TECHNIQUE OF LAPAROSCOPIC PYELOPLASTY
THOMAS W. JARRETT
Division of Endourology, Brady Urological Institute, School of Medicine, The Johns Hopkins University, Baltimore, USA
ABSTRACT
Pyeloplasty remains the gold standard therapy in the treatment of ureteropelvic junction obstruction. Laparoscopic pyeloplasty provides a minimally invasive alternative to open pyeloplasty without compromise of treatment success or durability. Presented is the surgical technique of laparoscopic pyeloplasty.
Key words:
ureteropelvic junction, obstruction, laparoscopy, pyeloplasty
Braz J Urol, 26: 76-81, 2000
INTRODUCTION
A
ureteropelvic junction (UPJ) obstruction is an impediment to urine flow
at the junction of the ureter and renal pelvis that leads to progressive
dilation of the collecting system. The condition can be primary or secondary
and may not present until later in life. The “gold standard”
therapy has been the open pyeloplasty with success rates consistently
greater than 90% for all types (1). Endoscopic incision either in an antegrade
or retrograde fashion provides a minimally invasive alternative, however
has success rates of only 70-89% even in well-selected patients (2,3).
Patients at high risk for failure include those with a large redundant
renal pelvis, the presence of crossing vessels, or poor renal function
(< 20%). In these cases, pyeloplasty has a clear advantage.
The first laparoscopic pyeloplasty was performed
by Schuessler et al. (4) in 1993 as an alternative to standard open pyeloplasty
performed through a flank incision. Initially there was some skepticism
surrounding the technical feasibility, success and durability of the procedure.
Recent studies however have shown overall success rates over 95% for primary
obstructions (5).
INDICATIONS AND
PATIENT
PREPARATION
Radiographic
evidence of a UPJ obstruction in conjunction with recurrent urinary tract
infections, pain, deterioration of renal function or calculus formation
are unequivocal indications.
In equivocal cases, a nuclear medicine examination
with lasix washout may be helpful. A urine culture is obtained pre-operatively
and any infection treated with appropriate antibiotics. The presence of
calyceal stones previously was a relative contraindication, however pyelolithotomy
can be safely performed in the same setting. If the patient has a stone
in the renal pelvis, the stone should be removed percutaneously and the
patient subsequently re-evaluated for UPJ obstruction. A mild bowel preparation
with clear liquids and laxative is given one day pre-op and the patient
is typed and screened.
TECHNIQUE
The patient is brought to the operating suite and cystoscopy with retrograde pyelography is performed to delineate ureteral anatomy and exclude distal stricture or filling defects due to calculus or tumor. A ureteral double pigtail stent is then placed and correct position confirmed with fluoroscopy. We perform this portion with flexible cystoscopy with the patient supine so that minimal re-positioning is required for the next portion of the procedure. A Foley catheter is placed just prior to proceeding to the laparoscopic portion of the procedure.
Patient
Positioning
The patient is moved to the flank position
with the ipsilateral side rotated up approximately 20-degrees. An axillary
role is placed, pressure points are padded and the table is flexed slightly
at the hips. The patient is secured to the table using wide cloth tape
at the lower extremities, hips and shoulders. This allows for the patient
to be rotated from a relatively horizontal position to the flank position
by simply rotating the table. The surgeon and assistant stand on the contralateral
side of the table and the scrub nurse at the feet (Figure-1). The abdomen
and flank is prepped and draped in the usual sterile fashion.
Insufflation
and Trocar Placement
Although both retroperitoneal and transperitoneal
approaches have been described, the author’s preference is transperitoneal
due to familiarity and ease of exposure of the UPJ. Open port placement
at the umbilicus or placement of the Veress needle can be performed with
the patient in the horizontal position. Correct placement in the peritoneum
is confirmed by aspiration with no withdrawal of air, urine, blood or
fecal matter and maintenance of a low pressure (10-mm Hg) with slow insufflation.
Following this step, three midline 10-12 mm trocars are placed as outlined
in Figure-2. Although smaller trocars can be used, this configuration
allows for passage of the camera as well as any instrument through any
of the ports. Accessory trocars can be placed lateral to the rectus fascia
at the level of the umbilicus for use by the assistant in retraction of
adjacent organs. For right-sided repairs, a small midline trocar just
below the xiphoid can be used for retraction of the liver.
Mobilization
of the Colon
The patient is rotated from the horizontal
to the flank position. Frequently, the hydronephrotic kidney can be identified
posterior and lateral to the colon. The posterior peritoneum overlying
the kidney is divided from the upper pole to a distance approximately
3 cm below the lower pole. Care must taken so as to not divide the lateral
attachments of Gerota’s fashion allowing the kidney to “flop”
medially. The reno-colic ligaments are divided allowing the colon to passively
move medially and provide clear exposure to the UPJ (Figure-3).
Identification
of the Ureter
The ureter is identified by following the
psoas muscle to a point just medial to the lower pole of the kidney. The
ureter can be distinguished from the gonadal vessels by peristalsis and
by the presence of the internal stent. If a stent had previously been
placed, this part of the case may be difficult due to marked peri-ureteral
inflammatory reaction. Care should be taken to not strip the peri-ureteral
tissues (and blood supply) except at the level of the UPJ. Once the ureter
has been identified, it is freed in a cephalad direction toward the UPJ.
A significant number of patients will have
a crossing vessel, which may be inadvertently injured if not identified.
At this point, the surgeon must commit to one of three following types
of repairs: 1)- Anderson-Hynes dismembered pyeloplasty, 2)- Foley Y-V
plasty or 3)- Fengerplasty (Heinke-Michuliz repair). Pyelolithotomy (discussed
later) is performed if stones are present prior to proceeding to surgical
repair.
Regardless of repair performed, the surgeon
needs to ensure that the repair can be made without tension. Maneuvers
to help decrease the distance between UPJ and ureter are the following:
1)- continued dissection of the UPJ and ureter (while maintaining its
blood supply), 2)- freeing the kidney outside the capsule so that may
be mobilized caudally and/or 3)- a nephropexy can be performed by suturing
the renal capsule at the lower pole to the psoas muscle.
Anderson-
Hynes Repair
An Anderson Hynes repair can be used with
any type UPJ obstruction and is the technique of choice with a crossing
vessel as the ureter can be divided and transposed anteriorly. To facilitate
this repair the pelvis is dissected (Figure-4) so as to allow for optimal
visualization and enough mobility to allow for a tension free anastomosis
with the ureter. The scissors are used to divide the ureter at the UPJ.
In the presence of a crossing vessel, the ureter is transposed anteriorly.
With a large redundant pelvis, a reduction needs to be performed prior
to final repair. The ureter is then spatulated on its lateral aspect (facing
the medial aspect of the kidney). Although free hand intra-corporeal suturing
can be performed, we have found this portion of the case facilitated by
use of an intra-corporeal suturing device (Endostitch, US Surgical, Norwalk,
CT). Three interrupted sutures (4-0 vicryl) are initially placed to properly
align the repair. The first interrupted stitch is placed from extraluminal
to intraluminal at the apex of the incision of the ureter and then from
intraluminal to extraluminal on the most dependent portion of the UPJ
(Figure-4). The ureter is then secured at the most cephalad portion anteriorly
and posteriorly in a tension free fashion to the corresponding site on
the pelvis. The repair is inspected and any gaps closed with interrupted
sutures. The cephalad portion of the defect is closed with a running repair
(Figure-4).
Foley
Y-V Plasty
A Foley Y-V plasty repair can be used in
the absence of a crossing vessel and is optimal for UPJ obstruction with
a high insertion. The advantages of this repair are that it significantly
reduces operative time and has less risk of devascularization of the UPJ.
The success of the Y-V plasty depends on proper placement of the incision
ensuring a broad-based flap of pelvis. Following incision the apex of
the flap is advanced and secured with an interrupted suture ensuring no
tension. The remaining gaps are then closed in an interrupted fashion
(Figure-5).
Heineke-Mikulicz
Repair
A Fengerplasty is technically the simplest
repair and can be used with a short stricture in the absence of a crossing
vessel or high insertion. With this type of repair, abnormal ureter is
identified and an incision created using scissors for a distance of approximately
7 mm above and below the stenosis. The incision is then closed in a transverse
fashion using interrupted sutures to bring the caudal and cephalad portions
of the incision together. The remaining gaps are then closed in an interrupted
fashion (Figure-6).
Pyelolithotomy
Pyelolithotomy can be performed in the same
setting for treatment of calyceal and non-obstructing renal stones. Review
of the pre-operative intravenous urography (IVU) and a plain film just
prior to the procedure is helpful in delineating the exact number and
location of the stones. For pyelolithotomy, an incision is created in
the renal pelvis as needed for the proposed repair (i.e. Anderson Hynes,
Y-V plasty). Many times the stones can be seen and grasped under direct
vision. If not readily seen or located in peripheral calyces, a flexible
cystoscope is passed through the upper port site and manipulated into
the renal collecting system. A tipless basket (Cooke Urologic; Spencer,
Indiana) or grasper is used for stone removal. If the stones are large
then lithotripsy may be necessary. One should not proceed to repair until
a stone free status is ensured.
At the end of the laparoscopic pyeloplasty,
a 5 mm closed suction drain is placed at the posterior axillary line and
positioned just posterior to the repair site and sutured in place. Trocar
sites are closed and the patient is transferred to the recovery room.
POST-OPERATIVE CARE AND DRAIN MANAGEMENT
Strict outputs from the Foley catheter and retroperitoneal drain are recorded. If there is minimal output from the retroperitoneal drain, the Foley is typically removed on post-operative day number two. The retroperitoneal drain is removed shortly thereafter if there is no increase in output. If there is persistent urine drainage from the retroperitoneal drain, the patient is sent home and educated on recording the outputs. The drains are removed when the above criteria are met.
FOLLOW-UP
The ureteral stent is removed in 4-6 weeks and an IVU is obtained two to three months post-operatively if the patient is without symptoms. Most failures will present in the first year
COMPLICATIONS
Complications related to laparoscopic pyeloplasty and their management are similar to those with open pyeloplasty. Intra-operative complications include bleeding that might require transfusion, injury to adjacent organs (bowel, liver, spleen and pancreas), conversion to an open procedure, adhesion formation, incisional hernia, infection or deep venous thrombosis. Postoperative complications include urinoma secondary due to persistent leakage and inadequate drainage.
COMMENTS
Laparoscopic pyeloplasty is a challenging but safe operation in the hands of an experienced laparoscopist. The advantages to the patient are optimal cosmetics, less post-operative morbidity leading to shorter hospitalization, less discomfort, and more rapid convalescence. Studies thus far indicate the approach is as efficacious as its open surgical counterpart when applied for the treatment of UPJ obstructions.
REFERENCES
- Scardino PT, Scardino PL: Obstruction of the Ureteropelvic Junction. In: Bergman H (ed.), The Ureter. New York, Springer-Verlag, p. 697, 1981.
- Cassis AN, Brannen GE, Bush WH, Correa RJ, Chambers M: Endopyelotomy: review of results and complications. J Urol, 146: 1492-1495, 1991.
- Van Cangh PJ, Wilmart JF, Opsomer RJ, Abi-Aad A, Wese FX, Lorge F: Long-term results and late recurrence after endoureteropyelotomy: a critical analysis of prognostic factors. J Urol, 151: 934-937, 1994.
- Schuessler WW, Grune MT, Tecyanhuey LV, Preminger GM: Laparoscopic dismembered pyeloplasty. J Urol, 150: 1795-1798, 1993.
- Jarrett TW, Fabrizio M: Laparoscopic Pyeloplasty : five-year experience (manuscript in progress).
_____________________
Received: June 20, 1999
Accepted: June 30, 1999
_______________________
Correspondence address:
Thomas W. Jarret, M. D.
Johns Hopkins Bayview Medical Center
4940 Eastern Avenue
Baltimore, Maryland, 21224, USA
Fax: (0021) (1) (410) 550-3341