Looking for help to determine treatment approach

I have visited a few Urologists and they all commented that my case is "interesting" from clinical view point and is not straight forward as to which approach to take.  I am looking for ideas and suggestions to select best approach.

I have been first diagnosed with moderate hydronephrosis due to UPJ obstruction and 7 mm stone in the lower pole (both conditions) in the right kidney almost 22 years ago (I was 21 years old) when I had an incident of strong pain on the right side.  At that time my doctor suggested that I increase intake of fluids and see how I will feel.   Since then, maybe twice a year, I had incidents with mild pain but it was very manageable.  Late last year during regular physical exam I inquired whether I should check out this condition and was referred to the Urologist.  I completed tests.  The Renal Scan test showed T/2 of 20 minutes for the right kidney and 50/50 split in renal function between the two kidneys.  CT scan showed that I have one stone in the lower pole of the right kidney of approximately 20 mm.    I had the following options proposed to me by the Doctors I consulted:
1)      Robotic Pyeloplasty + attempted stone extraction/fragmentation
2)      PCNL and then a pyeloplasty if needed in the future (since T/2 of 20 min is borderline and no degradation in renal function was noted)
3)      Pyeloplasty and then a PCNL in the future after everything has healed
4)     Open surgery to address both conditions

I reviewed option (1) with two Urologists.  One Doctor thought that there is 90% chance of success in being able to remove stone.  He said that infundibular stenosis condition (which he said no diagnostic tests are available to assess that prior to surgery with the stone size I have) can limit access to the stone.   Another Doctor in general thought that success rate in removing the stone in option (1) is only 50%.

Some questions that I am strugling with:
- should I have UPJ obstruction fixed (a) because it may deteriorate (b) because it will promote formation of the new stone
- whether I should attempt option (1)  
- is there a way (imaging test -?) to determine if infundibular stenosis condition exists prior to surgery?

I am very interested to know what your opinion is.   Any feedback will be greatly appreciated.
Thank you,
Leo

[S. Kaul, MD]

Hey Leo!

-Yes, I would recommend fixing PUJ obstruction. Even though it may not aggravate, it runs the risk of potential complications in future.
- I do not see a contraindication to option 1. In fact it has a high chance of success.
- A urography may help make a diagnosis but this may not be recommended with compromised renal function.
Hope this helps.

Take care!

[Leo0319]

Dr, Kaul,
Thank you for your response.  
Some urologists think that UPJ obstruction also maybe the cause of kidney stone but there is no consensus.  What is your opinon?

Also, I was recommended another approach is percutaneous stone removal combined with endopyelotomy (endoscopic incision of the UPJ narrowing).  What is your take on this versus option 1 above - ?

Regards,
Leo