Lithiasis of the renal allograft, a rare urological complication following renal transplantation: a single-center experience of 2,045 renal transplantations.

BACKGROUND AND PURPOSE: Urinary lithiasis represents an unusual urologic complication in renal transplantation, with an incidence of 0.17%-1.8%.We present our experience with renal graft lithiasis in our series of renal transplantations. MATERIAL AND METHODS: We reviewed the medical records for 2045 patients who underwent kidney transplantation from January 1983 to July 2013. Among the grafts, 9 patients were found to have allograft lithiasis. In 6 cases, the calculi were localized within the renal unit, and in 3 cases in the ureter. Two of the patients had relapsed after a few years from the first treatment. In both of them the stones were localized again in the ureter. RESULTS: In our series, incidence of graft lithiasis was 0.44% (n = 9). Three of the 9 patients (33.3%) were treated via percutaneous nephrolithotripsy (PCNL), 3 (33.3%) underwent extracorporeal shockwave lithotripsy (ESWL), 2 (22.2%) passed their stones spontaneously, and 1 (11.1%) underwent PCNL after 2 failed ESWL interventions. All patients are currently stone free but still remain under close urologic surveillance. CONCLUSIONS: Urinary stone formation can lead to significant morbidity and graft loss. The treatment options should be similar to those for patients in the general population. Long-term follow-up is substantial to determine the outcome and to prevent the recurrence.

Development and validation of a prognostic model in patients with metastatic renal cell carcinoma treated with sunitinib: a European collaboration.

BACKGROUND: Accurate prediction of outcome for metastatic renal cell carcinoma (mRCC) patients receiving targeted therapy is essential. Most of the available models have been developed in patients treated with cytokines, while most of them are fairly complex, including at least five factors. We developed and externally validated a simple model for overall survival (OS) in mRCC. We also studied the recently validated International Database Consortium (IDC) model in our data sets. METHODS: The development cohort included 170 mRCC patients treated with sunitinib. The final prognostic model was selected by uni- and multivariate Cox regression analyses. Risk groups were defined by the number of risk factors and by the 25th and 75th percentiles of the model's prognostic index distribution. The model was validated using an independent data set of 266 mRCC patients (validation cohort) treated with the same agent. RESULTS: Eastern Co-operative Oncology Group (ECOG) performance status (PS), time from diagnosis of RCC and number of metastatic sites were included in the final model. Median OS of patients with 1, 2 and 3 risk factors were: 24.7, 12.8 and 5.9 months, respectively, whereas median OS was not reached for patients with 0 risk factors. Concordance (C) index for internal validation was 0.712, whereas C-index for external validation was 0.634, due to differences in survival especially in poor-risk populations between the two cohorts. Predictive performance of the model was improved after recalibration. Application of the mRCC International Database Consortium (IDC) model resulted in a C-index of 0.574 in the development and 0.576 in the validation cohorts (lower than those recently reported for this model). Predictive ability was also improved after recalibration in this analysis. Risk stratification according to IDC model showed more similar outcomes across the development and validation cohorts compared with our model. CONCLUSION: Our model provides a simple prognostic tool in mRCC patients treated with a targeted agent. It had similar performance with the IDC model, which, however, produced more consistent survival results across the development and validation cohorts. The predictive ability of both models was lower than that suggested by internal validation (our model) or recent published data (IDC model), due to differences between observed and predicted survival among intermediate and poor-risk patients. Our results highlight the importance of external validation and the need for further refinement of existing prognostic models.

The loss of the tumour-suppressor miR-145 results in the shorter disease-free survival of prostate cancer patients.

BACKGROUND: Prostate cancer (PCa) is characterised by great heterogeneity of the disease progression rate. Tumours range from insignificant and not life threatening to high risk for relapse ones. Consequently, a large number of patients undergo unnecessary treatment. miR-145 is a well-documented tumour suppressor and its expression, which is regulated by the p53 pathway, has been found to be decreased in the majority of human malignancies. The aim of our study was to evaluate the clinical utility of miR-145 for the prognostication of PCa. METHODS: Total RNA was isolated from 137 prostate tissue specimens obtained from 73 radical prostatectomy-treated PCa patients and 64 transurethral- or open prostatectomy-treated benign prostate hyperplasia (BPH) patients. Following polyadenylation and reverse transcription, miR-145 levels were determined by quantitative real-time PCR assay, using SNORD48 (RNU48) for normalisation purposes. RESULTS: Downregulated miR-145 expression was found in PCa compared with BPH patients. The reduction of miR-145 expression in PCa was correlated with higher Gleason score, advanced clinical stage, larger tumour diameter and higher prostate-specific antigen (PSA) and follow-up PSA levels. In addition, higher risk for biochemical recurrence and significantly shorter disease-free survival (DFS) was found for the PCa patients expressing lower miR-145. Focusing on 'low- and intermediate-recurrence risk' PCa patients, miR-145 loss was revealed to be a reliable predictor of biochemical relapse and poor DFS independent from Gleason score, clinical stage, PSA and patients' age. CONCLUSION: The loss of the tumour-suppressor miR-145 increases the risk for disease progression and predicts the poor survival of PCa patients.

Prospective, open-label, randomized, phase III study of two dose-dense regimens MVAC versus gemcitabine/cisplatin in patients with inoperable, metastatic or relapsed urothelial cancer: a Hellenic Cooperative Oncology Group study (HE 16/03).

BACKGROUND: The combinations of methotrexate, vinblastine, Adriamycin, cisplatin (Pharmanell, Athens, Greece) (MVAC) or gemcitabine, cisplatin (GC) represent the standard treatment of advanced urothelial cancer (UC). Dose-dense (DD)-MVAC has achieved longer progression-free survival (PFS) than the conventional MVAC. However, the role of GC intensification has not been studied. We conducted a randomized, phase III study comparing a DD-GC regimen with DD-MVAC in advanced UC. PATIENTS AND METHODS: One hundred and thirty patients were randomly assigned between DD-MVAC: 66 (M 30 mg/m(2), V 3 mg/m(2), A 30 mg/m(2), C 70 mg/m(2) q 2 weeks) and DD-GC 64 (G 2500 mg/m(2), C 70 mg/m(2) q 2 weeks). The median follow-up was 52.1 months (89 events). RESULTS: The median overall survival (OS) and PFS were 19 and 8.5 months for DD-MVAC and 18 and 7.8 months for DD-GC (P = 0.98 and 0.36, respectively). Neutropenic infections were less frequent for DD-GC than for DD-MVAC (0% versus 8%). More patients on DD-GC received at least six cycles of treatment (85% versus 63%, P = 0.011) and the discontinuation rate was lower for DD-GC (3% versus 13%). CONCLUSIONS: Although DD-GC was not superior to DD-MVAC, it was better tolerated. DD-GC could be considered as a reasonable therapeutic option for further study in this patient population. Clinical Trial Number ACTRN12610000845033, www.anzctr.org.au.

Low-grade fibromyxoid sarcoma of the renal pelvis: first report.

Sarcomas of the genitourinary tract are quite rare, accounting for 2.1% of all soft tissue sarcomas and have a poor prognosis. Kidney sarcomas are quite rare, representing 1-3% of malignant renal cases. Low-grade fibromyxoid sarcoma (LGFS) of the kidney is an exceedingly uncommon, indolent but metastasizing soft tissue sarcoma with deceptively benign-appearing histological features. The estimated 5-year overall survival seems to be over 90%, but very late local relapses and distant metastasis may occur, which underlines the need for a long-term follow-up. We present a case of a 48-year-old male patient with a LGFS located on the renal pelvis. This is probably the first report of LGFS arising from the renal pelvis.

Urological complications: analysis and management of 1525 consecutive renal transplantations.

Urological complications after renal transplantation increase morbidity, delay graft function, and occasionally lead to graft and/or patient loss. The aim of this study was to analyze the causes of and therapeutic approaches to urological complications in renal transplantation as they related to patient outcomes. A series of 1525 consecutive renal transplantations were performed over a 24-year period. Renal grafts were obtained in 814 cases from living-related and in 711 from cadaveric donors. A Lich-Gregoire ureterovesical reimplantation technique with minimal bladder wall dissection was employed in all cases. Ureteral stents were routinely used in cadaveric transplants and exceptionally among living-related grafts. Urological complications were classified according to the mechanism and site of urinary tract involvement: graft ureteropelvic junction obstruction/stenosis (A), ureteral obstruction/stenosis (B), ureterovesical anastomosis obstruction/stenosis (C), urinary leakage (D), and other (E). Overall, we encountered 96 urological complications (6.3%). Group C complications occurred in 29 cases (30.2%), followed by 27 cases (28.1%) for group B patients, 25 cases (26.0%) for group D, 12 cases (12.5%) for group A, and 3 cases (3.1%) for group E patients. Surgical intervention was required in 49 (51.0%) of all urological complications. The others (n = 47, 49.0%) were treated either conservatively or by minimally invasive procedures. A rapid diagnosis of urological complications, assisted by early posttransplant DTPA scans, routine ultrasonography, and especially prompt treatment, resulted in compensation of renal graft dysfunction in the vast majority (n = 90, 93.8%) of cases. Surgical techniques of graft retrieval and reimplantation are of utmost importance to minimize the incidence of urological complications.

Levobupivacaine intravesical injection for superficial bladder tumor resection--possible, effective, and durable. Preliminary clinical data.

BACKGROUND: General and spinal anesthesia are currently in widespread use during transurethral bladder tumor resection. However, local anesthetic methods are claimed to provide sufficient intra-operative analgesia and satisfactory post-operative pain management. We evaluated whether local levobupivacaine infiltration of the tumor would result in outcomes, in terms of intra-operative analgesia, similar to those for utilization of general anesthesia. Post-operative analgesia and patient satisfaction were also assessed. PATIENTS AND METHODS: Twenty patients with recurrent solitary bladder tumors were randomly allocated in two groups. Group A, underwent tumor resection under general anesthesia and group B was treated with resection after local levobupivacaine infiltration. Post-operative analgesia was evaluated with utilization of a visual analogue scale, ranging from 0 to 10, with higher scores indicating more intense pain perception. RESULTS: Group A patients demonstrated significantly lower visual analogue scale scores at t=0, which peaked at 4 h post-operatively. Group B scores were higher at t=0, declined over a 2 h interval and reached zero after t=4 h. Patients younger than 60 years and women benefitted more. Local anaesthesia was the method of pain control preferred by 90% of patients. CONCLUSION: Local levobupivacaine infiltration for transurethral bladder tumor resection seems feasible, providing intra and post-operative pain control. In this preliminary setting, general anesthesia provided a higher level of pain control in the immediate post-operative period (<4 h) while local levobupivacaine infiltration demonstrated excellent late post-operative analgesia (>4 h). Also, patients seem to prefer local to general anesthesia in future surgery.

Cyclooxygenase-2 protein expression in relation to apoptotic potential and its prognostic significance in bladder urothelial carcinoma.

BACKGROUND: Cyclooxygenase-2 (COX-2), a critical enzyme in the conversion of arachidonic acid to prostaglandin E2, influences the biological behavior of human tumors, being involved in carcinogenesis, tumor progression, reduced apoptosis and differentiation. The aim of the present study was to investigate the role of COX-2 protein expression in urothelial carcinoma (UC) of the urinary bladder in relation to clinicopathological data and indices of apoptotic potential. MATERIALS AND METHODS: Immunohistochemistry was applied to 134 paraffin-embedded specimens of UC for the detection of COX-2, p53, bcl-2, caspase-3, bax protein, MLH1 and hTERT. RESULTS: Ninety-four UCs (70.1%) had an enhanced expression of COX-2. The COX-2 semi-quantitative expression was unrelated to tumor grade and local invasion, but it was positively linked with caspase-3 (CPP32) and bax protein semi-quantitative immunoreactivity (p = 0.007 and p = 0.026), as well as with the quantitative expression of MLH1 (p = 0.019). COX-2 was also found to be inversely correlated with the nuclear localization of the catalyst component of the telomerase complex, hTERT (p = 0.009). Multivariate statistical analysis showed that COX-2 immunopositivity was independently associated with worse prognosis of patients with non muscle-invasive UCs (p = 0.002). CONCLUSION: COX-2 overexpression, being possibly a subsequence of apoptosis activation, is associated with an unfavorable overall survival of patients with pTa-T1 UCs.

Methotrexate-paclitaxel-epirubicin-carboplatin (M-TEC) combination chemotherapy in patients with advanced bladder cancer: an open label phase II study.

The present phase II study aimed to define the application of a novel regimen incorporating methotrexate, paclitaxel, epirubicin, and carboplatin (M-TEC) in advanced bladder cancer, essentially as an M-VAC-like regimen, by substitution of cisplatin by carboplatin, doxorubicin by epirubicin and vinblastine by paclitaxel. Forty patients with advanced bladder cancer entered the study; 34 males/6 females, median age: 68 (range, 59-76), median PS (Karnovsky): 80, without receiving prior chemotherapy. Disease extention was as follows; 11/40 had local recurrence, 6/40 liver metastases, 14/40 lung metastases, bone and lymph node 8/40, bones-lymph node-lung metastases 4, lymph node and liver 4/40, lymph node-liver and lung metastases 2/40. Drug schedule and doses were as follows: paclitaxel 180 mg/m2, carboplatin AUC = 5 (according to creatinine clearance, based on Calvert's formula), and epirubicin 40 mg/m2 were administered during day 1, whereas methotrexate 30 mg/m2 and epirubicin 40 mg/m2 were administered on day 14. All patients were evaluable for response with 24/40 responding [response rate (RR) 60%]; 10/40 (25%) CR, 14/40 (35%) PR, 9/40 (22.5%) SD, and 7/40 (17.5%) PD. Symptomatic improvement was observed in 50% of patients. The median duration of response was 22 (14-32) weeks, median time-to-progression (TTP) 33 (12-44) weeks, and median survival was 56 (20-84) weeks. Toxicity was well accepted and was mainly neutropenia > grade 3: 17%, anemia >grade 3: 16%, thrombocytopenia > grade 2: 6%, nausea & vomiting mainly > grade 2: 31%, according to the administered chemotherapy cycles, whereas fatigue grade 2-3: 19%, neurotoxicity grade 1-2 13% of patients, and alopecia grade 2 was observed in all patients. The present pilot study indicates the feasibility of the M-TEC combination for bladder cancer with acceptable toxicity.

Prolonged ureteral stenting in obstruction after renal transplantation: long-term results.

BACKGROUND: Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most frequent urologic complication. We report our long-term follow-up results concerning endourologic treatment of ureteral obstruction after renal transplantation. METHODS: Between May 1997 and September 2000, 15 patients with renal transplant obstructive uropathy were managed with percutaneous nephrostomy and prolonged ureteral stenting. RESULTS: Percutaneous nephrostomies were performed successfully in all 15 kidneys. In 13 patients, antegrade ureteral stenting was attempted, which was successful in 11 patients (85%). After prolonged ureteral stenting (mean duration 15 months), the stent was removed in all patients, 90% of whom had no recurrence. During follow-up (36 to 71 months; mean 51), urea, creatinine, sodium, and potassium determinations and ultrasound scans were performed. Success was defined as a reduction in hydronephrosis. No major complications were observed. CONCLUSIONS: Modern endourologic procedures have replaced open reconstructive surgery in most patients with ureteral obstruction after renal transplantation, because they may offer a definitive treatment with low morbidity.

Obstructive uropathy in the transplanted kidney: definitive management with percutaneous nephrostomy and prolonged ureteral stenting.

BACKGROUND AND PURPOSE: Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most frequent urologic complication. We report our experience with percutaneous nephrostomy and antegrade ureteral stenting, which may offer a primary and definitive alternative to open surgery. PATIENTS AND METHODS: Fifteen patients with renal allograft obstructive uropathy were managed with percutaneous nephrostomy and prolonged ureteral stenting. RESULTS: Percutaneous nephrostomies were successfully performed in all 15 kidneys: In 13 patients, antegrade ureteral stenting was attempted, this being successful in 11 (85%). After prolonged ureteral stenting (mean duration 15 months), the stent was removed in eight patients, and six of them (75%) did not have recurrences. During follow-up, urea, creatinine, sodium, and potassium determinations and ultrasound scans were performed, and success was confirmed by the decline of creatinine and reduction in hydronephrosis. No major complication was observed. CONCLUSION: Percutaneous nephrostomy and ureteral stenting is a safe and effective treatment for renal allograft obstructive uropathy. Prolonged ureteral stenting may offer a definitive treatment with low morbidity.

Role of percutaneous urinary diversion in malignant and benign obstructive uropathy.

OBJECTIVES: We evaluated the feasibility and effectiveness of percutaneous urinary diversion in patients with obstructive uropathy. PATIENTS AND METHODS: A total of 206 percutaneous nephrostomies (PCNs) (right-sided in 54, left in 56, and bilateral in 48) were performed in 102 male and 57 female patients 18 to 94 years old. In 125 patients, malignancy was the underlying cause of the obstruction and in 30, benign disease. In four patients, the cause remained unknown. In most patients (N = 154), the access was guided with both ultrasound and fluoroscopy. RESULTS: Percutaneous nephrostomy was successful in 158 patients (99%). Antegrade ureteral stenting was attempted in 48 patients with a success rate of 81%. Fifteen days postprocedure, the mean urea and creatinine concentrations had declined from 160.8 mg/mL to 63 mg/mL and from 6.9 mg/dL to 2.2 mg/dL, respectively. In 66% of the patients, renal function returned to normal. In 28%, it improved with no need for hemodialysis, while in 6%, there was no improvement. Advanced age and prostate cancer were negative predictive factors for the improvement of renal function, whereas the BUN and creatinine concentrations before the procedure and performance of unilateral v bilateral nephrostomies were not. We did not have severe complications. Three patients received transfusions, and in one patient, a urinoma was drained percutaneously. Patients with malignancy had a median survival of 227 days. CONCLUSION: Percutaneous urinary diversion under radiologic guidance is a safe and effective procedure for patients with obstructive uropathy.

Immunohistochemical expression of transforming growth factor beta 1 and nm-23 H1 antioncogene in prostate cancer: divergent correlation with clinicopathological parameters.

BACKGROUND: Prostate cancer is one of the main causes of morbidity and mortality among men. Several oncogenes and growth factors have been studied in an attempt to explain the molecular basis of carcinogenesis and progress of this carcinoma. In this study we correlated the immunohistochemical expression of antioncogene nm-23 H1 and transforming growth factor beta 1 (TGF-beta 1) with the clinical stage, PSA values, Gleason score and survival in prostate cancer. MATERIALS AND METHODS: Fifty nine patients with prostate cancer were evaluated. PSA measurement, Gleason score determination and clinical staging were recorded for all the patients by the time of initial diagnosis and prior to any treatment. Follow-up ranged from 12 to 40 months. Tissue sections from representative areas of the tumors were immunohistochemically stained for nm-23 H1 and TGF-beta 1. The expression of these markers was correlated with stage, PSA values, Gleason score and survival. RESULTS: There was a negative correlation between nm-23 H1 staining and tumor stage and grade. High grade (Gleason score 8-10) and stage D tumors showed weaker staining than low stage and grade tumors. There was a positive correlation between TGF-beta 1 staining, tumor stage and serum PSA levels. Additionally, TGF-beta 1 proved to be a negative predicting factor for patient survival. In tumors expressing both markers, TGF-beta 1 was the one to determine the aggressiveness of the carcinoma. CONCLUSIONS: nm-23 H1 appears to be a tumor suppressor gene in prostate cancer, while TGF-beta 1 may act as a stimulating agent provoking aggressive behavior and metastasis. Their immunohistochemical staining may constitute complementary information in the evaluation of prostate cancer patients.

Acute ureteral elongation in two animal models using a balloon expander.

BACKGROUND AND OBJECTIVE: Repair of ureteral injuries and strictures often necessitates a major reconstructive procedure such as a psoas hitch, Boari flap, renal mobilization, ileal interposition, or autotransplantation. Tissue expanders have been used to elongate nerves and arteries. We examined the effects of acute ureteral elongation in two animal models. MATERIALS AND METHODS: In eight female rabbits, we exposed the left ureter through a midline incision and placed a Ruiz-Cohen balloon beneath the undermined portion. The expander was then inflated until the ureter was tightly stretched across it. After deflation, the expanded segment was measured in situ and compared with its original length. Follow-up urography was performed, and the tissue was harvested and examined by a pathologist. The same procedure was performed in five pigs; however, in these animals, a segment of ureter was excised, and a ureteroureterostomy was performed, after the acute expansion. RESULTS: We were able to achieve acute elongation of the expanded ureteral segment. The mean elongation was 31.3% in the rabbits and 32.0% in the pigs. An intravenous urogram (IVU) 6 weeks after the elongation showed a functioning kidney and a patent ureter. Histologic examination of the ureter within 24 hours after the expansion revealed that all segments were viable, the luminal epithelium was intact, and the muscular layers appeared normal. At 6 weeks, the expanded segment showed mild inflammatory changes, but the overall morphology, size, and cytology findings were similar to those of a normal control. CONCLUSIONS: Acute ureteral elongation using a tissue expander is a new method of increasing ureteral length. It may be useful to cover defects that would need major operations with greater morbidity.

Escherichia coli promotes macrophage apoptosis.

BACKGROUND: Escherichia coli is the bacterium most commonly isolated from the urine of patients with urinary tract infection (UTI). Recurrent episodes of UTI lead to renal interstitial scarring. In interstitial fibrosis and scarring, infiltration of mononuclear cells has been reported to play a key role. MATERIALS AND METHODS: We evaluated the effect of two strains of E. coli--the pathogenic BH-5 and the plasmidless, nonfimbriated HB-101-on human monocyte and murine macrophage apoptosis. RESULTS: E. coli BH-5 enhanced apoptosis in a time- and dose-dependent manner. It also promoted necrosis in a time- and dose-dependent manner. Strain HB-101 promoted monocyte apoptosis in a dose-dependent manner. However, the magnitude of HB-101-induced monocyte apoptosis was lower than BH-5-induced macrophage apoptosis. CONCLUSION: The ability of E. coli to induce apoptosis may contribute to its virulence and play a role in renal interstitial scarring.

Percutaneous removal of stone from caliceal diverticulum in patient with nephroptosis.

A novel method is introduced for percutaneous stone extraction from a lower pole caliceal diverticulum in a patient with nephroptosis, also known as a floating kidney. The patient was fully recovered and asymptomatic at 2 months postoperatively with her kidney fixed in the flank position.

Necrosis of the urethra and tissue sloughing: a delayed complication after transurethral microwave thermotherapy.

Transurethral microwave thermotherapy is a minimally invasive treatment for benign prostatic hyperplasia designed to destroy hyperplastic tissue without damaging the urethra. We present an unexpected complication of prostatic urethral necrosis and tissue sloughing after thermotherapy and discuss its possible cause.

The in vitro bactericidal effect of microwave energy on bacteria that cause prostatitis.

OBJECTIVES: We investigated the in vitro nonthermal effects of microwaves delivered from Prostatron 2.0 on Escherichia coli and Enterobacter cloacae. METHODS: The fingers of powder-free, sterile gloves were ligated, and bacterial solutions were transferred into the remaining area of the glove. The gloves were then sealed using silk ligatures. One set of gloves was subjected to the microwave treatment while another set was placed in a temperature-matched waterbath to act as control samples. The gloves containing the treatment group were taped around the probe, at the site where microwave energy exits the probe. During the treatment period, the temperatures from the urethral probe and the rectal probe were carefully monitored. RESULTS: The mean (+/-SD) energy delivered was 46.6 +/- 9.5 kJ (range 30.0 to 59.5) for the 10 trials on E. coli and colony counts in the experimental microwaved gloves decreased significantly compared with control samples (5.26 +/- 4.5 x 10(5) versus 10.16 +/- 9.3 x 10(5) CFU/mL, P = 0.02). For the experiments on E. cloacae the mean (+/-SD) energy applied was 38.5 +/- 12.5 kJ, and a significant decrease in colony counts of microwaved samples was also observed compared with controls (11.04 +/- 4.8 x 10(5) versus 20.08 +/- 10.1 x 10(5) CFU/mL, P = 0.004). CONCLUSIONS: Microwave energy, delivered from Prostatron 2.0, independent of heat production has an in vitro bactericidal effect on laboratory-cultured E. coli and E. cloacae.

Endopyelotomy after failed pyeloplasty: the long-term results.

PURPOSE: Endopyelotomy has been proposed as a technique to treat ureteropelvic junction obstruction after failed open pyeloplasty. However, to our knowledge no long-term results of this treatment have been reported. We report the long-term followup of a cohort of patients in whom pyeloplasty failed and who subsequently were treated with endopyelotomy. MATERIALS AND METHODS: From January 1985 to February 1996, 72 patients in whom open surgical pyeloplasty failed were treated with percutaneous endopyelotomy. Mean patient age was 35 years (range 5 to 82). The interval between pyeloplasty and subsequent failure ranged from 2 months to 30 years (mean 57 months). The major presenting symptoms were pain in 82% of cases, fever and urinary tract infections in 37.5%, stone formation in 25% and gross hematuria in 21%. RESULTS: Antegrade endopyelotomy using a hooked knife was performed in all patients with no unusual difficulty and minimal complications. A total of 63 patients (87.5%) had long lasting clinical and radiographic treatment success after a mean followup of 88.5 months. Of the 9 endopyelotomy failures (12.5%) 7 (77.8%) were detected immediately after stent removal at 6 weeks, 1 (11.1%) at 6 months and 1 (11.1%) at 10 months postoperatively (mean failure interval 3.3 months). The failures were corrected with repeat endopyelotomy in 1 patient, pyeloplasty in 3, ileal interposition in 1 and nephrectomy in 4. CONCLUSIONS: Endopyelotomy is the treatment of choice for recurrent ureteropelvic junction obstruction after failed pyeloplasty, with a high and sustained long-term success rate and no reported new failures after 1-year followup. Furthermore, endopyelotomy is technically easier with less morbidity than repeat open pyeloplasty.