Failed pyeloplasty presents unique challenges due to the delicate blood supply of the ureter and scarring that may complicate attempts at repeat intervention.¹ The failure of a pyeloplasty can present as persistent flank pain, sequelae of obstruction such as recurrent pyelonephritis or nephrolithiasis, or a decline in split renal function.¹ These persistent symptoms warrant further evaluation with imaging and may require intervention for resolution.

Preoperative Evaluation and Preparation

Pyeloplasty failure requires a thorough evaluation as to the cause of failure and potential ureteral pathology involved: the length and location, narrowed or obliterated, extrinsic vs intrinsic cause should be documented. We recommend 3-phase CT or MRI of the abdomen and pelvis with arterial and urographic phases. Nuclear renal scans may be helpful to confirm adequate renal parenchyma to justify repair and confirm evidence of an obstruction. If needed, antegrade and retrograde pyelography through a nephrostomy tube or ureteroscopy, respectively, should be performed prior to or intraoperatively for confirmation of obstruction and to confirm no other strictures are present more distally. Indications for secondary repair include evidence of obstruction on imaging and/or symptoms consistent with renal obstruction with diagnostic confirmation of ureteropelvic junction (UPJ) stricture. Prior to the procedure, we recommend removal of ureteral stents 1 to 6 weeks to allow for ureteral rest, which has been documented to improve the success rate of the procedure.² If stent removal cannot be tolerated, a nephrostomy tube can be placed. A urine culture should be collected and appropriate antibiotics given prior to stent removal.

Role of Robotic Surgery in Failed Pyeloplasty

The advent of robotic surgery has significantly influenced the approach to failed pyeloplasty. Robotic-assisted salvage pyeloplasty has emerged as the potential gold standard option for cases where primary pyeloplasty has failed. The benefits of the robotic approach include improved dexterity, precision, and visualization, enhancing outcomes in complex cases with challenging anatomy like dense adhesions or altered tissue planes from previous surgeries. Studies have shown success rates ranging from 88% to 97% with salvage pyeloplasty,¹ and that it has comparable if not improved success rates to open, laparoscopic, and endoscopic techniques with the benefit of shorter hospital stays, less pain, and less blood loss.³

In addition, indocyanine green can be used intraoperatively to correctly identify strictures. This is helpful in patients with prior failed pyeloplasty and altered anatomy in the presence of scarring and fibrosis from prior interventions.^2,4

Single-port (SP) robotic pyeloplasty is emerging as a viable alternative to multiport (MP) robotic pyeloplasty. A study comparing perioperative and postoperative outcomes of the initial experience with SP to MP robotic pyeloplasty found that SP robotic pyeloplasty has longer median operative times but achieves comparable perioperative and postoperative outcomes to MP robotic pyeloplasty.⁵ Despite its limitations, SP robotic pyeloplasty is a safe and acceptable alternative to MP robotic pyeloplasty. Notably, with the SP robot, salvage pyeloplasty can be performed through a transperitoneal incision or retroperitoneal approach. The supine anterior retroperitoneal access technique (incision approximately at McBurney’s point)⁶ has recently gained favor with SP surgeons due to the ease with which this approach provides access to the renal hilum, avoidance of peritoneal adhesions from previous abdominal surgery, and improved cosmesis.

Salvage Options for Failed Pyeloplasty

Pyeloplasty techniques that can be used include dismembered pyeloplasty, renal pelvis flap, or spiral flap reconstruction. Dismembered pyeloplasty would be appropriate for obliterated strictures and UPJ strictures without distal extension of scar tissue into the proximal ureter. For UPJ strictures of significant length and extension into the proximal ureter, a renal pelvis flap or spiral flap may be considered if the renal pelvis is not scarred. For strictures than cannot be bridged with native urothelium buccal mucosal graft ureteroplasty should be considered.⁷ Buccal mucosa graft ureteroplasty and buccal mucosa augmented ureteroplasty have shown excellent outcomes for patients with recurrent proximal strictures and prior failed treatment. One potential advantage of buccal mucosa ureteroplasty is minimizing the needed dissection and risk of devascularization.⁸

In some cases where pyeloplasty is not feasible or has repeatedly failed, ileal ureter replacement or autotransplantation can be considered.^1,7 These options are less commonly employed due to increased morbidity but can be beneficial in certain scenarios.

While endopyelotomy is also a minimally invasive alternative used for managing UPJ obstruction as a primary and salvage treatment, secondary endopyelotomy has fallen out of favor due to its higher failure rate.^1,9 There is a role for endopyelotomy for the patient who has undergone multiple failed pyeloplasties and is reluctant to undergo further reconstructive surgery.

Conclusion

In the modern era of robotic and minimally invasive surgery, the management of failed pyeloplasty requires a tailored approach. Robotic-assisted salvage pyeloplasty with either the MP or SP robot stands out as a highly effective option, delivering success rates comparable to primary pyeloplasty. Secondary endopyelotomy serves as a less invasive, quicker alternative, requiring careful patient selection. As the field advances, further studies and technological innovations will likely enhance these success rates and expand treatment options.