Laparoscopic Pyeloplasty

Abstract

Schuessler reported the first case of laparoscopic pyeloplasty in 1993 [12]. Since then several centres have taken it up and many large series on this procedure are available in literature. Today laparoscopic pyeloplasty is an established alternative procedure to standard open pyeloplasty [2]. The other minimally invasive alternative for pyeloplasty is endopyelotomy. Though less morbid, the success rate is around 75 % even in the best of hands. It is contraindicated in situations like the presence of crossing vessels, which may be associated in around 20 % of patients [3].

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1 Basic Principles

1.1 Introduction

Schuessler reported the first case of laparoscopic pyeloplasty in 1993 [1]. Since then several centres have taken it up and many large series on this procedure are available in literature. Today laparoscopic pyeloplasty is an established alternative procedure to standard open pyeloplasty [2]. The other minimally invasive alternative for pyeloplasty is endopyelotomy. Though less morbid, the success rate is around 75 % even in the best of hands. It is contraindicated in situations like the presence of crossing vessels, which may be associated in around 20 % of patients [3].

1.2 Indications

Pyeloplasty is indicated in significant pelvi ureteric junction obstruction; in the presence of more than 10 % difference in the split renal function; infection; type II O’Reilly curve in isotope renogram and in obstruction with secondary calculus.

1.3 Contraindication

• (a) All general contraindications to laparoscopy

• (b) Intrarenal pelvis

• (c) Failed pyeloplasty may be a relative contraindication.

1.4 Patient Preparation

• 1. Bowel preparation

• 2. Antibiotics.

1.5 Planning of Approach

Retrograde pyelogram (RGP) is done initially to assess the exact location and length of the narrow segment and pelvic configuration. RGP also rules out other ureteric pathology. Retrograde stent placement is an option after RGP, negating the slightly difficult antegrade stenting. The disadvantage of retrograde stenting is the difficulty in introduction of the scissors for spatulating the ureter in very narrow pelviureteric junction obstruction. In some situations the preplaced stent can impede suturing. Various minimally invasive approaches and techniques are available, like transperitoneal, retroperitoneal, transmesocolic approaches; and dismembered and nondismembered techniques. Retroperitoneal approach is preferable as it is akin to open approach. However the suturing is more difficult due to reduced space and overcrowding of instruments.

1.6 Complications

General complications are bleeding, bowel injury and transient ileus. Early specific complications are prolonged urinary leak resulting in ileus, persisting drainage or urinoma. This may settle spontaneously or with ultrasound scan guided percutaneous nephrostomy which is retained for about 2 weeks.

Delayed complications include UPJ stenosis, which might need reoperation.

2 Transperitoneal Approach

Entry

Patient is placed in 70° lateral position without kidney bridge elevation. The port position is as described in the Fig. 5.71. 10 mm camera port has to be placed in the midclavicular line about 5 cm above and lateral to umbilicus for a good view. Secondary ports are placed four-finger breadth apart for triangulation. A 30° telescope may be preferable for better view from different angles

The line of Toldt is incised with either a hook dissector or ultrasonic shears. Colon is reflected medially until the ureteropelvic junction and part of the pelvis is well seen. Additional port (5–10 mm convertible) is inserted in the epigastrium or flank for the retraction or suction if the redundant bowel disturbs the vision or there is collection.

Once the pelvis and UPJ are adequately mobilised, a stay suture is taken through the pelvis to stabilise it and avoid frequent unwanted movements of the instrument. A nylon suture on a straight needle is used for this purpose. The suture is brought out through the flank.

2.1 Dismembered Pyeloplasty

Dismembered pyeloplasty is preferable in large pelvis with very narrow UPJ or crossing vessel. Pelvis is incised at an angle, extending from the lateral to the superomedial border. Subsequently, the narrow UPJ and redundant pelvis is excised and the ureter is spatulated on the lateral aspect for about one cm using curved scissors (through subcostal port). Suturing is started at the angle of ureteric spatulation and continued along the posterior wall. Interrupted or continuous sutures with 4–0 or 5–0 absorbable material is preferred. Ureteric stent can be passed down antegrade at this stage (either directly through sub costal port or using veress needle. Finally anterior layer is sutured and pyelotomy is closed with 4–0 interrupted or continuous locking sutures.

2.2 Non Dismembered Pyeloplasty

If the pelvis is not large and the UPJ is short without a crossing vessel, Fengerplasty or

Y – V plasty can be done because it is technically easier and can give equally good results. Suturing technique described earlier in transperitoneal approach can be followed.

2.3 Transmesocolic Pyeloplasty [9, 10]

In left sided UPJ obstruction in children and in thin adults, the dilated pelvis bulges through the mesocolon. Once the mesocolon is incised, the bulging pelvis can be pulled into the peritoneal cavity provided that the mesocolic arterial arcade is wide trans mesocolic approach can be used. Thus the UPJ can be approached without the need for colonic mobilisation. In our series of 102 patients, 49 patients underwent transmesocolic pyeloplasty. Ref: [10, 16].

The advantages are

• (a) Very good illumination as there is not much of raw area with blood clots, which can absorb light.

• (b) UPJ can be quickly accessed.

Occasional problem in this approach is injury to left colic vessel. A stay suture on the pelvis will stabilize it and prevent retraction. Rest of the procedure viz. excision of UPJ and suturing techniques are the same as described under transperitoneal approach. The mean operative time is reduced by about 15–20 min.

3 Retroperitoneoscopic Approach

With the patient in the 90° lateral positions, and without the kidney bridge elevated, the primary (camera) port is inserted by open technique in the renal angle i.e. lateral to erector spinae just below the tip of 12th rib.

A 1.5 cm long incision is made. A haemostat is introduced to split the muscles and the lumbodorsal fascia. The index finger is introduced through the wound into the retroperitoneal space to push away the peritoneum anteriorly, thus enlarging the potential space. The space is inflated to the required volume (150–600 ml according to the built and age of patient) using balloon technique. Alternatively commercially available balloon trocars can be used directly. This camera port has to be fixed airtight with a mattress suture to prevent gas leak. Subsequent instrument ports are introduced under vision in the anterior axillary line – one each in the sub costal area and above iliac crest. An additional 5 mm port can be placed in the subcostal area for retraction, if necessary.

The first landmark to be identified is the psoas muscle. Dissection along this plane easily leads to the ureter. If the Gerota’s fascia with perinephric fat is extensive over the UPJ, it may be incised (or excised) for free movement of the hand instruments.

A preplaced stent or guidewire in ureter makes identification of ureter easier (gonadal vessel may be mistaken for ureter). UPJ and part of pelvis which need to be excised are mobilised.

3.1 Nondismembered Pyeloplasty

If pelvis is not very large and UPJ is short, nondismembered Y – V plasty or Fengerplasty [2] (Heineke Mikulicz) technique can be performed. One can use sharp scissors or endoknife for pyelotomy and spatulation of ureter. Suturing of anterior wall starts distally with 4–0 or 5–0 polyglactin or polydioxanone suture in an interrupted or continuous fashion. Once the anterior wall is completed, stent can be placed across the suture line (if there is no preplaced stent). Antegrade stenting can be done through an additional 3 mm port or veress needle. Subsequently the posterior layer is sutured.

3.2 Dismembered Pyeloplasty

This technique is similar to that of transperitoneal approach except that anterior layer is sutured first followed by the posterior layer. A peripelvic tube drain is advanced through one of the 5 mm ports. After irrigating and sucking all the collected fluids, ports are closed with 2–0 vicryl.

4 Special Situations

4.1 UPJ Obstruction in Horse Shoe Kidney

The important points to consider are the presence of isthmus and aberrant vessels. Aberrant vessels need to be dissected and preserved. The difference in the patient position and the port position is described in the figure (Fig. 5.71 in Horse shoe section). Rest of the steps are similar to the previously described transperitoneal technique.

4.2 UPJ Obstruction with Secondary Calculi

Various techniques can be used to remove the secondary calculi. They can be directly removed with grasper through pyelotomy. Multiple small calculi can be removed by flushing. Flexible cystoscope can be passed through one of the ports to reach the calyces and remove stones by basketing. Large stones can be dealt with by passing nephroscope through one of secondary ports to basket or grasp calculi.

4.3 Redopyeloplasty

The basic steps of redopyeloplasty (failed pyeloplasty), are not different from the classical transperitoneal pyeloplasty. Since open pyeloplasty is almost always retroperitoneal, retroperitoneoscopic approach may not be feasible due to extensive adhesions. So all these cases are better done by transperitoneal approach.

The adhesions around the PUJ need meticulous dissection and the surgeon should be prepared for the management of long defects. Since the UPJ is dependant and pelvis is small in secondary UPJO, non dismembered technique may be attempted (Table 5.1).

Table. 5.1 Comparison of various large series of laparoscopic pyeloplasty

Vessel crossing UPJ, difficulties in stenting, Horse shoe kidney with UPJ obstruction and Culp flap pyeloplasty have been illustrated.

5 Transperitoneal Dismembered Pyeloplasty

Fig. 5.1

CT image- right UPJ obstruction

Fig. 5.2

Ports position

Fig. 5.3

Initial laparoscopic view showing the bulging right renal pelvis

Fig. 5.4

Ureter is identified as a tubular structure, with characteristic vascular plexus, in the retroperitoneum

Fig. 5.5

Ureter is traced proximally till the dilated pelvis. Dissection of ureter is done outside the adventitial layer, preserving the vascular arcade

Fig. 5.6

Pelvi ureteric junction is identified as a transition between dilated pelvis and narrow ureter. Oblique pyelotomy done initially along the lateral aspect

Fig. 5.7

Ureter is spatulated laterally, using curved scissors or Potts scissors

Fig. 5.8

Spatulation is complete, when the normal calibre ureter with rugosities are seen. A ‘give’ may be felt when spatulation extends from the narrow segment to normal segment

Fig. 5.9

Pyelotomy is extended with a medial spatulation. A small strip is preserved along the posterior wall for better initial orientation

Fig. 5.10

Pelvi ureteric anastomosis started with the initial suture outside-in from the apex of pelvis using 4-0 PDS suture

Fig. 5.11

Corresponding suture is taken through the apex of the ureteric spatulation inside-out

Fig. 5.12

Preplaced stent is being repositioned

Fig. 5.13

Apical suture in place

Fig. 5.14

Dividing the posterior pelvic wall strip completes division of PUJ

Fig. 5.15

Apical suture is continued in the posterior layer

Fig. 5.16

Image shows the completed posterior wall suturing

Fig. 5.17

Anterior wall suturing is done next, with the similar suture

Fig. 5.18

Continuous suturing of anterior wall in progress

Fig. 5.19

Final stages of pelvi ureteric anastomosis

Fig. 5.20

Completed pyeloplasty

Fig. 5.21

Perinephric fat used as cover for anastomosis

Fig. 5.22

Drain placed through lower port

6 Transperitoneal Non Dismembered Pyeloplasty

Fig. 5.23

Left colon being reflected along line of Toldt

Fig. 5.24

Ureter identified in the retroperitoneum with its characteristic features

Fig. 5.25

Ureter traced proximally till pelvis

Fig. 5.26

Pelvi ureteric junction identified and dissected all around preserving adventitia around the ureter

Fig. 5.27

Pyelotomy being done in the shape of ‘V’ with the apex of V just proximal to PUJ

Fig. 5.28

Pyelotomy completed

Fig. 5.29

Ureteric spatulation being done as the vertical limb of ‘Y’

Fig. 5.30

Completed ‘Y’ incision

Fig. 5.31

Apical suture through the ureter with 4-0 polyglactin

Fig. 5.32

Corresponding suture through the apex of pelvic flap

Fig. 5.33

Apical suture in place

Fig. 5.34

Continuous suturing of lateral margin of flap in progress

Fig. 5.35

Lateral margin suturing in progress

Fig. 5.36

Lateral margin suturing completed

Fig. 5.37

Lateral wall suture seen through the inner aspect of pelvis

Fig. 5.38

Stent being inserted antegrade

Fig. 5.39

Medial margin suturing in progress

Fig. 5.40

Medial margin suturing in progress

Fig. 5.41

Medial margin suturing completed

Fig. 5.42

Completed ‘Y’ – ‘V’ plasty

Fig. 5.43

Diagrammatic representation of Y – V plasty

7 Transmesocolic Pyeloplasty

Fig. 5.44

RGP showing left UPJ narrowing

Fig. 5.45

Ports position

Fig. 5.46

Bulging pelvis seen through the mesocolon

Fig. 5.47

Incision of the mesocolon over the bulge, preserving the mesocolic vessels

Fig. 5.48

Pelvis seen through the mesocolic window

Fig. 5.49

Pelvis and upper ureter dissected through the mesocolic window and pelviureteric junction delineated

Fig. 5.50

Sling placed around the ureter for identification and retraction

Fig. 5.51

Mesocolon tacked to the abdominal wall

Fig. 5.52

Oblique pyelotomy in progress

Fig. 5.53

Anterior layer of pelvis incised completely

Fig. 5.54

Pyelotomy about to be completed. Note preplaced guide wire

Fig. 5.55

Lateral spatulation of ureter in progress

Fig. 5.56

Ureteric spatulation completed – beyond the narrowing

Fig. 5.57

Initial suture through the pelvis – outside-in using 4–0 Polydioxanone suture

Fig. 5.58

Corresponding suture through the spatulated end of ureter

Fig. 5.59

Apical suture in place

Fig. 5.60

Posterior layer suturing in progress

Fig. 5.61

Stent being inserted antegrade

Fig. 5.62

Final suture of anterior layer in place

Fig. 5.63

Completed anterior and posterior uretero pelvic sutures

Fig. 5.64

Final suture through center of the proximal end of ureter to the pelvis

Fig. 5.65

Completed pyelo ureteric anastomosis

Fig. 5.66

Closure of remaining pyelotomy rent

Fig. 5.67

Pyelotomy closure in progress

Fig. 5.68

Completed pyeloplasty

Fig. 5.69

Completed pyeloplasty

8 Horse Shoe Kidney with PUJ Obstruction

Fig. 5.70

CT showing malrotated RT moiety with PUJ obstruction of a horseshoe kidney

Fig. 5.71

Port placement. Camera port is at umbilicus as UPJ is at a lower and medial location

Fig. 5.72

Initial view showing the bulge caused by dilated pelvis over the lumbar region (Lower than usual)

Fig. 5.73

Right colon being reflected medially along the line of Toldt to enter retroperitoneum

Fig. 5.74

Dilated pelvis and narrow ureter visualised

Fig. 5.75

PUJ dissected

Fig. 5.76

Dialeted pelvis and the isthmus part seen

Fig. 5.77

Pelvis and grossly dilated calyces seen

Fig. 5.78

Pyelotomy in the dependant area

Fig. 5.79

Pyelotomy extended

Fig. 5.80

Pyelotomy extended on to ureter in preparation for non dismembered pyeloplasty

Fig. 5.81

Ureterotomy extended till normal caliber ureter

Fig. 5.82

Posterior layer suturing with 4–0 PDS suture (Non dismembered)

Fig. 5.83

Posterior layer suturing in progress

Fig. 5.84

Posterior layer suturing in progress

Fig. 5.85

Final sutures of posterior layer

Fig. 5.86

Posterior layer suture completed

Fig. 5.87

Stent placed antegrade

Fig. 5.88

Anterior layer suturing with same suture after knotting

Fig. 5.89

Anterior layer suturing in progress

Fig. 5.90

Anterior layer suturing in progress

Fig. 5.91

Anterior layer suturing layer completed

Fig. 5.92

Final view showing dependant UPJ

Fig. 5.93

Drain placed

9 Pyeloplasty in Ectopic Kidney

Fig. 5.94

CT urogram of right pelvic kidney with UPJ obstruction

Fig. 5.95

Port positions

Fig. 5.96

Initial view of pelvic kidney with the bulging pelvis as seen from head end (At the level of sacral promontory)

Fig. 5.97

Peritoneum over the pelvis incised

Fig. 5.98

Ureter with the ureteric catheter in situ, being dissected

Fig. 5.99

Crossing vein divided

Fig. 5.100

Crossing vessel around the pelvi ureteric junction dissected

Fig. 5.101

Ureter traced proximally till pelvis

Fig. 5.102

Pelvi ureteric junction delineated all around

Fig. 5.103

Pelvi ureteric junction dissected

Fig. 5.104

Pyelotomy started

Fig. 5.105

Pyelotomy completed and ureteric spatulation started

Fig. 5.106

Ureterotomy completed (UPJ not dismembered yet, for better orientation )

Fig. 5.107

Apical suture in the pelvis

Fig. 5.108

Corresponding suture in the spatulated ureter

Fig. 5.109

Apical suture in place

Fig. 5.110

Medial wall suturing started

Fig. 5.111

Pelviureteric junction being divided

Fig. 5.112

Pelvic flap excised

Fig. 5.113

Medial wall suturing in progress

Fig. 5.114

Medial wall suturing in progress

Fig. 5.115

Stent being inserted antegrade

Fig. 5.116

Antegrade stenting

Fig. 5.117

Lateral wall suturing in progress

Fig. 5.118

Lateral wall suturing completed

Fig. 5.119

Final view of completed pyeloplasty

FIG. 5.120

Drain placed

10 Redo Lap. Pyeloplasty

Fig. 5.121

Port position. (Scar of previous open pyeloplasty seen)

Fig. 5.122

Left colon being reflected medially and Gerota’s fascia seen

Fig. 5.123

Retroperitoneum exposed and gonadal vein is seen

Fig. 5.124

Ureter identified with difficulty due to surrounding fibrosis and adhesions

Fig. 5.125

Ureter dissected from tough pannus and fibrosis using hook diathermy (or ultrasonic shears)

Fig. 5.126

Ureter being dissected proximally negotiating significant adhesions

Fig. 5.127

Pelvis identified surrounded by adhesions

Fig. 5.128

Pelvis being dissected from surrounding pannus

Fig. 5.129

Dissected pelvis, ureter and pelvi ureteric junction

Fig. 5.130

Pelvi ureteric junction defined clearly

Fig. 5.131

Pyelotomy and ureterotomy done in ‘Y’ shape

Fig. 5.132

Lateral margin suture completed

Fig. 5.133

Medial margin suture completed

Fig. 5.134

Completed ‘Y – V’ plasty

11 Culp Flap Lap. Pyeloplasty

Fig. 5.135

IVU showing dilated pelvis and long segment of narrow ureter(Right)

Fig. 5.136

Right RGP showing long segment narrowing of upper ureter

Fig. 5.137

Port position

Fig. 5.138

Dilated pelvis and long narrow ureter seen

Fig. 5.139

Pyelotomy started along the medial aspect and extended inferiorly towards the ureter

Fig. 5.140

Pyelotomy completed and ureterotomy to be started

Fig. 5.141

Ureterotomy extended till normal ureter is seen

Fig. 5.142

Pelvic flap being created by extending the incision,then vertical pyelotomy on the lateral aspect(inverted U shape)

Fig. 5.143

Completed pelvic flap

Fig. 5.144

Flap rotated down to confrm the adequacy of length

Fig. 5.145

Initial outside -in suture through apex of pelvic flap using 4-0 vicryl

Fig. 5.146

Corresponding suture through the ureterotomy apex

Fig. 5.147

Initial apical suture in place

Fig. 5.148

Lateral ureterotomy edge sutured with the medial edge of pelvic flap to form the posterior layer

Fig. 5.149

Posterior layer suturing in progress

Fig. 5.150

Lateral edge of flap sutured with medial edge of ureterotomy – Anterior layer suturing in progress with 3-0 v-loc sutures

Fig. 5.151

Final part of suturing between the pyelotomy edges being done

Fig. 5.152

Suturing almost complete

Fig. 5.153

Final view of completed flap pyeloplasty

Fig. 5.154

Diagrammatic representation of Culp flap pyeloplasty

12 Reteroperitoneoscopic Dismembered Pyeloplasty

Fig. 5.155

Port placement (Right PUJ obstruction)

Fig. 5.156

Initial retroperitoneal dissection anterior to psoas

Fig. 5.157

Ureter and gonadal vein seen in the retroperitoneum

Fig. 5.158

Pelvis dissected and pevi ureteric junction delineated

Fig. 5.159

Ureterotomy done distal to the PUJ

Fig. 5.160

Partial ureterotomy done – for better orientation

Fig. 5.161

Pyelotomy proximal to narrow PUJ

Fig. 5.162

Pyelotomy in progress

Fig. 5.163

PUJ dismembered from pelvis

Fig. 5.164

Ureter spatulated after excision of PUJ

Fig. 5.165

Spatulated ureter

Fig. 5.166

Initial suture through the apex of spatulated ureter

Fig. 5.167

Corresponding suture through the pelvis

Fig. 5.168

Apical suture in place

Fig. 5.169

Posterior layer suturing in progress

Fig. 5.170

Posterior layer suturing almost complete

Fig. 5.171

Antegrade stenting after completion of posterior layer

Fig. 5.172

Anterior layer suturing in progress

Fig. 5.173

Completed pyeloplasty

13 Reteroperitoneoscopic Non Dismembered Pyeloplasty

Fig. 5.174

Left RGP showing UPJ narrowing

Fig. 5.175

Ports position

Fig. 5.176

Retroperitoneal dissection anterior to psoas

Fig. 5.177

Upper ureter being dissected

Fig. 5.178

Ureter being traced proximally till pelvis – Narrow PUJ seen

Fig. 5.179

Pelvic ‘Y’ flap creation started

Fig. 5.180

Pelvic ‘Y’ flap creation in progress

Fig. 5.181

Ureter spatulated laterally to create the vertical limb of ‘Y’ flap

Fig. 5.182

Completed ‘Y’ flap

Fig. 5.183

Stent being inserted antegrade

Fig. 5.184

Flap advanced downwards by placing interrupted 4-0 vicryl sutures, in the posterior layer

Fig. 5.185

Posterior layer suturing in progress

Fig. 5.186

Posterior layer suturing completed

Fig. 5.187

Apex of flap sutured with the apex of ureteric spatulation

Fig. 5.188

Posterior layer and apical suture completed

Fig. 5.189

Interrupted anterior layer suturing in progress

Fig. 5.190

Completed Y- V pyeloplasty

Fig. 5.191

Drain placed

14 Tips – Difficulty in Stent Insertion

Fig. 5.192

Difficulty in stent insertion negotiated using intra operative ureteroscopy through subcostal port-external view

Fig. 5.193

Difficulty in stent insertion negotiated using intra operative ureteroscopy -endoview

15 PUJ Obstruction with Secondary Calculus

Fig. 5.194

Calculi being removed with forceps

Fig. 5.195

Calculi being removed through 10 mm port

Fig. 5.196

Flexible ureteroscopy introduced through 5 mm port

Fig. 5.197

Calculi removed using flexible ureteroscope and basket