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Laparoscopic Pyeloplasty

  • Indication
  • Relief of uretero-pelvic junction obstruction due to intrinsic anatomic stenosis or crossing vessels . Patients usually present with symptoms related to UPJ obstruction (i.e. recurrent flank pain, recurrent urinary tract infections, pyelonephritis, ipsilateral nephrolithiasis, deterioration of renal function)

  • Method
    On preoperative day #1–placement of percutaneous nephrostomy

  • 1. Positioning of patient
  • 2.Planning and placement of trocars
  • 3.Entry into peritoneal cavity
  • 4.Exposure of retroperitoneal space (White line of Toldt)
  • 5.Identification of ureter and hilar structures and obstructed UPJ

  • 6.Management of UPJ according to characteristics of obstruction (always insertion of double J stent)
    • Hynes-Anderson dismembered
    • Y-V
    • Spiral
    • Incision of Pelvis and excision of UPJ

    • Ureteral spatulation
    • Suture of reconstructed UPJ, beginning from posterior aspect
    • Suture of anterior aspect of reconstructed UPJ
    • completed suture of UPJ secured with Lapra-Ty clip at pelvic end
  • 7.Placement of drainage tube
  • 8.Removal of trocars, exit from peritoneal cavity and suture of incisions

  • Tips and Tricks
  • Detailed preoperative imaging is necessary for proper diagnosis and for the proper planning of treatment
  • Patients with recurrent pyelonephritis may have extensive perinephric scarring, making dissection and proper anatomical repair very difficult
  • No matter what the repair (V-Y, Hynes Anderson, Culp, etc) the suture line should not be under tension, and be as water tight as possible
  • In order to place the pigtail catheter, use an 18G needle to puncture the abdomen and to direct a guide wire through the pelvis and ureter. Then the pigtail may be pushed over the wire without twisting in the abdominal cavity.
  • If suturing through the established ports is difficult, do not hesitate to place an extra 5 or 3mm port.
  • Placement of a nephrostomy tube before the operation will aid in decompressing the dilated pelvis, and will speed up the identification of the kidney. A decompressed pelvis is easier to manage than a dilated one.
Clinical Videos
Laparoscopic Pyeloplasty – Spatulization of UPJ and Pigtail insertion

Laparoscopic Pyeloplasty – Reconstruction of UPJ