Dr. med. Dirk Manski

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Laparoscopic Pyleoplasty: Surgical Treatment of Ureteropelvic Junction Obstruction

Indications for Pyeloplasty

Pyeloplasty is indicated as surgical therapy for ureteropelvic junction obstruction:

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 or liver surgery).

Surgical Technique of Laparoscopic Pyeloplasty

Preoperative Patient Preparation

Surgical Approach via Laparoscopy

Patient Positioning:

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.

Trocar positions:

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 pole of the kidney and continue dissection until the renal pelvis is reached. Watch out for crossing vessels to the lower pole of the kidney. The anterior and posterior aspect of the renal pelvis and the lower pole of the kidney have to be completely dissected.

Pyeloplasty:

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 near the anastomosis is unnecessary in most cases.

Care after Pyeloplasty

General measures:

Early mobilization. Respiratory therapy. Thrombosis prophylaxis. Laboratory controls (Hb). Wound inspections.

Analgesia:

Analgesics with a combination of NSAIDs and opioids.

Drains and catheters:

The drainage is removed if the daily drainage volume is below 50 ml, Bladder catheter additional 1–2 days or 3–5 day in total, 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



References



  Deutsche Version: Laparoskopische Nierenbeckenplastik