Advances in the percutaneous management of the ureteropelvic junction and other obstructions of the urinary tract in children.

In conclusion, endopyelotomy has been developed over the past several decades on the basis of sound laboratory and clinical research. The success rates have been similar to those of the standard open pyeloplasty, and the procedure is not associated with undue complications. Endopyelotomy has several distinct advantages over open surgery, including the decreased morbidity and associated expense of an open operation, minimal interference with the blood supply of the ureter, and avoidance of removal of the ureter from its natural sheath, preventing the tendency to adhere to adjacent structures and thus kink. As the instrumentation available for percutaneous renal surgery has improved and been miniaturized, the techniques developed in adults have been progressively applied to younger and smaller children. There seems to be little doubt that a comparison of morbidity and socioeconomic factors associated with a successful endopyelotomy versus an open pyeloplasty in adults heavily favors the percutaneous procedures, and judicious application to children would seem warranted. However, the changing presentation of ureteropelvic junction obstruction in children that has resulted from the widespread use of prenatal ultrasonography may make the question moot. Open infant pyeloplasty is a highly successful procedure, accompanied by minimal morbidity and accomplished in a 2- to 3-day hospital stay. The socioeconomic factors are obviated in the infant, who already requires constant maternal care. However, endopyelotomy deserves consideration in the older child, especially if the obstruction is secondary in nature after a previous open procedure.