Laparoscopic Pyleoplasty: Surgical Treatment of Ureteropelvic Junction Obstruction
Indications for Pyeloplasty
Pyeloplasty is indicated as surgical therapy for ureteropelvic junction obstruction:
- with scintigraphic evidence of obstruction or
- with decreasing (but sufficient) renal function of the affected kidney or
- with clinical symptoms (flank pain, nephrolithiasis or recurrent infections)
Contraindications for Laparoscopic Pyeloplasty
Nonfunctioning kidney (under 20% of total renal clearance). Coagulation disorders. Comorbidity, which prohibits elective surgery. Choose lumbar open pyeloplasty if the patient had significant previous intraabdominal surgery (like colon surgery of liver surgery).
Surgical Technique of Laparoscopic Pyeloplasty
Preoperative Patient Preparation
- Exclusion or treatment of a urinary tract infection
- Insertion of a DJ ureter stent and insuring the diagnosis with retrograde pyelography
- Perioperative antibiotic prophylaxis
- Insertion of a transurethral catheter.
- Gastric feeding tube during surgery to empty the stomach.
Surgical Approach via Laparoscopy
The patient is positioned in a lateral position at an angle of 45 degrees and with a mild lumbar hyperextension. A vacuum mattress enables a secure fixation of the patient, even if the operation table has to be tilted.
Pneumoperitoneum is created with the help of a mini-laparotomy or with the Veress needle next to the umbilicus (camera trocar 10 mm). A second 10 mm trocar is inserted slightly caudal to the navel lateral to the ipsilateral rectus. A 5 mm trocar is inserted between xiphoid and umbilicus in the midline. An additional 5 mm trocar is inserted (if necessary) for retraction of liver, colon or spleen, e.g. below the xiphoid or rib cage.
Surgical Approach to the Kidney:
Start with a laterocolic incision to mobilize the colon to the medial. The correct layer between meso of the colon and retroperitoneum is found most easily below the kidney. After sufficient colon mobilization, identify the ureter at the lower pol of the kidney and continue dissection until the renal pelvis is reached. Watch out for crossing vessels to the lower pol of the kidney. The anterior and posterior aspect of the renal pelvis and the lower pol of the kidney have to be completely dissected.
Anderson-Hynes dismembered laparoscopic pyeloplasty:
a) Dissection of the lower pole (kidney), ureter (ureter), and renal pelvis (NB). Traction sutures at the renal pelvis help to keep an overview. Crossing vessels are clearly seen (Ua). Furthermore, visible colon and spleen.
b) The obstructive ureteropelvic junction is removed and sent to pathology.
c–d) The ureter is repositioned to the anterior of the crossing vessels. The anastomosis is started with two corner stitches. The following anastomosis of the anterior wall is done with interrupted sutures Vicryl 4-0
e) Exposure for the dorsal anastomosis is done with the help of the traction sutures.
f) Situation after completed anastomosis: the crossing vessels are now posterior to the renal pelvis and ureter.
Dismembered pyeloplasty is the method of choice, if a crossing vessel is identified as the cause for the UPJ obstruction, and probably for most other indications, too. Traction sutures are placed at the renal pelvis. The sutures are brought to the outside transcutaneously with the help of a trocar incision closure system and secured with small clamps. The sutures are very helpful for the exposure of the renal pelvis. Excision of the UPJ obstruction is done with, if necessary, excision of excess renal pelvis (reduction pyeloplasty). The ureter is spatulated along the lateral wall (2–3 cm) [fig. laparoscopic dismembered pyeloplasty A to C]. The ureter is repositioned in relation to the crossing vessel, resulting in an anastomosis ventral of the crossing vessels.
Vicryl 4-0 is used as suture material, the anastomosis is done as an interrupted suture. After the first (corner) sutures, the position of the ureteral stent is controlled. Exposure of the posterior anastomosis is possible with the help of the traction sutures. The watertightness of the anastomosis may be controlled via filling of the bladder until reflux to the kidney is observed. A drain may be placed near the anastomosis.
Care after Pyeloplasty
Early mobilization. Respiratory therapy. Thrombosis prophylaxis. Laboratory controls (Hb). Wound inspections.
Analgesics according to the ladder of WHO pain management, e.g. metamizol and tramadol.
Drains and catheters:
- Wound drainage 1–2 days
- Bladder catheter 3-5 days
- Ureteral stent 2–4 weeks
Complications of Pyeloplasty
Bleeding, infection, urinoma, recurrent ureteral stricture, loss of kidney function, injury to adjacent organs (liver, spleen, pancreas).
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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