Laser is preferred in endopyelotomy procedures

Mansoura, Egypt-Acucise endopyelotomy is no longer employed at the Mansoura University Urology and Nephrology Center in Mansoura, Egypt. Instead, urologists there have switched to laser endopyelotomy.

"Retrograde laser endopyelotomy is safer and more effective than Acucise," said Ahmed R. El-Nahas, MD, who co-authored a comparative study of the two procedures. "Our study found a complication rate of 25% with Acucise compared to 10% with the laser. The success rate with the laser was 85% compared to a 65% success rate with Acucise."

Dr. El-Nahas presented findings of the 2-year prospective study comparing Holmium:YAG laser uteroscopic endopyelotomy (Coherent, Santa Clara, CA) and endopyelotomy using the Acucise (Applied Medical, Rancho Santa Margarita, CA) at the AUA annual meeting. He told Urology Times that the study was initiated because, although there were a number of studies of each procedure, no study has compared them head to head in a prospective, randomized fashion.

UPJ obstruction was primary in eight of the 20 laser-treated patients and in six of the 20 Acucise patients. It was secondary in the remaining 12 laser patients and the remaining 14 Acucise patients. The mean operative times for both procedures were comparable: 64.7 minutes for the laser and 58.7 minutes for the Acucise. Mean hospitalization times were shorter for the laser patients: 1.1 days versus 1.6 days for the Acucise patients.

Not all procedures went smoothly. Ureteroscopy was necessary in three Acucise patients. The Acucise balloon ruptured during one procedure, and two other patients failed to demonstrate contrast extravasation.

The procedure was considered successful in 17 (85%) of the laser patients and in 13 (65%) of the Acucise patients at a mean follow-up of 21.7 months (range, 6 to 36 months). Two (10%) of the laser patients were considered improved compared with three (15%) of the Acucise patients. One laser patient and four Acucise patients were rated as failures. Failure was defined as persistent or worsening symptoms associated with increased hydronephrosis grade, deterioration of glomerular filtration rate, or renal drainage obstruction. Success was defined as subjective relief or improvement of symptoms associated with objective relief of obstruction and improved or stable filtration rates.

Dr. El-Nahas said that visualization was perhaps the most problematic aspect of the Acucise procedure.

"The technology depends on fluoroscopic control of the incision at the ureteropelvic junction and this is more or less a blind incision. In contrast, with the ureteroscopy you can see the sides and path of the junction and tell if the incision is adequate," he said.

Although the study was too small for the data to reach statistical significance, the findings were sufficient for the authors to switch to the laser as their primary technology. They recognized that advanced endourologic skills were necessary to use the laser properly, but reiterated their observation that the safety and efficacy of the laser made it the preferred technology.