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Pyeloplasty: Surgical Treatment of Ureteropelvic Junction Obstruction
Indications for Pyeloplasty
Pyeloplasty is indicated as surgical therapy for ureteropelvic junction obstruction:
- with scintigraphic evidence of obstruction
- with decreasing (but sufficient) renal function of the affected kidney
- with clinical symptoms (flank pain, nephrolithiasis or recurrent infections)
Pyeloplasty can be performed open-surgically and laparoscopically (see next section); open surgery is recommended if the patient has undergone previous perirenal surgery.
Contraindications for Pyeloplasty
Nonfunctioning kidney (under 20% of total renal clearance). Coagulation disorders. Comorbidity, which prohibits elective surgery.
Surgical Technique of Pyeloplasty
Principles of dismembered pyeloplasty: schematic drawing of a ureteropelvic junction obstruction due to a lower pole-crossing vessel (left). Dismembered pyeloplasty (technique by Anderson and Hynes) with reposition of the ureter in relation to the lower pole-crossing vessel (right).
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
Surgical Approach via a Flank incision
For open pyeloplasty, the most common surgical approach to the kidney is done with a flank incision. In children, an anterior subcostal muscle-splitting approach is preferable. See also the following section for laparoscopic pyeloplasty.
The kidney is completely exposed while sparing the peritoneum. Identify the proximal ureter and mark with a vessel loop. Open the renal fascia and dissect the renal pelvis on the anterior and dorsal side.
Dismembered pyeloplasty is the method of choice, if a crossing vessel is identified as cause for the UPJ obstruction, and probably for most other indications. Traction sutures are placed at 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. dismembered pyeloplasty]. The ureter is repositioned in relation to the crossing vessel, resulting in an anastomosis ventral of the crossing vessels.
The anastomosis between the ureter and renal pelvis is done with fine PDS or Vicryl sutures (4-0, in children even finer). First, the cranial part of the opened renal pelvis is closed with a running suture. The caudal part of the renal pelvis (2–3 cm) is left open for the anastomosis with the ureter. The ureter is anastomosed with either a running or interrupted suture to the caudal portion of the renal pelvis. Before the last sutures are done, the position of the ureteral stent is controlled.
Spiral flap pyeloplasty:
The Culp-De Weerd technique is an option in recurrent surgery with a large ectatic renal pelvis [fig. spiral flap pyeloplasty]. A flap from the renal pelvis is used to bridge the UPJ stenosis or a scarred stricture until the proximal ureter.
Care after Pyeloplasty
Early mobilization, thrombosis prophylaxis, respiratory therapy, laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.
In adults, a flank approach is painful and an epidural catheter is an option. In addition, analgesics according to the ladder of WHO pain management are given, e.g. metamizol and tramadol.
Drains and catheters:
The retroperitoneal drainage is removed if daily volume of drainage is well 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).
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- ANDERSON, J. C. & HYNES, W.
Retrocaval ureter; a case diagnosed pre-operatively and treated successfully by a plastic operation.
Br J Urol, 1949, 21, 209–214
Deutsche Version: Nierenbeckenplastik