Background and Purpose: Controversy continues over the need to image the ureteropelvic junction (UPJ) before endopyelotomy to detect crossing vessels. We evaluated a selective management model for UPJ obstruction. Patients and Methods: Intraoperative ultrasonography was performed before endopyelotomy in 19 men and 16 women. Patients with large (>4-mm) crossing vessels underwent open or laparoscopic pyeloplasty; the others had ureteroscopic or percutaneous endopyelotomy with electrocautery or the holmium laser. Results: Crossing vessels were found in 25 of the 35 patients and a high-inserting ureter in 4. The vessels were >4 mm in nine patients, seven of whom had successful pyeloplasty and two of whom were managed expectantly with good results. Endopyelotomy was successful in 94% without a crossing vessel and 70% of those with a crossing vessel. The overall success rate (absence of symptom and resolution of obstruction on renal scintigraphy) was 89%. Conclusion: Selective management of UPJ obstruction, avoiding endopyelotomy in the presence of a large crossing vessel, appears to improve the success rate.
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