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Pyeloplasty

• Goal: widely patent anastomosis with watertight closure without tension
• Nephrostomy tube: only recommended if infection, severe pain, or worsening renal function (pelvic distension improves operative dissection)
• Techniques: Anderson Hynes dismembered pyeloplasty most common, but can perform Y-V, spiral flap
• Ureterocalycostomy: indicated for small intrarenal pelvis, horseshoe kidney, or salvage procedure
• Drain placement: consider to prevent urinoma formation, but do not place on suture line (creates fistula)

Endopyelotomy

• Technique: perform full-thickness lateral incision (avoids hilar vessels) into peripelvic fat, incise with laser or wire balloon
• Leave stent (tapered if possible) for ~4-6 weeks
• Pyeloplasty failure: reasonable option, no difference in outcomes even if prior pyeloplasty
• Consider antegrade access if simultaneous stone treatment required
• Contraindications: long stricture (> 2cm), active infection, coagulopathy, crossing vessel

Postoperative management

• Tube plan: usually remove foley first, confirm no increased drain output after foley removal, leave stent for 4-6 weeks
• Follow-up: repeat renal scan 1mo after stent removal, then follow up at 6mo then annually for 2-3yrs (will catch most failures)
• Imaging: renal US may show persistent hydronephrosis, renal scan is better study to confirm resolution of obstruction and check for recurrence
• Success rates: > 90% for pyeloplasty, 79-88% for endopyelotomy