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Background Since its first description, multiple reports proved efficacy and safety of the robotic platform. Further progress has been made allowing for the application of robotic surgery to smaller patients, including infants. Despite the early favorable results, the use of robot surgery in infants is still controversial and more studies are needed to confirm its benefits. Objective To our knowledge, we present the largest single-institution case series of robot-assisted laparoscopic pyeloplasty (RAL-P) in infants, aiming to contribute to the current literature with a guide for key technical steps and safety tips for infant RAL-P. Design, setting, and participants We performed a retrospective review of a prospectively maintained database. The study protocol was approved by the institutional review board. Surgical procedure Only infants (≤12 mo of age) with a diagnosis of congenital ureteropelvic junction obstruction (UPJO) undergoing primary robotic dismembered pyeloplasty were included in the study. Measurements We critically reviewed the clinical outcomes, described the main steps of the operation, and shared tips for a safe approach. Results and limitations From January 2012 to August 2019, 44 infants underwent RAL-P for UPJO––33 (75%) males and 11 (25%) females. All robotic cases were completed successfully, with no laparotomic conversions. The median age and weight were 4 (1–12) mo and 6.8 (3.8–10.5) kg, respectively. The mean operative time was 142 (±25) min. The mean estimated blood loss was 7 (±3.6) ml, and no intraoperative complications occurred. The mean length of hospital stay (LOS) was 1.4 (±0.7) d. Seven (15.6%) patients had postoperative complications—one (2%) ileus (Clavien-Dindo grade [CDG] I), four (9%) urinary tract infections (CDG II), and two (4.5%) port-site hernias (CDG III). At a median follow-up of 19 mo, the success rate was 100%. Conclusions Given the successful outcomes, benefits of decreased LOS, and improved cosmesis, RAL-P is an appealing management option for UPJO in infants. Market release of new systems, further miniaturization of instruments, and more affordable costs will hopefully be shedding light on more complex applications. Patient summary Infants (≤12 mo of age) diagnosed with ureteropelvic junction obstruction undergoing primary robotic dismembered pyeloplasty were selected and included in this study. No intraoperative complications or conversion to an open approach occurred. Seven patients (16%) developed postoperative complications—one (2%) postoperative ileus, four (9%) urinary tract infections, and two (4.5%) port-site hernias. At a median follow-up of 19 (7–66) mo, the success rate was 100%.

Background: Ureteropelvic Junction Obstruction (UPJO) is the most common congenital ureteral anomaly. Nowadays, according to the increasing incidence of urolithiasis, 20% of children with UPJO presents urolithiasis. Open pyeloplasty was the standard treatment before the introduction of minimally invasive surgery (MIS). Nevertheless, only scattered experiences on MIS were previously described and universal agreement on the treatment of UPJO plus urolithiasis is still missing. Objective: The study aim was to describe our experience with a series of pediatric patients affected by UPJO and urolithiasis treated with robot-assisted pyeloplasty (RAP) and endoscopic removal of stones using a flexible cystoscope and a stones basket in a singular tertiary referral center. Material and methods: We retrospectively reviewed our data from pediatric patients affected by UPJO and urolithiasis undergoing RAP between April 2013 and December 2019. The analysis was conducted on seven patients. All procedures were performed by one expert robotic surgeon and one endoscopic surgeon skilled in the management of urolithiasis. Results: The mean age was 7 years (IQR 4–16). The median stone area was 77.7 mm two (IQR 50.2–148.4). Most of them (71.4%) presented preoperative symptoms. The median operative time was 110 min (IQR 104–125) with a console time of 90 (IQR 90–105). The median length of stay was 5 days (IQR 4–5). Median follow-up was 16 months (IQR 10–25). Conclusion: RAP with concomitant flexible ureteroscope is a safe and effective option for the simultaneous management of UPJO with urolithiasis with excellent outcomes in children.

Background Upper urinary tract urothelial cancer (UTUC) may have unique etiologic and genomic factors compared to bladder cancer. Objective To characterize the genomic landscape of UTUC and provide insights into its biology using comprehensive integrated genomic analyses. Design, setting, and participants We collected 31 untreated snap-frozen UTUC samples from two institutions and carried out whole-exome sequencing (WES) of DNA, RNA sequencing (RNAseq), and protein analysis. Outcome measurements and statistical analysis Adjusting for batch effects, consensus mutation calls from independent pipelines identified DNA mutations, gene expression clusters using unsupervised consensus hierarchical clustering (UCHC), and protein expression levels that were correlated with relevant clinical variables, The Cancer Genome Atlas, and other published data. Results and limitations WES identified mutations in FGFR3 (74.1%; 92% low-grade, 60% high-grade), KMT2D (44.4%), PIK3CA (25.9%), and TP53 (22.2%). APOBEC and CpG were the most common mutational signatures. UCHC of RNAseq data segregated samples into four molecular subtypes with the following characteristics. Cluster 1: no PIK3CA mutations, nonsmokers, high-grade FGFR3 mutations, low-grade tumors, tobacco use, noninvasive disease, no bladder recurrences. Cluster 3: 100% FGFR3 mutations, 71% PIK3CA , no TP53 mutations, five bladder recurrences, tobacco use, tumors all KMT2D (62.5%), FGFR3 (50%), TP53 (50%) mutations, no PIK3CA mutations, high-grade pT2+ disease, tobacco use, carcinoma in situ, shorter survival. We identified a novel SH3KBP1-CNTNAP5 fusion. Conclusions Mutations in UTUC occur at differing frequencies from bladder cancer, with four unique molecular and clinical subtypes. A novel SH3KBP1 fusion regulates RTK signaling. Further studies are needed to validate the described subtypes, explore their responses to therapy, and better define the novel fusion mutation. Patient summary We conducted a comprehensive study of the genetics of upper urinary tract urothelial cancer by evaluating DNA, RNA and protein expression in 31 tumors. We identified four molecular subtypes with distinct behaviors. Future studies will determine if these subtypes appear to have different responses to treatments.

Context The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. Objective To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. Evidence acquisition The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; ureteroscopy; nephroureterectomy; adjuvant treatment; instillation; recurrence; risk factors; and survival. References were weighted by a panel of experts. Evidence synthesis Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing number of retrospective articles in UTUC. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification, as well as for radical and conservative treatment; prognostic factors are also discussed. A single postoperative dose of intravesical mitomycin after radical nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumours and two functional kidneys. Conclusions These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. Patient summary Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis; appropriate diagnosis and management is most important. We present recommendations based on current evidence for optimal management.

Background Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. Objective To report a stage 2a study of robot-assisted single-site (R-LESS) pyeloplasty for ureteropelvic junction obstruction (UPJO). Design, setting, and participants This study is an investigative pilot study of 30 consecutive cases of R-LESS pyeloplasty performed at two participating institutions between July 2011 and September 2013. Surgical procedure Dismembered R-LESS pyeloplasty was performed at two surgical centers. Measurements Feasibility (conversion rate), safety (complication rate and Clavien-Dindo classification), efficacy (clinical outcome) of the procedure were assessed. Results and limitations The median patient age was 37 yr (range: 19–65 yr) and median body mass index was 23kg/m 2 (range: 19–29kg/m 2 ). The median operative time was 160min (range: 101–300min), the median postoperative stay was 5 d (range: 3–13 d), and the median time to catheter removal was 3 d (range: 2–10). Two cases required conversion, the first one to standard laparoscopic technique and the second one to standard robotic technique. No intraoperative complications were reported. In three cases, an additional 5-mm trocar was needed. The postoperative complications rate was 26% ( n =8). Most of them were grade 1 complications ( n =4; 13%), followed by grade 2 ( n =3; 10%) and grade 3 ( n =1; 3.3%) complications, according to the Clavien-Dindo classification. One patient needed a surgical reintervention with standard robotic technique 3 d after surgery for urinary leakage. The overall success rate, considered as the resolution of symptoms and the absence of functional impairment at postoperative imaging, was 93.3% ( n =28) at a median follow-up of 13 mo (range: 3–21 mo). The main limitations of this study are the limited number of patients included and the short-term follow-up. Conclusions Single-site robotic pyeloplasty is a feasible technique in selected patients, with good cosmetic results and excellent short-term clinical outcomes. Prospective studies are needed to further assess its role for the treatment of UPJO. Patient summary Single-site robot-assisted pyeloplasty is a feasible technique with good cosmetic results and excellent short-term clinical outcomes.

Context Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized. Objective To critically analyze the current status of laparoscopic and robotic repair of UPJO. Evidence acquisition A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Evidence synthesis Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population. Conclusions Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.

BACKGROUND Prior studies examining the value of lymph node (LN) dissection (LND) in patients with urothelial carcinoma of the upper urinary tract (UTUC) have produced conflicting results. The objective of the current study was to assess the relationship between LN yield and survival among patients undergoing radical nephroureterectomy (RNU). METHODS The National Cancer Data Base was used to identify patients with non-metastatic UTUC who were treated with RNU between 2004 and 2012. The association between LN yield and overall survival (OS) was assessed using Cox proportional hazards regression, with adjustment for patient, tumor, and facility characteristics. RESULTS Of the 14,472 patients, 2926 (20%) underwent LND. The median yield was 2 LNs (interquartile range 1-6 LNs). Among the entire cohort and the LN-negative (pN0) subgroup, a higher LN yield was associated with lower all-cause mortality (multivariable hazard ratio [HR] 0.94 per 5 LNs removed, 95% confidence interval [95% CI] 0.89-1.00 [P = .034] for the entire cohort and HR 0.86, 95% CI 0.79-0.94 [P = .001] for the pN0 subgroup). Among patients with positive LNs (pN+), there was no association noted between LN yield and OS; however, positive and negative LN counts were found to be independent predictors of OS (HR 1.27 per 5 positive LNs, 95% CI 1.16-1.39 [P

Laparoscopic pyeloplasty in children remains controversial and is not included in most pediatric urology centers because of technical difficulties and lack of long-term results.To critically analyze our 10-yr experience with the retroperitoneal approach (RA), with a particular interest on the impact of the learning curve in a teaching center.Patients who underwent pyeloplasty between 1999 and 2010 at our institution were reviewed (n=390). The diagnosis of ureteropelvic junction obstruction was confirmed by ultrasound and technetium Tc 99m mercaptoacetyltriglycine-3 renal scan or magnetic resonance imaging; the same criteria were used to evaluate the outcome. The lateral RA was selected in children1 yr of age without abnormal migration or fusion of the kidney (n=104).Dismembered pyeloplasty and anastomosis were performed using running monofilament 5-0 or 6-0 absorbable suture. All were drained by double-J stent except 20 cases drained by external transanastomotic stent.We assessed intra- and postoperative morbidity and analyzed the teaching of technique and learning curve. Data are expressed as medians and interquartile range (25th, 75th percentiles) for quantitative variables.Median age was 6.2 yr (2.2-10.3). Thirty-three patients had crossing vessels. Median operative time was 185 min (160-235). Median hospital stay was 2 d (1-2). Redo pyeloplasty was needed in only two children (2%). Median follow-up was 2.1 yr (1.4-4.1). Operative time was3 h after 35 cases. After 30 cases performed by the same surgeon, standardization of the technique was feasible, which helped in the teaching process because 50% of the final 30 cases were done by trainees.Retroperitoneal dismembered laparoscopic pyeloplasty is a safe, reliable, and efficient procedure with an excellent outcome in selected children according to their indications and age, and the experience of the surgical team. Even if the transmission to trainees is successful, it is still a long learning process and remains a challenging task for a teaching center.

This study tested the technical feasibility and short-term perioperative outcomes of the novel da Vinci Single-Site Instrumentation platform for the treatment of upper ureteropelvic junction obstruction (UPJO) in a selected group of patients. Nine patients underwent robotic laparoendoscopic single-site (R-LESS) pyeloplasty using a new single-site platform for UPJO at our department of urology. All the procedures were completed without the need for traditional robotic surgery or laparoscopic/open conversion, although in one patient with congenital hepatomegaly it was necessary to use an auxiliary 3-mm trocar to retract the liver properly and expose the surgical field. Mean operative time was 166min, and no intraoperative complications were recorded. The indwelling catheter was removed on postoperative day 2 in five patients and on postoperative day 3 in four patients. Patients were discharged the day after drain removal. One patient experienced transient hyperpyrexia, treated with antibiotics. No other complications were observed. All patients had the DJ stent removed 4 wk after surgery, following a negative urine culture and abdominal ultrasound evaluation. The five patients who reached a 3-mo follow-up had a clinical resolution of preoperative symptoms and hydronephrosis at the abdominal ultrasound. The same results were maintained in the two patients with 6-mo follow-up evaluations. In selected patients, R-LESS pyeloplasty using the new single-port platform appears to be a technically feasible and reproducible surgical procedure for the minimally invasive treatment of UPJO. Prolonged follow-up and larger series are required to confirm its potential role as a valid alternative to standard robotic pyeloplasty.

It is not known whether the primary tumour location of upper urinary tract urothelial carcinoma (UUT-UC) is associated with prognosis.To evaluate the impact of initial primary tumour location on survival in patients who had undergone radical nephroureterectomy (RNU).Using a multi-institutional, retrospective database, we identified 609 patients with UUT-UC who had undergone RNU between 1995 and 2010. Tumour location was categorised as renal pelvis, ureter, or multifocal.All patients had undergone RNU.Tumour location was tested as a prognostic factor for survival through univariate and multivariable Cox regression analysis.Tumour location was renal pelvis in 317 cases (52%), ureter in 185 cases (30%), and multifocal in 107 cases (18%). Compared to renal pelvic and ureteral tumours, multifocal tumours were more likely to be associated with advanced stages (pT3/pT4; 39%, 30%, and 54%, respectively; p0.001) and high-grade disease (53%, 56%, and 76%, respectively; p0.001). On multivariable analysis, tumour location was an independent prognostic factor for cancer-specific death, disease recurrence, and metastasis (p0.05). The 5-yr cancer-specific death-free survival probability was 86.8% for renal pelvic tumours, 68.9% for ureteral tumours, and 56.8% for multifocal tumours (p0.001). The retrospective design of this study was its main limitation.Ureteral and multifocal tumours had a worse prognosis than renal pelvic tumours. These findings are not in line with recently published data and should be investigated in a prospective assessment to obtain a definitive statement regarding this matter.

Risk stratification of upper tract urothelial carcinoma (UTUC) patients and tumours is crucial for highlighting that an alternative to radical extirpative surgery now exists and should be considered for all patients who qualify as having low-risk UTUC.

Background Upper urinary tract (UUT) tumours are often a diagnostic challenge. Because of delayed diagnosis at an advanced stage, prognosis is less qualitative when compared to bladder tumours. There is, therefore, a need for reliable markers to improve diagnosis. Objective Because of the difficulty in interpreting washing cytologies of the UUT, we evaluated the reliability of fluorescence in situ hybridisation (FISH) in the detection of upper tract urothelial cancer. Design, setting, and participants A prospective, multicentre cohort study was carried out on 55 consecutive patients with a suspected UUT tumour. Measurements Between May 2007 and May 2009, 55 consecutive patients (mean age 71.7 yr; range: 52–93) with a suspected urinary tract tumour were studied with intravenous pyelography, cytology, washing cytology, ureterorenoscopy, and endoscopic biopsies. The patients were followed for a mean observation time of 12.21 mo (range: 0.5–20; standard deviation: 6.12). A multicolour-FISH approach was performed on a liquid-based washing urinary cytology in all cases. Results and limitations Twenty-one out of 55 patients had a histologically proven urothelial carcinoma, of which 10 had stage pTa disease, 6 had pT1 disease, 2 had pT2 disease, 2 had pTis disease, and 1 had pTx disease (6 G1, 6 G2, and 9 G3). Three patients had a papilloma, 2 had renal cell carcinoma, 27 had a negative histologic report, and 2 had a nondiagnostic histology. In total, 68 analyses were performed. The cytology was negative or doubtful in 60 out of a total 68 specimens (88.2%) and was suspicious or positive for malignancy in 7 (10.3%) specimens. One specimen was not diagnostic. FISH was negative in 37 of 68 analyses (54.4%) and positive in the other 30 analyses (44.1%). One FISH analysis was not diagnostic as a result of insufficient cellular material. The overall sensitivity of the cytology was 20.8% and of FISH 100%. The specificity was 97.4% for cytology and 89.5% for FISH. Even though this is the largest UUT cohort studied with FISH, the sample size is relatively small. Conclusions The UroVysion FISH test is a reliable method in the diagnosis of UUT tumours in cases with clinical suspicion but negative or doubtful cytology and no diagnostic histology.

A retrocaval ureter is a rare entity that has traditionally been treated with open pyeloplasty techniques. In this paper, we describe the successful performance of a laparoscopic dismembered pyeloplasty for a retrocaval ureter and present important technical points. In reviewing the available literature about this technique, the laparoscopic approach should be considered to be first-line treatment for this anatomic anomaly due to the good track record, quick convalescence, and relative technical ease.

Objectives To analyse the indications and long-term results of endoscopic and minimal access approaches for the treatment of ureteropelvic junction (UPJ) obstruction and to compare them to open surgery. Methods A review of the literature from 1950 to January 2007 was conducted using the Ovid Medline database. Results A lack of standardisation of techniques used to diagnose UPJ obstruction and to follow up treated patients introduces a degree of inaccuracy in interpreting the success rates of the various modalities of treatment. However, there is no indication that any one of these techniques is affected by this to a greater or lesser extent than another. Open pyeloplasty achieves very good (90–100% success) results, endopyelotomy and balloon disruption of the UPJ fail to match these results by 15–20%, and minimal access pyeloplasty produces results that are at least as good as those of open surgery but with the advantages of a minimal access approach. Conclusions Minimal access pyeloplasty is likely to gradually replace endopyelotomy and balloon disruption of the UPJ for the treatment of UPJ obstruction. The much higher cost of robotic pyeloplasty and greater availability of laparoscopic expertise in teaching centres are likely to limit the dissemination of robotic pyeloplasty.

To assess the process of renal function deterioration in patients with unilateral ureteropelvic junction (UPJ) obstruction and its impact on their treatment course.The files of patients treated for unilateral UPJ obstruction at our department from 1996 to 2003 were retrospectively reviewed. All patients were initially treated conservatively and followed up regularly. Criteria for conversion to surgical treatment were increase in anteroposterial renal pelvis diameter, increase in T(1/2) washout pattern, and drop of relative renal function (RRF) below 40% in diuretic renogram. Patients operated on because of multiple urinary infections, pelvic stones, or solitary kidneys were excluded. Patients were divided into group A, which included those whose treatment was converted from conservative to surgical, and group B in which patients were treated conservatively. All patients operated on underwent dismembered pyeloplasty.Sixty-four patients with grade three or four hydronephrosis in postnatal ultrasound examination and an obstructive pattern in diuretic renogram were studied. All group A patients (n=47) reached an RRF below 40%; in 41 (87.2%) deterioration of RRF was detected in at least two sequential follow-up studies. In group B patients (n=17), deterioration was also detected in seven (41.1%) patients in two sequential studies (p0.0005), although the RRF never dropped below 40%. No differences in gender, side of obstruction, or frequency of follow-up were detected between the two groups.RRF deterioration and its progression for at least two sequential follow-ups could serve as a predictive factor for surgical treatment.

Objectives We investigated the relation between the presence and degree of stone induced hydronephrosis and the outcome of extracorporeal shock wave lithotripsy (SWL) in patients with solitary proximal ureteral stones. Methods 130 patients with or without hydronephrosis were treated with SWL. The degree of hydronephrosis was defined by renal ultrasound. Patients were divided into four groups according to the degree of stone induced hydronephrosis. Group 0 (24%) had no urinary system dilatation, group 1 (31.2%) had a mild dilatation of the renal pelvis, group 2 (40%) had a moderate and group 3 (4.8%) a severe dilatation of the renal pelvis and calices. The stone size, number of shock waves applied and number of sessions required to achieve stone clearance were recorded. Results Mean stone size was 8.2mm±2.5mm. Mean time to stone clearance was 13.7 days±16.3. In 74.4% of patients stone clearance was observed. Additional 4.8% harbored residual fragments ≤3mm after 3 months. Differences among the four groups in terms of stone size, time to stone clearance and treatment failure were not significant. Conclusions The presence or degree of hydronephrosis caused by a proximal ureteral stone does not affect the time to stone clearance or success rate after SWL.

Objective Laparoscopic dismembered pyeloplasty has been quoted to have equivalent success rates to the traditional open procedure in the treatment of pelvi-ureteric junction obstruction (PUJO). The aim of this study was to report our experience with laparoscopic pyeloplasty. Patients and methods All patients with PUJO are entered into a database to record patient, operative and post-operative details. Over an eleven-year period, 176 procedures were performed. Eighty-three procedures were dismembered laparoscopic pyeloplasties, of which two retroperitoneal procedures were converted to open. The first 17 procedures were performed via the retroperitoneal approach and the following 66 via the transperitoneal route. Thirty-one procedures were open pyeloplasty. Results The retroperitoneal group had a mean follow up of 35 (16–66) months. Five patients (33%) developed recurrent symptoms with evidence of obstruction seen on the renogram within 4 months and required further surgery. The transperitoneal group had a mean follow up of 15 (3–38) months. Five patients were classified as failures (mean time to failure 4.6 months) resulting in a success rate of 92% for the transperitoneal route. Both groups had a mean post-operative hospital stay of 3.6 days. Open pyeloplasty at our institution has a success rate of 88% at a mean follow up of 85 months (range 3–260 months) and a mean length of post-operative stay of 6 days. Conclusion Overall our success rate following laparoscopic pyeloplasty is 88%. However, our preferred approach is transperitoneal, which is associated with a success rate of 92%. This is equivalent, if not better than that seen following open pyeloplasty with the additional benefits of reduced hospital stay and time to recovery. There are many possible explanations for this difference in success rates between approaches, however equivalent results are reported in the literature and therefore the learning curve is likely to be the major factor in this series.

Fetal renal pelvis dilatation is a frequent abnormality that has been observed in 4.5% of pregnancies. The majority of these cases have a tendency to resolve during infancy. Nevertheless, fetal renal pelvis dilatation may be due to significant structural abnormalities such as pelvi-ureteric junction stenosis or vesico-ureteral reflux that may adversely affect renal function or cause urinary infection or sepsis. This review article aims to summarize the data regarding fetal renal pelvis dilatation and to analyze controversial attitudes in the light of the various lines of practice, and to present rational antenatal and postnatal investigation strategy.

Purpose: Open dismembering pyeloplasty has high success rates but is associated with significant morbidity and moderate cosmetic results. Aim of this study was to evaluate laparoscopic dismembering pyeloplasty compared with other laparoscopic techniques and open surgery in this respect. Material and Methods: Between September 1999 and September 2002 we performed 25 laparoscopic dismembering (LDP), 15 laparoscopic non-dismembering (LNDP) and 15 open pyeloplasties (ODP) in 55 patients. For laparoscopy two 12mm and two 5mm ports were used, a ureteric stent remained in place for 4 weeks. ODP was performed via a flank incision, a percutaneous ureteric stent and a nephrostomy remained for 10 days. Postoperative morbidity was assessed by visual analogue scale (VAS). Mean follow-up was 23.4±9.1 months (range 7–42) for laparoscopy vs. 21.9±8.8 (range 9–41) months for open surgery. Success was evaluated with postoperative i.v. pyelogram or diuretic nephrography. Results: A crossing vessel could be identified in 82.5% (33/40) with laparoscopy vs. 47.0% (7/15) in ODP. Postoperative VAS score was lower in the laparoscopic group (day 1 3.5±1.6 vs. 5.4±3.1, day 5 0.9±1.2 vs. 3.1±1.8, p =0.001). Length of skin incision was 4.1±0.7 vs. 23.8±9.1 cm and hospital stay was 5.9±2.1 vs. 13.4±3.8 days for laparoscopy and ODP respectively. Success rate was 96.0% (24/25) for LDP, 73.3% (11/15) for LNDP and 93.4% (14/15) for ODP. Two patients with LNDP and one with ODP required re-operation. Clot retention was observed in two with LDP and one with ODP. Two abdominal wall herniations and one thromboembolism occurred with ODP. Conclusion: Short-term results demonstrate that dismembering laparoscopic pyeloplasty has the same success rates as open surgery but morbidity and complications are significantly decreased. Non-dismembering techniques have the least favourable results. This finding may suggest that LDP has the potential to replace open surgery as the gold standard for treatment of uretero-pelvic junction obstruction.

To compare functional outcome after pyeloplasty in two groups of patients affected by hydronephrosis, which had different modalities of diagnosis. The first, asymptomatic, detected by prenatal ultrasonography and the second referred later because of clinical symptoms.84 patients (54 prenatally detected and 30 symptomatic) among 339 observed with hydronephrosis, operated in a single centre for ureteropelvic junction obstruction, have been retrospectively studied. Seventeen cases with prenatal diagnosis had an early treatment and thirty-seven were operated on after an initial observation. Symptomatic cases were all operated on at diagnosis. Ultrasonographic and renographic assessment were made at diagnosis, before and after surgery.Renal function of prenatally detected cases was not influenced by early or delayed surgery. Insignificant functional loss was recorded among some cases operated after conservative management. Improvement in differential renal function (p0.05) was recorded in symptomatic patients after pyeloplasty. A high percentage of obstructions secondary to lower polar crossing vessel were found among symptomatic cases (12 out of 30). Intrinsic obstructions were predominant among cases with in utero diagnosis (48 out of 54). Whenever the cause of obstruction is considered, postoperative functional improvement was limited to crossing vessels cases.Renal function among antenatally diagnosed obstructions is scarcely influenced by surgery; potential risk of further renal damage cannot be excluded when expectant management is decided. Later detected, symptomatic cases show a better functional response to surgery. This seems corresponding to distinct clinical entities based on different causes of hydronephrosis. A reversible renal damage seems to be associated to extrinsic obstructions from polar vessel, which are predominant among symptomatic, later detected cases. A congenital, irreversible loss of function accompanies intrinsic obstructions, typical of prenatally diagnosed cases.

Acute flank pain is a common and complex clinical problem which might be caused by a variety of urinary and extraurinary abnormalities among which ureterolithiasis being the most frequent cause. Plain abdominal radiographs combined with intravenous urography (IVU) have been the standard imaging procedures of choice for the evaluation of acute flank pain over the last decades. Direct detection of even small ureteral calculi is achieved in 40-60%, whereas using indirect signs such as ureteral and renal pelvic dilatation stone detection is possible in up to 80-90% of all cases. However, IVU might be hampered by poor quality due to lack of bowel preparation, by nephrotoxicity of contrast agents, by serious allergic and anaphylactic reactions in 10% and 1% of the patients, respectively, and by significant radiation exposure. The use of ultrasonography (US) in the management of acute flank pain has been growing and when combining the findings of pyeloureteral dilatation, direct visualization of stones, and the absence of ureteral ejaculation, the sensitivity to detect ureteral dilatation can be as high as 96%. Recently, unenhanced helical CT (UHCT) has been introduced as imaging modality with a high sensitivity and specificity for the evaluation of acute flank pain. UHCT has been demonstrated to be superior since (1) it detects ureteral stones with a sensitivity and specificity from 98% to 100% regardless of size, location and chemical composition, (2) it identifies extraurinary causes of flank pain in about one third of all patients presenting with acute flank pain, (3) it does not need contrast agent, and (4) it is a time saving imaging technique being performed within 5min. Based on the data published, one can predict that UHCT will become the imaging procedure of choice for evaluation of acute flank pain within the next years. The purpose of this review is to critically evaluate the role all imaging modalities available for a modern approach of diagnosis and management of acute flank pain with regard to their sensitivity, specificity, positive and negative predictive values and their complications, toxicicty and morbidity.

To evaluate the efficacy of the vessel transposition technique in ureterovascular hydronephrosis in children.Over a 25-year period, we treated 111 patients with 112 instances of ureterovascular hydronephrosis. In order to determine the obstructive effect of the vessels, we performed an intraoperative diuretic test. Using this approach, 61 patients judged to have only vascular pyeloureteral junction obstruction underwent vessel transposition. However, 50 patients in whom the intraoperative diuretic test proved doubtful needed pyeloplasty.Surgical success was achieved in 98% of the patients. Only 1 child treated by vessel transposition had an unsatisfactory outcome which necessitated a subsequent pyeloplasty for persistent hydronephrosis. This was due to a previously unrecognized intrinsic pyeloureteral junction obstruction.Based on our clinical experience, the intraoperative diuretic test has proven to be a safe and effective diagnostic tool in children with ureterovascular hydronephrosis. Its use may contribute to treating some cases of ureterovascular hydronephrosis without resorting to pyeloplasty.

To assess the effect of anatomic factors, especially the angle of the lower-pole infundibulum, on stone clearance following shock wave lithotripsy (SWL) in order to determine selection criteria for percutaneous nephrolithotomy.We retrospectively analyzed 116 patients with single lower-pole stones measuring 11-20 mm treated with SWL. Intravenous urograms were reviewed to measure the infundibulopelvic angle, the angle of the infundibulum to the vertical, and the anatomy of lower-pole calyces.The overall stone-free rate was 52%. Factors most closely associated with a stone-free status were obtuse infundibulopelvic angle, lack of calyceal distortion, and a large infundibular diameter. The infundibulopelvic angle was the only factor to attain significance in predicting stone-free status (p = 0.012). The size of the stone did not predict eventual stone-free status (p = 0.911), but larger stones were more likely to require intervention after SWL.For solitary lower-pole stones 11-20 mm in size, the angle of the lower-pole infundibulum as it relates to the pelvis plays a role in eventual stone clearance and should be taken into account before choosing a mode of treatment.

Objectives To investigate the influence of two sizes of internal ureteral stents, 7 F and 12 F, on ureteropelvic junction (UPJ) healing after antegrade endopyelotomy. Methods A right UPJ stricture was created in 10 pigs using an open surgical retroperitoneal approach. This model of obstruction consists of initially bridging the UPJ with a Terumo guide wire through an upper third ureterotomy and securing two 2.0 chronic gut ties around the UPJ over the guide wire and a 6 F ureteral catheter. The ureteral catheter is then withdrawn and the guide wire left in situ coiled up within the lumbar wall and fixed to the urogenital opening. Eight days later, each UPJ stricture was incised percutaneously using the invagination technique. Five pigs received a 7 F double-pigtail ureteral stent, while the remaining 5 pigs received a 12/7 F internal endopyelotomy stent. These stents were removed 1 week later. Retrograde ureteropyelography was performed at three months and the UPJ were examined grossly and harvested for histologic studies. Results One of the 5 pigs in each study group developed a recurrent stricture. The two groups were not statistically different in terms of histologic findings, although fibrosis of the muscle layer was more pronounced in the 12 F group. Conclusion The use of a large caliber stent after experimental antegrade endopyelotomy does not provide any advantage over the use of a smaller easily positioned 7 F stent.

Background Although the effect of tumor complexity on perioperative outcome measures is well established, the impact of renal pelvic anatomy on perioperative outcomes remains poorly defined. Objective To evaluate renal pelvic anatomy as an independent predictor of urine leak in moderate- and high-complexity tumors undergoing nephron-sparing surgery. Design, setting, and participants Patients undergoing open partial nephrectomy (PN) for localized RCC were stratified into intermediate- and high-complexity groups using a nephrometry score (7–9 and 10–12, respectively). A renal pelvic score (RPS) was defined by the percentage of renal pelvis contained inside the volume of the renal parenchyma. On this basis, patients were categorized as having an intraparenchymal (>50%) or extraparenchymal ( Outcome measurements and statistical analysis Characteristics of patients with and without an intraparenchymal renal pelvic anatomy were compared. Results and limitations Inclusion criteria were met by 255 patients undergoing PN for intermediate (73.6%) and complex (26.4%) localized renal tumors (mean size: 4.6±2.9cm). Twenty-four (9.6%) renal pelves were classified as completely intraparenchymal. Following stratification by RPS, groups differed with respect to Charlson comorbidity index, body mass index, and largest tumor size, while no differences were observed between hospital length of stay, nephrometry score, estimated blood loss, operative time, and age. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (75% vs 6.5%; p =0.001), secondary intervention (37.5% vs 3.9%; p p =0.025). Conclusions Intraparenchymal renal pelvic anatomy is an uncommon anatomic variant associated with an increased rate of urine leak following PN. Elevated pressures within a small intraparenchymal renal pelvis might explain the increased risk. Preoperative imaging characteristics suggestive of increased risk for urine leak should be considered in perioperative management algorithms.

Context: The European Association of Urology (EAU) guideline group for upper tract urothelial carcinoma (UTUC) has prepared updated guidelines to aid clinicians in assessing the current evidence-based management of UTUC and to incorporate present recommendations into daily clinical practice. Objective: To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians in their daily clinical practice. Evidence acquisition: The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified using a systematic search of Medline. Data on urothelial malignancies and UTUCs in the literature were searched using Medline with the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; nomogram; and survival. References were weighted by a panel of experts. Evidence synthesis: There is a lack of data in the current literature to provide strong recommendations (ie, grade A) due to the rarity of the disease. A number of recent multicentre studies are now available, and there is a growing interest in UTUC in the recent literature. Overall, 135 references have been included here, but most of these studies are still retrospective analyses. The TNM 2009 classification is recommended. Recommendations are given for diagnosis as well as radical and conservative treatment (ie, imperative and elective cases); additionally, prognostic factors are discussed. Recommendations are also provided for patient follow-up after different therapeutic options. Conclusions: These guidelines contain information for the management of individual patients according to a current standardised approach. Physicians must take into account the specific clinical characteristics of each individual patient when determining the optimal treatment regimen including tumour location, grade, and stage; renal function; molecular marker status; and medical comorbidities. (C) 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Specimens (2-3 x 3-5 mm) of human urinary tract mucosa from bladder (67 cases), ureter and renal pelvis (35 cases) were implanted intramuscularly into cortisone-treated mice in order to elucidate whether human urothelium has the potency to induce osteogenesis. Although xenogeneic epithelium survived up to 14 days after implantation, in none of the 300 implants performed was a bone or cartilage induction observed. Implantation of urinary bladder mucosa from guinea pig and dog resulted in a heterotopic bone and cartilage formation in the graft's vicinity in 28 of 39 cases. The survival of animal transitional epithelium was similar to that of human. It is concluded that human transitional epithelium does not possess osteoinductive potency. Some clinical data pointing to a link between heterotopic osteogenesis and surgical intervention on urinary tract have been reconsidered and explained by the authors' own hypothesis. In addition, data presented in this paper indicate that one should be very careful when attempting to transmit results performed on dog urinary tract to humans.

Forty-eight patients with large renal staghorn calculi of more than 35 mm in maximum length on plain X-rays were treated by extracorporeal shock wave lithotripsy (ESWL) monotherapy for a period of 2 years. Thirty patients, with a follow-up of more than 6 months after the last treatment, were included in this study. The surface area of the calculi was 1,290 mm2 on average. Based on plain X-rays, 9 cases (30%) became free of calculi while 12 patients (40%) had a small amount of residual fragments (less than 100 mm2 in area). Adding these cases to those in which all the residual calculi were eliminated, the total turned out to be 21 cases (70%) and the treatment of staghorn calculi with ESWL was thus considered to have been fairly effective in the present series. The remaining 9 cases (30%) contained a considerable amount of residuals (more than 100 mm2). The present study in the ESWL of large staghorn calculi revealed no clear relationship between the surface area of the stones and evacuation of the fragments. The amount of the residual fragments was significantly small when either the renal collecting system was less than 2,000 mm2 in area (p < 0.05), or when the ureteropelvic junction (UPJ) was equal or greater than 5 mm in diameter (p < 0.02) according to intravenous pyelography (IVP) before treatment. The complications associated with this treatment were minimal, with a high fever in only 3 patients that were treated easily by antibiotic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Background Conventional laparoendoscopic single-site (C-LESS) pyeloplasty is technically challenging due to instrument clashing, loss of triangulation, and difficulty sewing. Application of the da Vinci S or Si robotic platforms could potentially overcome these challenges. Objective Compare our initial experience with robotic assisted laparoendoscopic single-site (R-LESS) pyeloplasty to our latter experience with C-LESS pyeloplasty (ie, after the initial 15 patients). Design, setting, and participants This single-institution retrospective observational cohort study involved consecutive patients who presented with symptomatic ureteropelvic junction obstruction and who were deemed suitable for single-incision pyeloplasty by the treating surgeon. Measurements Demographic, clinical, perioperative, and early postoperative comparative outcomes. Results and limitations Ten patients each underwent R-LESS or C-LESS pyeloplasty by a single surgeon between March 2009 and July 2011. For R-LESS and C-LESS groups, age, gender distribution, body mass index, proportion of patients with prior abdominal surgery, estimated blood loss, and hospital length of stay were statistically similar. Mean operative time was significantly longer for R-LESS (226 vs 188min; p =0.007). C-LESS pyeloplasty alone required an accessory port for the anastomosis in 10 of 10 cases. Two conversions to standard laparoscopy and two postoperative complications occurred in 3 of 10 patients in the C-LESS group, compared with no conversions and one postoperative complication in the R-LESS group ( p =0.26). Study limitations are a retrospective design, a modest number of patients, and a lack of quantification of subjective outcomes such as instrument clashing and maneuverability. Conclusions Adaptation of the da Vinci Si robotic surgical platform to laparoendoscopic single-site pyeloplasty appears to reduce the physical learning curve for this complex procedure. Future prospective, comprehensive evaluation of additional outcomes including subjective parameters, cosmesis, and longer term functional outcomes will help better define its role in minimally invasive dismembered pyeloplasty and better estimate its associated learning curve.

Endopyelotomy or percutaneous pyeloplasty has become an attractive alternative to open pyeloplasty in adult patients in recent years. However, the experience and reports of this procedure in the paediatric population have been limited to date. We report our experience in paediatric patients undergoing this procedure. Seventeen children with primary (14) or secondary (3) pelvi-ureteric junction (PUJ) obstruction were consented for endopyelotomy over a 3-year period. Patient age ranged from 4 months to 16 years, and the male to female ratio was 11:6. Percutaneous nephrostomy was established in 5 patients prior to endopyelotomy either for diagnosis or for drainage of an acutely obstructed upper tract. The remaining 12 had endopyelotomy as a one-stage procedure. The average duration of the procedure was 103 min (range 60-150 min) and the average hospital stay was 5 days (range 3-9 days). Follow-up averaged 15 months (range 3-36 months). Endopyelotomy was successful in 10/13 patients (77%), unchanged in 1, and failed in the remaining 2. We believe that percutaneous pyeloplasty can be safely and successfully performed in children with primary and secondary PUJ obstruction.

Background Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO). Objective To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate. Design, setting, and participants We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement). Intervention Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity. Measurements We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity. Results We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: −10.4min; 95% CI: −24.6–3; p =0.15) and significantly shorter hospital stay compared with CLP (WMD: −0.5 d; 95% CI: −0.6–−0.4; p p =0.40) and success (OR: 1.3; 95% CI: 0.5–3.5; p =0.62). Conclusions RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time.

Background Laparoscopic retroperitoneal partial nephrectomy in children remains a complex technique with limited diffusion among the paediatric surgical community. Objective To report our experience with laparoscopic heminephrectomy in duplex kidneys after a 15-yr practise of the technique in children and infants. Design, setting, participants Forty-eight children with retroperitoneal laparoscopic partial nephrectomy (36 upper-pole nephrectomies [UPN] and 12 lower-pole nephrectomies [LPN]) were retrospectively included in this single-institution study. Median age at surgery was 8.6 mo (range 1.5–89), with a policy of early surgical intervention for UPN in cases involving a massively dilated upper tract. Intervention Retroperitoneal laparoscopic partial nephrectomy for duplex kidney in lateral position ( n =31) and prone in the last 17 cases. Measurements We assessed intraoperative and postoperative morbidity. Follow-up (median 14 mo, range 6–125 mo) was based on clinical review and renal ultrasound. Results and limitations Median duration of surgery was 120min (range 71–215). Ten procedures (21%) were converted into open surgery, mostly at the beginning of the experience (eight during the first 20 cases, as compared to one conversion in the last 20). Among four converted LPNs, three were converted for difficulties during parenchymal section. Six UPN were converted for difficulties of exposure, with a strong correlation with age: all six were infants, with a median age of 3.25 mo (range 1.5–8 mo). We observed one case (case 4) of functional loss of the remaining lower moiety. Conclusions This study shows a high conversion rate during the learning curve for laparoscopic heminephrectomy. Retroperitoneoscopic UPN remains a challenging procedure in children, especially in small infants with very dilated collecting systems. The possibility of vascular damage to the remaining moiety warrants a very cautious dissection of the renal pedicle and should lead to conversion when clear visualization of vascular anatomy is not ascertained.

From June 1987 to October 1988, 52 staghorn calculi were treated without anesthesia by shock wave lithotripsy with the second-generation lithotriptor, Lithostar Siemens. 36 calculi were evaluated. Multiple sessions (n = 1-6) were necessary according to the size of the stone. The mean hospital stay for complete treatment was 7 days. Double-J stenting was used in 45% of the patients with calculi of less than 40 mm and in 81% of the patients with calculi of greater than 40 mm. After 3 months, 50% of the patients with calculi of less than 40 mm were free of stones, as were 43% of the patients with calculi greater than 40 mm. After 9 months, the stone-free rate rose to 75%. At 3 months, the success rate (stone free or residual fragments of less than 4 mm) is 87.5% and rose to 92% at 9 months. Two severe complications were observed: one patient with acute infected hydronephrosis with sepsis and one with perirenal hematoma. Shock wave lithotripsy monotherapy of staghorn calculi is possible in multiple treatment sessions. Double-J stenting is mandatory in most of the cases but, even in this condition, anesthesia is not necessary.

Udgivelsesdato: 2008-Dec OBJECTIVES: Irrigation during ureterorenoscopic procedures causes increased pelvic pressure (PP), which may lead to intrarenal backflow with potential harmful consequences. This study aims to investigate PP response to intraluminal administration of isoproterenol (beta-agonist; ISO) during flexible ureterorenoscopy. METHODS: Twelve patients admitted for retrograde intrarenal stone surgery (RIRS) were included. Patients were randomized to (1) irrigation with saline (n=6) or (2) irrigation with ISO 0.1 microg/mL (n=6). Irrigation rate was standardized to 8 mL/min. A ureteral catheter was retrogradely placed in the renal pelvis for PP measurements. PP, heart rate (HR), and mean arterial pressure (MAP) were also measured. RESULTS: Baseline PP was 12.1+/-4mm Hg in the saline group and 10.3+/-4mm Hg in the ISO group (p=0.44). In the saline group, PP increased to a mean 33+/-12 mm Hg during ureterorenoscopy. In the ISO group, PP was a mean 19+/-3mm Hg (p=0.029). During endoscopy, PP peaks as high as 328 mm Hg were noted during saline irrigation. The number of pressure peaks above 50mm Hg was minimized dramatically during ISO irrigation (p=0.035). No systemic side effects to ISO irrigation were observed. CONCLUSION: For the first time, a randomized, controlled human study demonstrates that pharmacologic modulation of the ureter is possible during upper urinary tract endoscopy. The ability to relax ureteral tone during endoscopy may have clinical advantages.

Objective: To assess the use of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels at the ureteropelvic junction (UPJ) in patients with ureteropelvic junction obstruction (UPJO). Materials and methods: Forty-eight patients aged 18-69 yr (mean age, 52) who had been diagnosed with an UPJO on intravenous pyelography and diuretic renography were included. Contrast-enhanced CDI was performed by using both color Doppler frequency and color Doppler amplitude ("Power") modes. Spiral CT was performed by using a three-phase CT (arterial, venous, and excretory phases) allowing for CT angiography. MRI technique included dual-phase magnetic resonance angiography (arterial, venous) for the assessment of respective arteries and veins. The type (ie, arterial or venous) and position of the vessel relative to the UPJ (ie, anterior or posterior) were assessed. The CDI, CT, and MRI findings were correlated with the surgical findings at laparoscopic pyeloplasty. Results: Forty-four of 48 patients (92%) demonstrated crossing vessels at subsequent laparoscopy. Altogether a total of 60 vessels were detected. Contrast-enhanced CDI and MRI correctly detected all crossing vessels (accuracy, 100%), whereas CT missed four posterior crossing veins (accuracy, 93%). Conclusion: Contrast-enhanced CDI is recommended as first-line imaging modality for the detection of crossing vessels in patients with UPJO.

Objective To assess the use of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels at the ureteropelvic junction (UPJ) in patients with ureteropelvic junction obstruction (UPJO). Materials and methods Forty-eight patients aged 18–69 yr (mean age, 52) who had been diagnosed with an UPJO on intravenous pyelography and diuretic renography were included. Contrast-enhanced CDI was performed by using both color Doppler frequency and color Doppler amplitude ("Power") modes. Spiral CT was performed by using a three-phase CT (arterial, venous, and excretory phases) allowing for CT angiography. MRI technique included dual-phase magnetic resonance angiography (arterial, venous) for the assessment of respective arteries and veins. The type (ie, arterial or venous) and position of the vessel relative to the UPJ (ie, anterior or posterior) were assessed. The CDI, CT, and MRI findings were correlated with the surgical findings at laparoscopic pyeloplasty. Results Forty-four of 48 patients (92%) demonstrated crossing vessels at subsequent laparoscopy. Altogether a total of 60 vessels were detected. Contrast-enhanced CDI and MRI correctly detected all crossing vessels (accuracy, 100%), whereas CT missed four posterior crossing veins (accuracy, 93%). Conclusion Contrast-enhanced CDI is recommended as first-line imaging modality for the detection of crossing vessels in patients with UPJO.