparoscopic surgery as a potential treatment option," said Christopher S. Ng, MD, an endourologist at Cedars-Sinai Medical Center, working with Gerhard J. Fuchs, MD, and colleagues. "Interestingly, of the respondents who did not do an endourology fellowship, 46% of U.S. and 70% of non-U.S. urologists offered laparoscopic pyeloplasty."

Compared with both private urologists and those who practice abroad, academic urologists in the United States were more likely to offer laparoscopic pyeloplasty as the preferred treatment in the setting of crossing vessels and severe hydronephrosis, the Cedars-Sinai group found. However, for UPJ obstruction with mild hydronephrosis and no crossing vessels, endopyelotomy was the preferred urologic intervention among all subsets of respondents.

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