2 The procedure
2.1.1 Pelviureteric junction (PUJ) obstruction occurs when the connection between the renal pelvis and the ureter is narrow or tight. When this occurs, urine passing from the kidney to the ureter can not drain easily and accumulates, causing enlargement of the renal pelvis (hydronephrosis).
2.1.2 The standard intervention for PUJ obstruction is open pyeloplasty. There are several different ways to approach the kidney to perform this operation. These include a flank incision, a subcostal incision, a transabdominal approach, or an incision in the back.
2.2.1 The purpose of the procedure is to refashion the narrowed portion of the PUJ and attach it to the ureter in a way that allows easy drainage of urine through the ureter. This procedure has the same goal as open pyeloplasty but uses the laparoscopic approach. Laparoscopy involves making three or four small incisions through which the operation is carried out. A stent may be inserted after the operation, which is later removed.
2.3.1 No randomised studies were identified. One of the non-randomised, comparative studies looking at laparoscopic pyeloplasty versus open pyeloplasty found that 41 out of 42 patients (98%) who had the laparoscopic procedure had no obstruction at follow-up, compared with 33 out of 35 patients (94%) who had the open procedure. Of the 42 patients treated laparoscopically, 26 (62%) were pain-free and 12 (29%) had a significant reduction in flank pain postoperatively. Of the 35 patients who had the open procedure, 21 (60%) were pain-free and 11 (31%) had a significant reduction in flank pain postoperatively. For more details, refer to the Sources of evidence section.
2.3.2 The Specialist Advisors expressed no concerns about the efficacy of this procedure. One Advisor, however, commented on the lack of randomised comparisons of open versus laparoscopic procedures, and a scarcity of long-term follow-up data.
2.4.1 Few complications were reported in the studies identified. In some comparative studies obstruction after stent removal, stent migration and pyelonephritis were reported as occasional complications, however these complications were reported at similar levels in patients having open surgery. For more details, refer to the Sources of evidence section.
2.4.2 One Specialist Advisor considered the risks of this procedure to be similar to those expected with conventional open surgery: infection, failure to correct obstruction and bleeding. This Advisor also noted that the usual safety issues associated with laparoscopic surgery applied, as well as the effects of a prolonged procedure, and the need to convert to open surgery.