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Medical Instructor, University of Missouri-Columbia School of Medicine

Roles of outward potassium currents in the action potentials of guinea pig ureteral myocytes allergy help buy loratadine 10 mg. Actions of dibutyryl cyclic adenosine monophosphate allergy shots maintenance cheap loratadine, papaverine allergy testing san francisco buy loratadine 10 mg lowest price, and isoprenaline on intestinal smooth muscle allergy testing columbia sc buy cheap loratadine. Age-dependent alterations in betaadrenergic receptor function in guinea-pig ureter. The predictive accuracy of antegrade pressure flow studies in equivocal upper tract obstruction. Identification of G binding sites in the third intracellular loop of the M3-muscarinic receptor and their role in receptor regulation. The expression of Cajal cells at the obstruction site of congenital pelviureteric junction obstruction and quantitative image analysis. Role of angiotensin in the congenital anomalies of the kidney and urinary tract in the moose and the human. The comparison and efficacy of 3 different 1-adrenergic blockers for distal ureteral stones. Renin-angiotensin system in ureteric bud branching morphogenesis: implications for kidney disease. Effects of intrinsic prostaglandins on the spontaneous contractile and electrical activity of the proximal renal pelvis of the guinea pig. The influence of calcium on the electrical and mechanical activity of the guinea pig ureter. Effects by silodosin on the partially obstructed rat ureter in vivo and on human and rat isolated ureters. Developmental changes in the biochemical and functional properties of endothelin receptors in rabbit renal pelvis. Pharmacological characterization of -adrenoceptor subtypes mediating relaxation in porcine isolated ureteral smooth muscle. Abnormal innervation and altered nerve growth factor messenger ribonucleic acid expression in ureteropelvic junction obstruction. Resistance of a separated form of canine ureteral phosphodiesterase activity to inhibition by xanthines and papaverine. The purpose of this chapter is not to turn urologists into nephrologists, but rather to provide a firm fundamental knowledge of renal physiology and pathophysiology to provide the foundation for urologic-specific conditions and therapies. In normal circumstances, the pressure within the Bowman space is essentially zero, and only in conditions of urinary obstruction does the pressure increase to clinically significant levels. It may, however, lead to increased filtration of larger molecules not normally filtered, such as albumin. Under normal circumstances, plasma proteins are not filtered across the glomerular membrane and so oncotic pressure within the Bowman space is essentially zero. Blood enters the kidney through the renal arteries and divides into progressively smaller arteries (interlobar, arcuate, and interlobular arteries) until it enters the glomerular capillary through the afferent arteriole. A portion of the plasma that enters the glomerulus is filtered across the glomerular membrane; this is called the filtration fraction. The rest of the blood exits the glomerular capillary through the efferent arteriole. In nephrons located in the renal cortex, these capillaries travel in close proximity to the tubules and modulate solute and water reabsorption. In juxtamedullary nephrons (located deeper in the medulla), the efferent arterioles branch out to form vasa recta, which participate in the countercurrent mechanism through which urine is highly concentrated and body water conserved (see later discussion). Flow to the outer cortex is two to three times greater than that to the inner cortex, which in turn is two to four times greater than that to the medulla (Dworkin and Brenner, 2004). This is accomplished through the processes of autoregulation and tubuloglomerular feedback. Through the passive ultrafiltration of plasma across the glomerular membrane, the kidney is able to regulate total body salt and water content, to regulate electrolyte composition, and to eliminate waste products of protein metabolism. The process of filtration is analogous to fluid movement across any capillary wall, and is governed by Starling forces. These clearances are also very accurate, but are again limited in clinical use by their cost and availability (Perrone et al, 1990). The rate of production varies from individual to individual, but for a single individual, daily variability is less than 10%. Although creatinine production is constant within an individual from day to day, there is marked variation in production rates between individuals. The absolute rate depends on muscle mass, which in turn is influenced by age, sex, and body mass. It can, however, be estimated by a variety of methods, some more accurate (but usually more cumbersome) than others. Urea production and excretion are highly variable, influenced, for instance, by dehydration, high-protein diets, and increased tissue breakdown. It has a constant rate of production unaffected by diet, and clearance is not influenced by tubular functions (Filler et al, 2005). It has the advantage of being very simple, but it is not as accurate as other methods when renal function is impaired.

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Although symptomatic urolithiasis may be an uncommon complication of pregnancy allergy shots make you sick buy loratadine 10mg with mastercard, renal colic during pregnancy is a serious concern because such an event may be dangerous to both the mother and the fetus allergy forecast rockford il generic 10 mg loratadine with amex. Swartz and associates (2007) analyzed the hospital discharge data from 1987 through 2003 in the state of Washington and found that women admitted for nephrolithiasis had a significantly greater (adjusted odds ratio 1 allergy medicine 24 hour discount loratadine online mastercard. Horrigan and associates (1996) reported that renal resistive index remains unchanged from the nonpregnant state throughout the course of pregnancy and also is unaffected by the physiologic hydronephrosis of pregnancy allergy forecast erie pa buy generic loratadine 10mg online, which suggests that this imaging modality may be useful in detecting acute obstruction in this population. Shokeir and associates (2000) evaluated pregnant women in a manner similar to their initial study and found that resistive index had a sensitivity of 45% and a specificity of 91% in detecting an obstructing ureteral calculus; change in resistive index had a sensitivity of 95% and a specificity of 100%. If an obstructing calculus cannot be visualized by conventional renal sonography, transvaginal ultrasonography can provide imaging of the distal ureter. White and associates (2013) performed a multicenter longitudinal study of imaging modalities to detect stone in pregnant women (White et al, 2013). Importantly, they found that 14% of women undergoing intervention for a radiographically detected stone ultimately were found to harbor no such stone. If the clinician determines that ultrasound evaluation is inadequate, other imaging studies may be considered. Stothers and Lee (1992) were able to visualize calculi in 16 of 17 pregnant patients with a three-film study, obtaining scout, 30-second, and 20-minute films. Nuclear renography is a technique that can provide a functional assessment of pregnant patients with suspected ureteral obstruction while exposing them to a limited amount of radiation. However, the radioisotope is excreted in the urine, and the bladder reservoir can provide a significant source of radiation exposure to the fetus, necessitating high fluid intake and frequent voiding for these patients (Biyani and Joyce, 2002). This radiographic technique unfortunately does not provide good anatomic detail or visualization of calculi. The visualization of smaller stones with this technique is difficult (Hattery and King, 1995; Roy et al, 1995). Stothers and Lee (1992) reported that 28% of pregnant patients ultimately diagnosed with an obstructing stone were initially, and incorrectly, diagnosed with appendicitis, diverticulitis, or placental abruption. Hematuria can occasionally occur in the normal course of pregnancy; however, hematuria without discomfort is unusual in a patient with stone disease (Swanson et al, 1995). Other symptoms that may indicate urolithiasis include irritative voiding symptoms, chills, nausea, and vomiting. However, these symptoms also may occur with other intra-abdominal conditions so the urologist must maintain a high index of suspicion when examining these patients. An important factor in the radiographic evaluation of pregnant patients with stone disease is the risk for ionizing radiation exposure to the fetus. The principal effects of irradiation on the fetus include teratogenesis, carcinogenesis, and mutagenesis. However, the risk associated with radiation depends critically on the gestational age and the amount of radiation delivered (Biyani and Joyce, 2002). During the first trimester, the period of early organogenesis and rapid cell division, the embryo is sensitive to the effects of radiation (Swartz and Reichling, 1978). Although the fetus has diminished sensitivity to the teratogenic effects of radiation in the second and third trimesters, such exposure may increase the risk for development of childhood malignant neoplasia (Harvey et al, 1985). Because the radiation dose below which no deleterious effects on the fetus may occur has not been defined with certainty, it may be presumed that exposure to any level of radiation will carry some degree of risk. For this reason ultrasonography has become the standard initial study in evaluation of the pregnant patient thought to be experiencing renal colic. Unfortunately, it can be difficult to adequately visualize the ureter with ultrasound examination as well as to distinguish dilation of the ureter that may be associated with a normal pregnancy from ureteral obstruction because of calculus. Stothers and Lee (1992) reported that renal ultrasonography for the detection of calculi had a sensitivity of 34% and a specificity of 86%. Butler and associates (2000) similarly reported that ultrasonography diagnosed 60% of 35 women who were later proved to have nephrolithiasis. Several techniques have been recommended to improve the diagnostic capability of this technology. Color Doppler imaging allows the sonographer to differentiate the iliac artery and vein from the dilated ureter. MacNeily and associates (1991) reported that the use of this technique can distinguish a dilated infrailiac ureter, which was strongly correlated with ureteral obstruction. Color Doppler imaging also can demonstrate jets of urine expelled from the ureter into the bladder. Deyoe and associates (1995) reported that if there are no ureteral jets on the suspected side of obstruction, ureteral obstruction can be diagnosed with a sensitivity of 100% and a specificity of 91%. However, Burke and Washowich (1998) reported that there is variation in ureteral jet symmetry in later pregnancy and recommended the use of this technique with caution. Magneticresonanceurogramfromapregnantwoman with right renal colic, demonstrating a right ureteropelvic junction stoneasafillingdefectinthebright,T2-weightedurinarycollecting system. Treatment Of pregnant patients with symptomatic calculi, 50% to 80% will pass their stones spontaneously when treated conservatively with hydration and analgesia (Denstedt and Razvi, 1992; Stothers and Lee, 1992; Gorton and Whitfield, 1997; Parulkar et al, 1998). Intervention is required in approximately one third of patients, usually for pain uncontrolled by analgesia or signs of persistent obstruction and infection. When treatment is selected, it should be recognized that there is some controversy regarding the most appropriate method of intervention. Some have maintained that ureteral stents are the optimal treatment of such patients. Although ureteral stents do effectively drain an obstructed collecting system, they are by no means the perfect solution to this problem. The changes in urinary chemistry that occur during pregnancy, in particular the hypercalciuria and hyperuricosuria, have been implicated in the accelerated encrustation of ureteral stents that is encountered in this population.

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Intratubular hydrostatic pressure in testis and epididymis before and after vasectomy allergy symptoms to yellow dye discount loratadine 10mg amex. The case for conservative surgical management of the ilioinguinal region after inadequate orchiectomy allergy symptoms yogurt purchase 10 mg loratadine mastercard. Preliminary report of a comparative study of vasectomy with and without prophylactic antibiotic allergy treatment worms buy loratadine in united states online. A population based assessment of complications following outpatient hydrocelectomy and spermatocelectomy allergy shots 3 year old purchase loratadine 10 mg without a prescription. Clinical and consumer trial performance of a sensitive immunodiagnostic home test that qualitatively detects low concentrations of sperm following vasectomy. The clinical implications of procedural deviations during orchiectomy for nonseminomatous testis cancer. Microsurgical denervation of the spermatic cord: a surgical alternative in the treatment of chronic orchialgia. Metronidazole is still the drug of choice for the treatment of anaerobic infections. Local infiltration and spermatic cord block for inguinal, scrotal and testicular surgery. Proliferative activity of benign human prostate, prostatic adenocarcinoma and seminal vesicle evaluated by thymidine labeling. Robot-assisted excision of seminal vesicle cyst associated with ipsilateral renal agenesis. Sutureless vasectomy, an improved technique; 1300 cases performed without failure. Laparoscopic excision of seminal vesicle cyst revealed by obstruction urinary symptoms. Management of incidental impalpable intratesticular masses < or = 5 mm in diameter. Vasectomy reversal for the postvasectomy pain syndrome: a clinical and histological evaluation. Normal human ejaculatory duct anatomy: a study of cadaveric and surgical specimens. Multiple nodules of the scrotum: histopathological findings and surgical procedure. Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Anesthetic infiltration of the spermatic cord in surgery for voluminous hydrocele. A technique for atraumatic scrotal pouch orchiopexy in the management of testicular torsion. Long-term results of wide surgical excision in 106 patients with hidradenitis suppurativa. Prostate cancer and vasectomy: a hospital-based case-control study in China, Nepal and the Republic of Korea. The role of transrectal ultrasonography in the diagnosis and management of prostatic and seminal vesicle cysts. A comparative study of the no scalpel and standard incision approaches to vasectomy in 5 countries. Endoscopic extraperitoneal radical prostatectomy: initial experience after 70 procedures. Microsurgical denervation of the spermatic cord for chronic orchialgia: long-term results from a single center. Seminoma of testis masquerading as orchitis in an adult with paraplegia: proposed measures to avoid delay in diagnosing testicular tumours in spinal cord injury patients. Transvesical seminal vesiculotomy in treatment of congenital obstruction of seminal vesicles: case report. Sperm-related antigens, antibodies, and circulating immune complexes in sera of recently vasectomized men. The post-vasectomy length of the testicular vasal remnant: a predictor of surgical outcome in microscopic vasectomy reversal. American Urological Association best practice policy statement on urologic surgery antimicrobial prophylaxis. Evaluating the risk of epididymal injury during hydrocelectomy and spermatocelectomy. To make it more interesting for urologists, we provide clinical, radiologic, surgical, and endoscopic correlations. Of course, the human body never ceases to amaze explorers with its variations from the "normal. However, the surgeon is still advised to be cautious of the minute anomalies not appreciated on perioperative imaging studies. The kidneys lie on the psoas muscles; thus the longitudinal axes of the kidneys are oblique (arrows. Therefore, during percutaneous renal access, it should be noted that the lower pole of the kidney lies laterally and anteriorly relative to the upper pole. In addition, the medial aspect of each kidney is rotated anteriorly at an angle of approximately 30 degrees. The exact position of the kidney within the retroperitoneum varies during different phases of respiration, body position, and presence of anatomic anomalies. For example, the kidneys move inferiorly approximately 3 cm (one vertebral body) during inspiration and during changing body position from supine to the erect position. Because of the inferior displacement of the right kidney by the liver, the right kidney sits 1 to 2 cm lower than the left kidney.

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In all cases the incision is made from the ureteral lumen out to periureteral fat in a full-thickness fashion allergy forecast for san antonio purchase loratadine australia. Proximally and distally allergy forecast westchester ny purchase loratadine american express, the endoureterotomy should encompass 2 to 3 mm of normal ureteral tissue allergy medicine 18 months 10mg loratadine. In certain instances the stricture must be balloon dilated to gain access across the stricture allergy symptoms versus sinus symptoms purchase loratadine pills in toronto. Similarly, the strictures may be balloon dilated after endoincision, to enlarge the incision. Once the endoureterotomy incision is complete, the remaining guidewire is used to pass an internal stent. In general, the largerdiameter stents should be considered because larger stents (8 to 12 Fr) have been associated with improved results (Hwang et al, 1996; Wolf et al, 1997). Similarly, Wolf and colleagues (1997) found benefit in the injection of triamcinolone ureteroscopically after endoureterotomy. Steroids and other biologic response modifiers may eventually have a role in the future in managing select strictures. A, Preoperative excretory urogram showing proximal ureteral stricture after ureteralinjury. There is early evidence that strictures related to stone impaction and prior stone treatment may have lower success rates (56% in one series) than typical benign strictures (Gdor et al, 2008a). Of note, as ureteroscopy and laser lithotripsy continue to grow, more strictures involving impacted stones may be encountered, and this may become a growing clinical problem. The familiarity of ureteroscopy, coupled with relative availability of the holmium laser, makes retrograde laser endoureterotomy an attractive initial management strategy for ureteral strictures less than 2 cm in length. Meretyk and Razdan both reported poor results using the retrograde approach in patients with strictures longer than 2 cm (Meretyk et al, 1992; Razdan et al, 2005). When direct visual ureteroscopic access to the strictured area cannot be accomplished in a retrograde fashion, an antegrade approach may be used. Nephrostomy tube drainage is instituted, and any associated infection or compromised renal function is allowed to resolve before definitive incision. The percutaneous tract is dilated to a size large enough to allow a working sheath through which a flexible ureteroscope is passed. A safety wire should be in place at all times alongside the ureteroscope, across the obstructed area and coiled distally in the bladder. Rarely, a ureteral stricture is associated with an area of complete ureteral obliteration across which a wire cannot be passed to allow subsequent balloon dilation or ureteroscopic endoureterotomy. In such cases a combined retrograde and antegrade approach has been described (Cardella et al, 1985; Conlin et al, 1996; Beaghler et al, 1997; Knowles et al, 2001). The obstructed area is defined radiographically with a simultaneous antegrade and retrograde pyelogram. Endoscopes are passed simultaneously in both a retrograde and an antegrade manner, and the two opposing ureteral ends are localized under fluoroscopic guidance. A working guidewire is then passed from one end of the ureter, through and through to the other lumen, using a combination of fluoroscopic and direct visual control. For completely obliterated ureteral segments, this is most easily accomplished using the stiff end of a guidewire passed through a semirigid ureteroscope via the retrograde approach, although when a semirigid ureteroscope cannot be placed, a flexible ureteroscope or even an open-end ureteral catheter can be used to stabilize the wire from above or below. The ureteral segments are aligned as closely as possible under endoscopic and fluoroscopic guidance, and the light source to one of the ureteroscopes is turned off. The light from the opposite ureteroscope is then used to aid incisional restoration of urinary continuity. The strictured area is then recannulated using the stiff end of a guidewire, a small electrocautery electrode, or holmium laser. Once through-and-through control is obtained with a guidewire, a stent is passed and left in place for 8 to 10 weeks. As with other endourologic approaches to ureteral strictures, success rates are inversely related to the length of the strictured area. Although success rates may be uncertain, internalization of urinary flow, even when dependent on long-term stent placement, can be a quality-of-life advantage for certain high-risk patients. Bach and colleagues reported a retrograde blind (fluoroscopically guided) endoureterotomy with a 61% success rate in patients with subtotal ureteral strictures (Bach et al, 2008). It is critical to assess the renal unit for function before starting treatment because endourologic therapies typically require 25% function of the ipsilateral moiety. Innovations in stents and stent techniques have led to long-term success in select patients with malignant ureteral obstruction. Contraindications to this approach include active infection or a stricture longer than 2 cm. In contrast, upper ureteral strictures are incised laterally or posterolaterally, away from the great vessels. SurgicalRepair Before any surgical repair, it is essential to conduct careful evaluation of the nature, location, and length of the ureteral stricture. Preoperative assessment typically includes an intravenous pyelogram (or antegrade nephrostogram) and a retrograde pyelogram if indicated, because the location and length of the stricture heavily influence the options for repair. Other studies such as a nuclear medicine renogram to assess renal function and ureteroscopy, ureteral barbotage, and/or brushing to rule out carcinoma should be individualized. On the basis of such information, the appropriate surgical procedure can then be planned for the patient (Table 49-2). Ureteroureterostomy A short defect involving the upper ureter or mid-ureter, either in the form of stricture or as a consequence of recent injury, is most appropriate for ureteroureterostomy. On the other hand, a lower ureteral stricture is usually best managed by ureteroneocystostomy with or without a psoas hitch or Boari flap. In the transplant setting, a donor ureteral stricture may be managed by a ureteroureterostomy to a healthy, native ureter. Because tension on the anastomosis almost always leads to stricture formation, only short defects should be managed by end-to-end ureteroureterostomy.

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Renal pelvic pressure ranging up to 12 to 15 cm H2O during this infusion suggests a nonobstructed system allergy medicine gastritis 10mg loratadine amex. In contrast allergy medicine and alcohol generic loratadine 10 mg without a prescription, pressures in excess of 15 to 22 cm H2O are highly suggestive of a functional obstruction allergy medicine itchy skin discount loratadine 10mg on-line. Although pressure perfusion studies can often provide valuable information regarding the functional significance of an apparent obstruction allergy forecast berkeley buy generic loratadine 10mg online, these studies can at times be inaccurate. This inaccuracy may be a result of variations in renal pelvic anatomy and compliance (Koff et al, 1986) or positional variations (Ellis et al, 1995). The urologist must collate the clinical presentation and results of all diagnostic studies performed to identify the best clinical intervention. The primary goal of intervention is relief of symptoms and preservation or improvement of renal function. Traditionally, such intervention should be a reconstructive procedure aimed at restoring nonobstructed urinary flow. This is especially true for neonates, infants, or children in whom early repair is desirable because these patients will have the best chance for improvement in renal function after relief of obstruction (Bejjani and Belman, 1982; Roth and Gonzales, 1983; Wolpert et al, 1989). However, timing of the repair in neonates remains controversial (DiSandro and Kogan, 1998; Koff, 1998; Hanna, 2000; Koff, 2000; Shokeir and Nijman, 2000), mostly because of difficulty in defining those kidneys truly at risk for functional obstruction. B, Follow-up study reveals normal renal drainage after robotic pyeloplasty with spontaneous drainage before furosemideadministration. Occasionally, if the patient is asymptomatic and the physiologic significance of the obstruction seems indeterminate, careful observation with serial follow-up renal scans is appropriate. When intervention is indicated, the procedure of choice has historically been dismembered pyeloplasty; however, less invasive endourologic approaches have a role as an alternative (Brannen et al, 1988; Motola et al, 1993a; Kletscher et al, 1995; Cohen et al, 1996; Nadler et al, 1996; Thomas et al, 1996; Tawfiek et al, 1998; Lechevallier et al, 1999; Gerber and Kim, 2000; Nakada, 2000; Conlin, 2002). Moreover, laparoscopic and robotic pyeloplasty has gained acceptance as primary therapy at centers with appropriate experience (DiMarco et al, 2006; Rassweiler et al, 2007). Although success rates with most endourologic techniques have not proven to be comparable with those of pyeloplasty, it has been suggested that the success rates may be improved with careful patient selection. In an important prospective study, Van Cangh and colleagues (1994) achieved an overall success rate for endopyelotomy of 73%. However, these investigators found the presence of crossing vessels to be a major determinant of outcome (42% success rate in the setting of a crossing vessel vs. Furthermore, when endopyelotomy was applied to patients with "a high degree of obstruction," the success rate was only 60% compared with an 81% success rate for those patients with "low-grade" obstruction. When patients with both a crossing vessel and a high degree of obstruction were excluded from analysis, the success rate improved to 95%, which is comparable with that of open pyeloplasty. However, other studies have suggested a less important role for these factors with regard to their impact on a successful outcome (Gupta et al, 1997; Danuser et al, 1998; Nakada et al, 1998). Moreover, an incisional approach may be favored in patients who are poor surgical candidates or in patients poorly suited to an abdominal approach (Elabd et al, 2009). Accordingly, each patient should be advised individually on the basis of all the anatomic and functional information available preoperatively. In this setting, many patients will opt for a minimally invasive approach, even with the understanding that success rates may be lower or that secondary intervention may become necessary. Of note, the results of endourologic management after failed pyeloplasty remain excellent (Jabbour et al, 1998; Canes et al, 2008, Patel et al, 2011). Indications for nephrectomy as primary therapy include diminished function or nonfunction of the involved renal moiety and a normal contralateral kidney on the basis of radiographic and nuclear studies. Renography can provide quantitative measures of renal function, and, in general, kidneys with less than 15% differential function are nonsalvageable in adults. If the potential for salvageability of function is still unclear, an internal stent or percutaneous nephrostomy may be placed for temporary relief of obstruction and renal function studies subsequently repeated. Nephrectomy may also be considered for patients in whom the obstruction has led to extensive stone disease with chronic infection and significant loss of function in the face of a normal contralateral kidney. Removal of the kidney may also be chosen over reconstruction for patients in whom repeated attempts at repair have already failed and in whom further intervention would therefore be extremely complicated. This option should be considered only when the contralateral kidney is essentially normal. In addition, the option to reduce the size of the renal pelvis is readily available with this approach. Although formal pyeloplasty has stood the test of time with a published success rate of nearly 95%, endourologic alternatives to standard operative reconstruction are still used (Clark et al, 1987; Elabd et al, 2009). The advantages of endourologic approaches include reduced hospital stays and postoperative recovery. However, the success rate does not approach that of open, laparoscopic, or robotic pyeloplasty. Of note, Albani and colleagues (2004) reported contemporary long-term results with various endopyelotomy approaches to have a success rate of 67%, with the majority of failures in the first 32 months. More recently, DiMarco and colleagues (2006) reported long-term follow-up of more than 400 patients undergoing either percutaneous antegrade endopyelotomy or pyeloplasty. The 3-, 5-, and 10-year success rates were superior for pyeloplasty, 85% versus 63%, 80% versus 55%, and 75% versus 41%. Moreover, Rassweiler and colleagues (2007) compared retrograde laser endopyelotomy with laparoscopic retroperitoneal pyeloplasty in 256 patients in a 10-year single-surgeon experience and found success rates were 73% for laser endopyelotomy compared with 94% for pyeloplasty. Although various nuances in the technique have been described (Korth et al, 1988; Van Cangh et al, 1989; Ono et al, 1992), the basic concept of the endopyelotomy is a full-thickness lateral incision through the obstructing proximal ureter, from the ureteral lumen out to the peripelvic and periureteral fat. Recently, Vaarala and colleagues reported a small series of 64 patients who underwent either antegrade or retrograde cold knife or cautery wire balloon endopyelotomy. In this study, success rates ranged from 79% to 83%, without statistically significant differences among the three treatments (Vaarala et al, 2008). Of note, transplantation complications are particularly suited to endoscopic management, either antegrade or retrograde (Schumacher et al, 2006; Gdor et al, 2008b).

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