For referring physicians
UPJ obstruction: how I choose the operation
Primary ureteropelvic junction obstruction in adults, with or without a crossing vessel, and the junction that has scarred again after a pyeloplasty, an endopyelotomy or stone surgery. The questions I ask, in order, with a video for each operation.
Primary obstruction: I do not transect the ureter
The common pyeloplasty is the dismembered Anderson-Hynes repair. Transecting the ureter compromises its blood supply and makes any revision more complex. I do a non-transecting Y-V flap pyeloplasty with stricturoplasty instead: the junction is opened and rebuilt with a flap of renal pelvis, the narrow segment is widened, and the longitudinal blood supply of the ureter is kept. The dismembered repair stays available if a revision is ever needed.
I do it single-port through the retroperitoneum, without entering the abdomen, and most patients go home the same day. With a crossing vessel, the flap repair is done with the vessel in place.
After a failed pyeloplasty
Redo pyeloplasty is ruled out by the length of the stricture, not by the prior failure. In the reoperative field I use a buccal mucosa graft onlay more often, and ureteroscopy with near-infrared fluorescence to find the ureter. If a wire crosses, the junction has a lumen and an onlay is on the table. The obliterated junction, or the one whose stricture runs down the proximal ureter, is the proximal ureter question: onlay if there is a lumen, replacement if there is not, and never an ileal ureter for a ureter that can be rebuilt in place.
Ureterocalycostomy
The ureter is joined to the lower-pole calyx instead of the pelvis. I do it single-port through the retroperitoneum: the ureter is transected at its most proximal point, the lower-pole parenchyma is removed to open the calyx, and the anastomosis is sewn over a stent. It is an operation for unfavorable upper tract anatomy and for salvage, and it is not a first move.
Videos by operation
Most operative videos are age-restricted on YouTube, so you need to be signed in to watch them.
Primary UPJ obstruction: non-transecting Y-V flap pyeloplasty
- SP robotic pyeloplasty, Y-V flap for a narrowed UPJ, 33 minutes uncut
- SP retroperitoneal Y-V pyeloplasty, full length, 34 minutes
- Y-V pyeloplasty, retroperitoneal, SP robot
- Retroperitoneal pyeloplasty with a crossing vessel, Y-V flap
- SP left pyeloplasty after Indiana pouch
- SP robotic pediatric transperitoneal pyeloplasty
After a failed pyeloplasty: redo pyeloplasty
After a failed pyeloplasty: ureterocalycostomy
Papers
- Single-port robotic non-transecting Y-V flap pyeloplasty with stricturoplasty for ureteropelvic junction obstruction: a case series. World J Urol. 2026. PubMed 42303909
- Multi-institutional experience comparing outcomes of adult patients undergoing secondary versus primary robotic pyeloplasty. Urology. 2020. PubMed 32687842
- Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure. Asian J Urol. 2024. PubMed 39139522
- Single-port robotic laparoscopic ureterocalicostomy: surgical technique and clinical outcomes. Can J Urol. 2024. PubMed 39675039
- Preoperative predictors of surgical success for robotic ureteral reconstruction of proximal and middle ureteral strictures. Urology. 2023. PubMed 38104667
- Ureteral rest is associated with improved outcomes in patients undergoing robotic ureteral reconstruction of proximal and middle ureteral strictures. Urology. 2021. PubMed 33639184
- Outcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients. BJU Int. 2015. PubMed 25682696
- Ureteral stricture: current treatment algorithm and key surgical principles in the robotic upper urinary tract reconstruction era. World J Urol. 2026. PubMed 41546831