You need to log in to watch this media!

Click here to log in.

Extraperitoneal laparoscopic pyeloplasty

Authors

Abstract

The description of the extraperitoneal laparoscopic pyeloplasty covers all aspects of the surgical procedure used for the management of ureteropelvic junction (UPJ) obstruction.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: Gerota's fascia, dissection, resection, reconstruction, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.

Media type

Publication

2002-06

Popular

Favorites

Audio

E-publication

WeBSurg.com, Jun 2002;2(06).
URL: http://www.websurg.com/doi-ot02en276.htm

Extraperitoneal laparoscopic pyeloplasty

1. Introduction

Recognition of the disadvantages of a loin wound has led to the introduction of minimal access alternatives to open pyeloplasty (balloon dilatation and endopyelotomy) with varying rates of success. Interpretation of the results of ureteropelvic junction (UPJ) obstruction treatment is confounded by the lack of standardisation of investigations. The data available suggests that dismembered pyeloplasty is the most successful intervention (Eden et al., 2001), as well as being the only technique capable of correcting all cases of UPJ obstruction. It has become the standard against which all other modalities are measured.

The superiority of pyeloplasty and an increasing confidence in performing complex laparoscopy have persuaded a small number of urologists to investigate laparoscopic pyeloplasty, achieving success rates which are 5-10% higher than in open surgery (Eden et al., 2001), thus setting a new standard of care for correcting UPJ obstruction.

2. Anatomy

• Topographic anatomy

1. Right kidney
2. Left kidney
3. Renal pelvis
4. Left ureter
5. Psoas major muscle
The kidneys lie on the posterior abdominal wall on either side of the spine. The left renal pelvis lies at the level of the first (transpyloric plane) or second lumbar vertebra, and the right renal pelvis at a slightly lower level, due to the presence of the liver.

• Local anatomy

1. Superior major calyx
2. Middle major calyx
3. Renal pelvis
4. Inferior major calyx
5. Ureteropelvic junction
6. Renal papillae
7. Minor renal calyces
8. Vascular renal pedicle
The renal pelvis may be either intra-renal or extra-renal in disposition and joins the upper ureter inferomedially at an anatomically indistinct junction: the ureteropelvic segment. The dilated upper, middle and lower extremities of the pelvis form the major calyces, into which a dozen or more minor calyces drain. These, in turn, drain the renal papillae. The extra-renal pelvis lies along the lateral border of the psoas major and quadratus lumborum muscles. The renal vascular pedicle lies immediately anterior to the pelvis, which typically has a capacity of under 5 mL. The ureters lie on the psoas major muscle, pass medial to the sacroiliac joints, course laterally at the ischial spines and then turn medially again to insert into the base of the bladder. Anatomical variations, such as complete or partial duplication of the collecting system, are common.

• Vasculature

1. Ureter
2. Renal pelvis
3. Vessel of the lower pole of the kidney
The collecting system derives its blood supply from the segmental vessels in the renal sinus, which spread out over the pelvis. The venous drainage of the kidney parallels its arterial inflow. Accessory arteries and veins are common, especially to the lower pole of the kidney. A vessel is present adjacent to the UPJ in 65% of patients (Sampaio, 1998) although it is thought to be the cause of UPJ obstruction in a lower percentage, estimated at 39% by van Cangh (1994).

• Physiopathology

1. Renal pelvis
2. Ureteropelvic junction
3. Vessel of the lower pole of the kidney
4. Ureter
UPJ obstruction is commonly believed to be a congenital abnormality. When it is encountered in adulthood, it is viewed as a late clinical manifestation of a congenital pathology. Several possible causes for intrinsic obstruction at the UPJ, responsible for approximately two thirds of cases, have been suggested (Eden, 1994):
- disproportionate growth of the lumbar region compared with the ureter;
- ureteral valves or tumours;
- the presence of an inelastic cuff of collagen;
- an abnormality of smooth muscle development;
- incomplete recanalisation of the embryonic ureter;
- high insertion of the ureter into the renal pelvis leading to kinking;
- ureteric compression by lower pole renal vessels in the fetus that disappear, leaving a stricture.
The remaining one third of cases are thought to be caused by ureteric compression or kinking by lower pole renal vessels as they cross the UPJ or upper ureter.

3. Indications

Indications
- primary and secondary UPJ obstruction.

Contraindications
- children <40 kg, previous renal surgery and the coexistence of renal calculi are contraindications for the novice.
- a horseshoe kidney mandates an anterior (transperitoneal) approach.

4. Preop period

An up-to-date serum creatinine, urine culture and renogram should be available. A renal ultrasound is acceptable imaging in children but an intravenous urogram should be available for adults to exclude coexisting renal calculi and to provide information on the pelvicalyceal anatomy. During the process of obtaining consent from the patient the surgeon should discuss the possibility of conversion to open surgery, the circumstances that might lead to this and his personal experience and results with the technique.

An appropriate intravenous antibiotic and subcutaneous heparin should be administered at induction of anaesthesia. Thromboembolic deterrent and pneumatic calf-compression stockings are used throughout the case. A cystoscopy and retrograde ureterogram are performed immediately prior to laparoscopy to exclude coexisting ureteric pathology and to opacify the pelvicalyceal system to confirm correct positioning of the proximal coil of a double-pigtail stent. A urinary catheter is placed following cystoscopy.

5. Operating room set-up

• Patient

- general anaesthesia with endotracheal intubation;
- lateral position with table angulated 30° under the loin;
- a padded lumbar support applied against the upper back and a padded arm gutter prevent the torso from rolling laterally. Wide adhesive tape is wound around the patient’s hips and the operating table to support the lower body.

• Team

1. The surgeon stands behind the patient.
2. The assistant stands in front of the patient until extraperitoneal access has been achieved. Thereafter he or she stands to the left of the surgeon, on a platform, to prevent clashing of elbows.
3. The scrub nurse stands in front of the patient for the duration of the procedure.

• Equipment

1. The laparoscopic unit and monitor are placed opposite the surgeon and assistant.
2. The diathermy and suction equipment are placed at the patient’s feet.

6. Trocar placement

• Principles

It is helpful to mark the following elements on the patient’s skin:
1. the 12th rib
2. the iliac crest
3. the erector spinae muscle

• Optical trocar

Trocar A (5-10 mm), for the camera: an open access technique is used to enter the retroperitoneum inferior to the tip of the 12th rib. A balloon made out of the middle finger of a size 8 surgical glove tied to a 20F catheter is inserted and slowly inflated with 500-700 mL saline and kept inflated for 5 minutes before deflating.

• Other trocars

Secondary ports are inserted under guidance of a finger inserted through this incision, as this is faster and safer than under endoscopic control
Trocar B (5 mm), for the surgeon’s left hand: placed below the 12th rib and anterior to the erector spinae muscle.
Trocar C (5-10 mm), for the surgeon’s right hand: placed midway between port B and the iliac crest.
Trocar D (5-10 mm), for the fan retractor: placed superior to the anterior superior iliac spine.
Once the secondary ports have been inserted, port A is placed in the primary access site. The skin is sutured around it to make an airtight seal.

7. Instrumentation

• Optical

1. Laparoscope, 0°, 5 or 10 mm
- camera system and high-flow insufflator

• Operating

1. 5 mm fine, curved scissors
2. 5 mm dissecting forceps
3. 5 mm suction device
4. Pair of matched 5 mm needle holders
5. 5 or 10 mm clip applier

• Retracting

1. 10 mm fan retractor

8. Gerota's fascia

1. Gerota's fascia
2. Psoas major muscle
3. Perirenal fat
Gerota's fascia is identified as an unyielding white sheet immediately above the psoas major muscle. It should be incised just above and parallel to the psoas major muscle, as far superiorly as the deflection of the instruments allows and inferiorly to a few centimetres below the position of port A. It is difficult to confuse it with the peritoneum, which appears blue and is located more anterior. Once Gerota’s fascia has been incised the perirenal fat is revealed. This fat contains blood vessels that can bleed heavily. It should be dissected cautiously until the lower pole of the kidney is identified.

9. Dissection

• Lower pole kidney

1. Lower pole of the kidney
The lower pole of the kidney should be dissected just enough to allow the insertion of a fan retractor below it. Elevation of the lower pole of the kidney using the retractor allows the renal pelvis to be easily identified at the renal hilum by gentle blunt dissection. Peripelvic fibrosis due to local infection can make this step more difficult. The hilar vessels should not be in danger as they lie medial to the pelvis. Time should not be wasted trying to find the ureter first as the kidney is a larger target.

• Renal pelvis and ureter

1. Dissected ureter
2. Ureteropelvic junction
3. Dissected renal pelvis
4. Dissected vessel of the lower pole of the kidney
The pelvis is dissected towards the UPJ. The first few centimetres of the proximal ureter are then also mobilised, taking care to preserve as much of the periureteric vasculature as possible. It is sometimes useful to retract the ureter caudally at this stage using a 2.0 polypropylene suture on a straight needle inserted percutaneously. Vessels adjacent to the UPJ are commonly present (65% of cases). Such a vessel should be dissected circumferentially only if it prevents the ureter from lying in a straight line. In such a case the ureter, once dismembered, should be transposed medial to the vessel before re-attachment to the pelvis.

10. Resection

• Pelvic incision

1. Ureter
2. Ureteropelvic junction
3. Renal pelvis
The renal pelvis is entered with scissors near the kidney. The pyelotomy is continued towards the UPJ, excising an amount of pelvis that is appropriate to the degree of hydronephrosis.

• Division of ureter

1. Ureter
2. Vessel of the lower pole of the kidney
The UPJ is then dismembered and the stent retrieved. If renal stones are present it is better not to complete the dismemberment of the UPJ until the stones have been retrieved with a flexible cystoscope.

• Spatulation

1. The ureter is drawn towards the operator and spatulated medially with scissors over 2 cm.

11. Reconstruction

• Pelvic traction

1. Vessel of the lower pole of the kidney
2. Renal pelvis
3. Ureter
If the ureter must be transposed medial to a vessel, a 2.0 polypropylene suture on a straight needle is inserted percutaneously at this stage to place caudal traction on the renal pelvis.

• Anastomosis

Interrupted 4.0 polyglactin sutures are placed at 3 mm intervals starting at the 'heel' of the anastomosis. The stent is replaced in the renal pelvis after the 'heel' suture has been inserted. The renal pelvis is closed with a separate running 3.0 polyglecaprone suture if necessary. All knots are tied intracorporeally.

12. End of procedure

1. A 20F drain is inserted through the lowermost port.
The port sites are closed in 2 layers. The incisions are infiltrated with local anaesthetic.

13. Postop period

Regular oral diclofenac sodium and opiate-paracetamol compound are given until discharge, supplemented by intermittent intramuscular morphine sulphate as required. Parenteral antibiotics are given for 48 hours.

Oral fluids and diet are given on the first postoperative day. The drain and catheter are also usually removed on the first day. Patients are discharged after 2 or 3 nights. The ureteric stent is removed 3 weeks after surgery.

Diuresis renography is performed at 3 months and then yearly for 3 years. Retrograde ureterography and ureteroscopy are used to investigate equivocal renogram excretion curves.

14. Conclusion

The excellent results listed above demonstrate that laparoscopic pyeloplasty has at least as high a success rate as open pyeloplasty. Coupled with the generic advantages of laparoscopic surgery, the results suggest that in expert hands laparoscopic pyeloplasty is probably now the standard of care by which other interventions should be judged.

15. Reference

Bauer JJ, Bishoff JT, Moore RG, Chen RN, Iverson AJ, Kavoussi LR. Laparoscopic versus open
pyeloplasty: assessment of objective and subjective outcome. J Urol 1999;162:692-5.
Eden CG. The laparoscopic pyeloplasty. MS thesis, University of London. 1994
Eden CG, Cahill D, Allen JD. Laparoscopic dismembered pyeloplasty: 50 consecutive cases. BJU Int
2001;88:526-31.
Janetschek G, Peschel R, Altarac S, Bartsch G. Laparoscopic and retroperitoneoscopic repair of
ureteropelvic junction obstruction. Urology 1996;47:311-6.
Moore RG, Averch TD, Schulam PG, Adams JB, 2nd, Chen RN, Kavoussi LR. Laparoscopic
pyeloplasty: experience with the initial 30 cases. J Urol 1997;157:459-62.
Sampaio FJ. Vascular anatomy at the ureteropelvic junction. Urol Clin North Am 1998;25:251-8.
Tan HL. Laparoscopic Anderson-Hynes dismembered pyeloplasty in children. J Urol 1999;162:1045-7;
discussion 1048.
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 1994;151:934-
7.

Username
Password
	Remember me (needs cookies)