Lap pyeloplasty
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This document discusses urinary tract obstruction, specifically ureteropelvic junction obstruction (UPJO). It covers the causes, evaluation, and surgical treatment options for UPJO, with a focus on laparoscopic pyeloplasty. Key points include that UPJO can be congenital or acquired, and indications for intervention include symptoms, impaired renal function, stones or infection. Laparoscopic pyeloplasty is a less invasive alternative to open surgery that provides comparable success rates while reducing morbidity. The procedure involves mobilizing the colon, dissecting the ureter, and performing a dismembered pyeloplasty reconstruction.
Lap pyeloplasty
- 1. BY : Dr Sumit Gupta Moderator : Prof AK.Kaku Singh
- 2. Introduction Urinary tract obstruction is a major clinical problem that affects both children and adults and can result in permanent renal damage. The degree of injury to the kidney and the effect on overall renal function depends on: the severity of the obstruction (partial or complete, unilateral or bilateral), The chronicity of the obstruction (acute vs. chronic), The baseline condition of the kidneys, And the presence of other mitigating factors such as urinary tract infection (UTI).
- 3. The cause of urinary tract obstruction can be congenital or acquired and benign or malignant. Obstructive uropathy accounts for approximately 10% of all cases of renal failure.
- 4. URETEROPELVIC JUNCTION OBSTRUCTION The diagnosis of ureteropelvic junction (UPJ) obstruction (UPJO) describes a functionally significant impairment of urinary transport from the renal pelvis to the ureter. Although most cases are congenital, the problem may not become clinically apparent until much later in life. Acquired conditions such as stone disease, postoperative or inflammatory stricture, or urothelial neoplasm may also manifest clinically with symptoms and signs of obstruction at the level of the UPJ. Similarly, extrinsic obstruction can occur at this level as well.
- 5. Controversy persists regarding the potential role of “aberrant” vessels in the etiology of UPJO. Significant crossing vessels have been noted in up to 63% of patients with UPJO but in as little as 20% of individuals with normal kidneys. UPJO may also result from vesicoureteral reflux which can lead to upper tract dilation with subsequent elongation, tortuosity, and kinking of the ureter.
- 6. Indications for intervention for UPJO The presence of symptoms associated with the obstruction, Impairment of overall renal function or progressive impairment of ipsilateral function, Development of stones or infection, or, Rarely , causal hypertension.
- 7. The primary goal of intervention is Relief of symptoms and preservation or improvement of renal function. Such intervention should be a reconstructive procedure aimed at restoring nonobstructed urinary flow.
- 8. When intervention is indicated, the procedure of choice has historically been dismembered pyeloplasty;. However , less invasive endourologic approaches have a role as an alternative. Moreover, laparoscopic and robotic pyeloplasty has gained acceptance as primary therapy at centers with appropriate experience
- 9. Pre operative evaluation The patient undergoes the usual preoperative evaluation to confirm a functionally significant UPJO in an adequately functioning kidney, as well as evaluation for fitness for surgery. Radiological investigations include intravenous pyelography, diuretic isotope renal scan (MAG3/DTPA), and a three-dimensional computed tomography (CT) scan to rule out crossing anomalous vessels. These radiological tests evaluate the severity of obstruction, degree of hydronephrosis, renal pelvic size, the anatomical configuration of the UPJ, crossing vessels, and differential renal function
- 10. Renography can provide quantitative measures of renal function, and, in general, kidneys with less than 15% differential function are nonsalvageable in adults.
- 11. Laparoscopic and Robotic Intervention. Laparoscopic approach to pyeloplasty was first introduced in 1993 by Schuessler and colleagues This has developed worldwide as a viable minimally invasive alternative to open pyeloplasty and endopyelotomy. Relative to both open pyeloplasty and endopyelotomy, laparoscopic pyeloplasty is associated with greater technical complexity and a steeper learning curve . In the hands of experienced laparoscopic surgeons, it has been shown to provide lower patient morbidity, shorter hospitalization, and faster convalescence, with the reported success rates matching those of open pyeloplasty (≥90%).
- 12. Following the similar surgical principles of anatomic dissection and repair used in open pyeloplasty, laparoscopic pyeloplasty has been shown to provide the success rates surpassing those of endopyelotomy by approximately 10% to 30%
- 13. Indications and Contraindications. The indications and contraindications for a laparoscopic repair are similar to those for either an endourologic or an open operative procedure. Indications to intervene include the presence of clinical symptoms of UPJO, the progressive impairment of renal function, and the development of ipsilateral upper tract calculi or infection. Cases requiring the transposition of crossing vessels obstructing the UPJ or the size reduction for massively dilated renal pelvis are also suitable for the laparoscopic approach.
- 14. Absolute contraindications Uncorrected coagulopathy, Active urinary tract infection, Presence of cardiopulmonary compromise unsuitable for surgery. The objective of the laparoscopic surgery Provide a tension-free, watertight repair with a funnel-shaped drainage to relieve clinical symptoms and to preserve renal function
- 15. Types of laparoscopic techniques for pyeloplasty Standard transperitoneal approach (including transmesenteric), Retroperitoneal approach, Anterior extraperitoneal approach, Laparoendoscopic single-site surgery (LESS) approach, and Robotic-assisted approach. For each approach, a dismembered Anderson-Hynes pyeloplasty is preferred by most surgeons.
- 16. Transperitoneal Laparoscopic Approach Was first described by Schuessler and colleagues (1993) and Kavoussi and Peters (1993). This approach has been the most widely used laparoscopic method owing to its associated large working space and familiar anatomy. Before the laparoscopic portion of the procedure, cystoscopy with retrograde pyelography may be first performed to define the anatomy and confirm the diagnosis, followed by placement of a ureteral stent and a urethral Foley catheter. Alternatively, the surgeon may place a stent laparoscopically in an antegrade fashion after incising the UPJ.
- 17. Position For transperitoneal procedures,including robotic-assisted laparoscopy surgery and LESS, patients are positioned in a 30- to 45-degree flank-up position. Care is taken to pad all pressure points to minimize risk of nerve injury and reduce the incidence of tissue breakdown and rhabdomyolysis. The patient is secured to the operating table to allow lateral tilting of the table. Tilting the table away from the affected kidneywill help move bowel out of the operative field. There is no needto flex the table or elevate the kidney rest as there is with open surgery.
- 20. Trocar placement A 12-mm trocar is placed in the anterior axillary line at the level of the umbilicus. This trocar is used for instrumentation and the passage of sutures, bulldog clamps, or staplers to secure and divide hilar vessels. In shorter patients, this may be placed in the midline, halfway between the umbilicus and pubis. A 10-mm trocar is placed at the umbilicus for camera manipulation A 5- or 10-mm port is inserted in the midline 2 cm below the xiphoid process. In obese patients, all trocar sites are shifted laterally. Additional trocars for retraction may be needed for visualization or assistance with organ entrapment. Additional low midline 10- or 12-mm trocars can be used for assistants to retract or use clamps or stapler device.
- 23. Access to the peritoneal cavity is obtained via either the Veress needle or the Hasson access technique. Colonic mobilization to expose the retroperitoneal structures is the initial step of the laparoscopic procedure In a nontransmesenteric approach, after medial mobilization of the colon, the ureter is identified and dissected in the cephalad direction to achieve mobilization of the ipsilateral proximal ureter, UPJ, and renal pelvis .
- 24. Extensive dissection of the ureter and excessive electrocautery use in close proximity to the ureter should be avoided to minimize injury to its vascular supply. At this time, the anatomy of the proximal ureter, renal pelvis, and nearby vasculature are carefully examined to determine the cause of the UPJO and the appropriate type of surgical repair. The general methods and principles of various types of surgical repair for laparoscopic pyeloplasty are identical to those described for open pyeloplasty. If dismembered pyeloplasty is to be performed, which is suitable for the presence of crossing vessels, the renal pelvis is first transected circumferentially above the UPJ and the lateral aspect of the proximal ureter is spatulated .
- 26. The renal pelvis and proximal ureter are then transposed to the opposite side of the crossing vessel, if such vessel is present, and the ureteropelvic anastomosis is then completed with intracorporeal suturing techniques. If the surgeon opted for antegrade laparoscopic stent placement, this can be accomplished by passing a wire down the ureter though either the upper quadrant port or a 14-gauge angiocatheter passed through the subcostal region. Clamping the Foley catheter and allowing the bladder to fill before wire passage can facilitate this process.
- 27. After the wire has been placed, a stent can be inserted over the wire using the pusher. In the presence of redundant renal pelvis, reduction pelvioplasty may be performed by excising redundant renal pelvic tissue and closing the pyelotomy. Suturing can be Either continuous running or simple interrupted sutures typically with 4-0 absorbable suture. A surgical drain is placed after the completion of the anastomosis, and one of the trocar sites is typically used as the drain exit site.
- 29. Transmesenteric Modification of the Transperitoneal Approach In select cases, it may be possible to forgo the initial step of colonic mobilization to reveal the UPJ by instead carefully opening the mesocolonic mesentery directly over the UPJ, being careful not to damage any mesenteric or crossing vessels. After incision of the mesentery, the UPJ is mobilized and reconstructed in the same fashion as the standard retrocolic approach. To use the transmesenteric approach, the dilated renal pelvis must be well visualized, and this is more often possible in thinner, younger patients with less adipose in their mesenteries.
- 30. Retroperitoneal Laparoscopic Approach The initial retroperitoneoscopic approach to pyeloplasty was first reported by Janetschekand colleagues (1996). Cystoscopy with retrograde pyelography and ureteral stent placement are first performed.
- 31. Patient Positioning and Trocar Placement With this approach, patients are placed in a full-flank position. Modest table flexion can help increase the distance between the ribs and iliac crest to facilitate trocar placement. A 15-mm transverse incision is made in the posterior axillary line, midway between the tip of the 12th rib and the iliac crest. After the dissection is deepened downward through the lumbodorsal fascia, the retroperitoneum is entered, and a working space may be developed using blunt dissection with the tip of a finger in the space between the psoas muscle and the kidney.
- 32. A simple balloon created from two fingers of a size 8 or 9 glove may then be inserted and filled with CO2 or saline, or alternatively, a purpose-built trocar with an integrated balloon may be used to dissect the fat away from the overlying musculature. A Blunt Tip Trocar is then passed through the incision, and the trocar cuff is expanded and cinched to the skin to prevent leakage of CO2.
- 33. Entry into the retroperitoneum may be confirmed by the appearance of the characteristic yellow retroperitoneal fat; insufflation is initiated, and blunt dissection using only the laparoscope is performed to develop a working space. Caution must be used not to enter too anteriorly because inadvertent peritoneal entry or colon injurymay occur; entering too posteriorly may result in bleeding from entry into the quadratus lumborum or psoas muscles.
- 34. The ureter is usually identified early in the procedure, and the dissection, mobilization, and UPJ repair steps are identical to those described for the transperitoneal approach. Once the working space has been established a 5-mm trocar is placed just off the tip of the 12th rib, and a 12- mm trocar is placed posteriorly and superiorly relative to the camera port.
- 38. Anterior Extraperitoneal Laparoscopic Approach Cystoscopy with retrograde pyelography and ureteral stent placement are first performed For the anterior extraperitoneal approach, medial mobilization of the peritoneal sac containing the bowel contents en bloc is performed. Subsequently, full exposure of the anterior aspects of the retroperitoneal structures including the ipsilateral ureter and kidney comes into view. The proximal ureter, UPJ, and renal pelvis are identified, dissected, mobilized, and repaired as in the transperitoneal laparoscopic pyeloplasty.
- 39. Robotic-Assisted Laparoscopic Approach The most widely used robotic system in the clinical setting today is the da Vinci Robotic System . Reported benefits of the robotic system include enhanced 3D vision, motion scaling, tremor reduction, improved dexterity, and increased range of motion. Typically the procedure is performed in a transperitoneal manner providing a larger working space for the robotic arms.
- 40. A ureteral stent may be placed in a cystoscopic retrograde or laparoscopic antegrade manner. In both transperitoneal and retroperitoneal approaches, at least four trocars are used in a robotic- assisted procedure, including three for the robotic arms (including one for the camera) and one for the surgical assistant to perform suction, irrigation, retraction, and suture introduction.
- 43. Laparoendoscopic Single-Site Surgery Approach LESS approach may offer patients improved cosmetic outcomes by decreasing the number of ports from three, four, or five to a single periumbilical incision that is often hidden. In LESS, all the instruments are inserted through a single location. This approach abandons the common laparoscopic principle of triangulation of the ports and results in challenge of clashing of instruments as they compete for space in a limited working area. Although this approach increases the level of complexity in performing the procedure, in experienced hands, complication rates of LESS pyeloplasty are similar to those with other minimally invasive approaches.
- 46. Postoperative Care and Complications Typically, a clear liquid diet is initiated on postoperative day 1 and advanced rapidly after minimally invasive pyeloplasty. Perioperative prophylactic antibiotic coverage is maintained. The Foley catheter is usually removed 24 to 36 hours postoperatively, and the surgical drain is removed before hospital discharge if the drain output remains negligible. If the drain output increases after the Foley catheter removal, the Foley catheter should be replaced for 7 days to eliminate urinary reflux along the stent in the treated ureter and decrease urinary extravasation at the ureteropelvic anastomosis. The ureteral stent is typically removed 4 to 6 weeks later in an outpatient setting, and follow-up including the use of imaging studies such as diuretic renal scan is performed as for an open pyeloplasty.
- 47. Most of the complications of laparoscopic pyeloplasty are similar to those of general laparoscopic procedures including colonic injury,hemorrhage,ileus,pneumonia, congestive heart failure, thrombophlebitis,and urinoma formation
- 48. Results Most of the published laparoscopic pyeloplasty reports have used the classic Anderson-Hynes dismembered technique. In the experienced hands, the entire procedure can be consistently performed in less than 3.5 hours. Perioperative complication rates are low, ranging from 2% to 15.8%, demonstrating the safety of the laparoscopic procedure. Open conversion rates are also low, in the range of 0% to 5.5%. Furthermore, blood transfusion risks are low. Postoperative analgesic use is typically minimal. Mean length of hospital stay is in the range of 2.2 to 2.8 days
- 49. Most failures from laparoscopic pyeloplasty occur in the first 2 years, although up to 30% of failed cases may occur after 2 years postoperatively . For the patients in whom laparoscopic pyeloplasty fails, open surgery has been used as a salvage procedure, with success rates of approximately 86% However, most patients can be well managed with endoscopic intervention such as endopyelotomy, with success rates of approximately 70%
- 51. Laparoscopic Dismembered Tubularized Flap Pyeloplasty. Presence of a significant upper ureteral defect after the excision of UPJ stricture may also be managed laparoscopically with success. Using a four-port transperitoneal approach, a wide- base renal pelvic flap was created and tubularized to bridge the defect,
- 52. Dismembered Pyeloplasty Indications. This approach can be used regardless of whether the ureteral insertion is high on the pelvis or already dependent. It also permits reduction of a redundant pelvis or straightening of a tortuous proximal ureter. Anterior or posterior transposition of the UPJ can be achieved when the obstruction is the result of accessory or aberrant lower pole vessels. Only a dismembered pyeloplasty allows complete excision of the anatomically or functionally abnormal UPJ itself.
- 53. It is important to note that a dismembered pyeloplasty is not well suited to UPJO associated with lengthy or multiple proximal ureteral strictures or to patients in whom the UPJO is associated with a small, relatively inaccessible intrarenal pelvis.
- 54. Technique Surgical exposure to the UPJ is achieved by first identifying the proximal ureter in the retroperitoneum. The proximal ureter is then dissected cephalad to the renal pelvis, leaving a large amount of periureteral tissue to preserve the ureteral blood supply. A marking stitch of fine suture can be placed on the lateral aspect of the proximal ureter, below the level of the obstruction for proper orientation for the subsequent repair. The UPJ tissue is typically excised, and the proximal ureter is then spatulated on its lateral aspect.
- 55. The apex of this lateral, spatulated aspect of the proximal ureter is brought to the inferior border of the renal pelvis, and the medial side of the ureter is brought to the superior aspect The anastomosis is then performed with fine interrupted or running absorbable sutures, placed full thickness through the ureteral and renal pelvic walls, in a watertight manner. If the renal pelvis is exceptionally redundant, a “reduction”pyeloplasty can be performed by excising the redundant portion of the pelvis. The cephalad aspect of the pelvis is then closed with running absorbable sutures down to the dependent portion, which will subsequently be anastomosed to the ureter.
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