Editorial Comment on: “Risk Factors and Management Options for the Adult Failed Ureteropelvic Junction Obstruction Repair in the Era of Minimally Invasive and Robotic Approaches: A Comprehensive Literature Review” by Chow et al.

Failure after a procedure that boasts a >90% success rate is one of the most frustrating situations faced by a surgeon. As surgeons, we use failures as tools for learning and methods to identify practices for improvement. For many procedures, failures can often be traced to certain techniques or patient conditions that tend to result in poorer outcome. This is not so in pyeloplasty. With success rates reported between 90% and 100% in modern robotic surgery series, failure after pyleoplasty can be as frustrating to the surgeon as it is to the patient. A failure after pyleoplasty often leads us scratching our heads in confusion.

In the preceding review, Chow et al. studied failure after pyleoplasty in a method to identify potential causes. ¹ They reviewed data on five different potential factors that could lead to failure after pyeloplasty, including (1) patient renal function at the time of surgery, (2) age, (3) prior intervention (endopyelotomy) and early urine leak, (4) presence of stone, and (5) histologic abnormalities on renal biopsy. Only urine leak after surgery or before (caused by endopyelotomy) and histologic abnormalities seemed to contribute to failure. These are rare situations and largely out of our control. Unless subclinical urinary leaks are the primary source of failures in patients without previous endopyelotomy, these findings bring no solace to the surgeon or patient who otherwise underwent an uneventful pyeloplasty.

Not all failures are really failures. Patients may have poor drainage, however, maintain function and be symptom free. In those situations, no intervention and continued follow-up are all that is necessary. However, when interventions are needed, it appears that most pyeloplasty failures can be salvaged with an endopyelotomy or redo pyeloplasty. A redo pyeloplasty appears to have better outcomes with more durable result compared with endo pyelotomy, but the majority of patients would prefer the less invasive treatment before a redo surgery.

Although this review tries to put a light on the etiology of pyeloplasty failures, it really highlights our failures. Our failures in identifying and improving upon the underlying causes of a failure after pyeloplasty. Although a 90% success rate sounds great, conversation with an otherwise normal young patient who underwent a straightforward pyeloplasty that failed is not great. Our job is to continue to look at the data in new ways and try to figure out how we can make this procedure a little better or at least to better identify the patients who will not have that great outcome.