Laparoscopic intraperitoneal pyeloplasty

The description of the laparoscopic intraperitoneal pyeloplasty covers all aspects of the surgical procedure used for the management of ureteropelvic junction obstruction and hydronephrosis. 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: exposure, colon mobilization, dissection/division of ureter, pyelic resection, ureteropelvic anastomosis, end of the procedure. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   intraperitoneal   pyeloplasty

Authors
C Saussine
Abstract
The description of the laparoscopic intraperitoneal pyeloplasty covers all aspects of the surgical procedure used for the management of ureteropelvic junction obstruction and hydronephrosis.
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: exposure, colon mobilization, dissection/division of ureter, pyelic resection, ureteropelvic anastomosis, end of the procedure.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-12
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E-publication
WeBSurg.com, Dec 2001;1(12).
URL: http://www.websurg.com/doi-ot02en250.htm

Laparoscopic   intraperitoneal   pyeloplasty

1. Introduction
Ureteropelvic junction (UPJ) obstruction is a major cause of hydronephrosis.
The presence of a functional blockage at the UPJ hinders the flow of urine and results in the progressive dilation of urinary cavities anterior to the UPJ with destruction over time of the renal parenchyma.
2. Therapeutic modalities
Conventional treatment
Anderson-Hynes (dismembered) pyeloplasty is the most common treatment for UPJ (Anderson and Hynes, 1949). This procedure is generally performed via a lumbar or posterior approach. The obstructed segment is completely resected, with anastomosis of the renal pelvis and ureter. The functional outcome is usually good. The sequelae related to the lumbar or posterior approach include residual pain, conspicuous scars and flank hernia.

Endoscopic treatment
Endoscopic retrograde or antegrade techniques were developed to reduce the sequelae of conventional treatment (Brooks et al., 1995). They consist of opening the ureteropelvic junction endoluminally. The repair is then guided with a flexible ureteral stent. In the case of crossing lower pole vessels, the endoscopic approach is contraindicated due to the risk of injury and severe bleeding complications (Schwartz and Stoller, 1999; Quillin et al., 1996). The functional outcomes of these techniques are poorer than those obtained with conventional surgery, especially in cases of major ureteropelvic dilatation.

Laparoscopic treatment
The use of laparoscopy for reconstructive procedures (Schuessler et al., 1993; Pattaras and Moore, 2000) has made it possible to maintain the good functional results obtained by open surgery while avoiding approach-related sequelae (Bauer et al., 1999). Laparoscopic pyeloplasty may be performed via a transperitoneal or a retroperitoneal approach (Janetschek et al., 1996). This chapter focuses on the transperitoneal approach.
3. Anatomy
• Ureter
The ureteropelvic junction and the ureter are retroperitoneal structures. In order to expose these structures via a transperitoneal approach, colonic mobilization is mandatory. This is achieved by opening Toldt’s fascia.
• Ureter and testicular (ovarian) vein
During colonic mobilization, the testicular (ovarian) vein is exposed first. It should not be mistaken for the ureter.
• Renal vascular pedicle
Anatomical variations of this pedicle are common and give rise to polar vessels. The inferior polar vessels wrap around the junction.
4. Indications
Indications
Laparoscopy pyeloplasty is indicated for patients with either symptomatic or complicated ureteropelvic junction obstruction.
Clinical signs are as follows: pain, pyelonephritis, dilatation of the renal pelvis and calyces with massive late-onset secretion, thinning of the renal parenchyma and reduction in renal function on scintigraphy with a residual renal function higher than 10% in absolute value. If residual renal function is lower than 10%, it is advisable to perform a nephrectomy.

Contraindications
Contraindications for laparoscopic treatment of the ureteropelvic junction obstruction are essentially those for anesthesia.
Anesthesia:
The patient must be able to tolerate general anesthesia and pneumoperitoneum.
Coagulation disorders:
Results of coagulation tests must be normal.
Abdominal surgery:
Laparoscopic treatment can be performed despite previous history of abdominal surgery. Freeing of peritoneal adhesions is necessary. The placement of the first trocar via open technique is mandatory. A retroperitoneal approach may be preferred in these cases.
5. Preop period
Clinical signs
Ureteropelvic junction obstruction manifests the following clinical signs: permanent or renal colic type lower back pain, or urinary infection with pyelonephritis.

Imaging evaluation
Ultrasonography shows dilatation of the renal pelvis and calyces. Incidental cases of UPJ are sometimes discovered by ultrasonography in symptom-free patients.
Intravenous urography typically reveals dilatation of the cavities of the renal pelvis and calyces with a delay in the secretion and excretion of the contrast material (there may be lack of secretion of contrast in one kidney). More often than not, the ureter is not visible. Late images show stasis of the contrast. In certain cases, these signs increase after IV administration of diuretics.
An abdominal CT scan may show some of these signs.
Renal scintigraphy determines the residual function level of the affected kidney. When this level is almost nil, a nephrectomy is indicated to avoid the recurrence of symptoms. If the kidney maintains a certain level of functioning, a surgical repair procedure is suggested.

Preoperative workup
The anesthetic workup evaluates the respiratory and cardiac functions of the patient. Coagulation tests should be normal. Urine should be sterile.
The patient is informed of the risks of the procedure and of the possibility of required conversion to open surgery. A previous history of laparotomy increases the risk of conversion due to the resulting adhesions. In that setting, a retroperitoneal approach is recommended.
Bowel preparation is not done routinely, but an enema may be performed the evening before and on the morning of the procedure.
Skin preparation is similar to that for open pyeloplasty, with the shaving of hair from the costal margin to the mid-thigh level.
6. Operating room set-up
• Patient
- general anesthesia;
- right or left lateral decubitus position, contralateral to the operative side;
- sandbag is optional (useful in case of conversion);
- patient is supported by two posterior cushions (at sacral and shoulder level);
- adhesive strips securing the patient to the table and to the support cushions are placed at shoulder and pubis level;
- the low arm is brought out perpendicular to the patient and is placed on an axillary roll;
- the other arm is positioned parallel to the first arm from which it is separated with an additional axillary roll (or it can be secured to a bar placed above the patient);
- urinary catheter.
It is not necessary to routinely place a double-J stent in the ureter before the operation. In cases of a non-secreting kidney, a double-J stent would have been placed before the operative workup. Its presence often hinders dissection because of the inflammatory changes that it causes.
• Variation
Certain teams place the patient in supine position and may or may not use drapes to lift up the operative side. They can then adapt the lateral tilt of the table to place the patient in a somewhat lateral position.
• Team
1. The surgeon stands in front of the patient, closer to the feet for a right UPJ obstruction and closer to the head for a left UPJ obstruction.
2. The assistant stands in front of the patient to the right of the surgeon for both right and left obstructions.
3. The scrub nurse stands in front of the patient, facing the feet.
• Equipment
The laparoscopic unit and the monitor are positioned behind the patient.
7. Trocar placement
• Landmarks
Landmarks for trocar placement are:
- the umbilicus;
- the costal margin on the side of the obstruction;
- the anterior superior iliac spine on the side of the obstruction.
The first trocar is placed by open technique. It may be placed after establishing a pneumoperitoneum with a Veress needle. The other trocars are then placed under the visual guidance provided by the laparoscope.
• Trocar placement
The size and placement of trocars are as follows:
A: 10-12 mm, on the external margin of the rectus abdominis muscle, at umbilical level or 2-3 cm above the umbilicus
B: 12 mm, 5 cm lateral to A
C: 5 mm, 2 cm medial to, and occasionally above the anterior superior iliac spine
D: 5 mm, below the costal margin on the same line as C
8. Instruments
• Instruments
A standard set of instruments are required for the laparoscopic treatment of UPJ obstruction:
1. 0° laparoscope;
2. monopolar scissors;
3. ultrasonic scalpel (depending on availability and the surgeon’s preference);
4. bipolar grasper;
5. grasper;
6. needle holder;
7. suction-irrigation device;
8. double-J ureteral stent with its guidewire;
9. urinary catheter.
• Trocars/instruments
The trocars through which the instruments are inserted depend on the side of the obstruction. Instructions for a right-handed surgeon:
For a right-side obstruction:
A: laparoscope
B: monopolar or ultrasonic scalpel, needle holder
C: grasper or bipolar grasper
D: grasper
For a left-side obstruction:
A: laparoscope
B: monopolar or ultrasonic scalpel, needle holder
C: grasper
D: bipolar grasper or grasper
For a right UPJ obstruction, the surgeon uses trocars B and C and the assistant uses trocars A and D.
For a left UPJ obstruction, the surgeon uses trocars B and D and the assistant uses trocars A and C.
The suction device can be used in trocars B, C or D.
5 mm clips are necessary in rare cases.
9. Major principles
1. sufficient colon mobilization
2. limited dissection of the ureter to avoid devascularizing it
3. renal pelvis resection distal to calices
4. ureteropelvic anastomosis, tension-free and as wide as possible
5. drainage of the ureteropelvic anastomosis with a ureteral double-J stent
10. Exposure
Lateral decubitus position
Due to effects of gravity, the intestinal loops move to the contralateral paracolic gutter and do not impair visualization of the operative field.

Urinary catheter
This ensures an empty bladder throughout the procedure.

Nasogastric tube
The tube is placed during the procedure.
11. Colon mobilization
Right UPJ obstruction
Right colon mobilization is not extensive. It is seldom necessary to mobilize the hepatic flexure of the colon. Kocherization of the duodenum is generally not required.

Left UPJ obstruction
Left colon mobilization is often more extensive than on the right.
12. Dissection/division of ureter
• Dissection of the ureter
Right or left colonic detachment exposes the genital vein. This vein lies in a more superficial and external plane than the ureter. The ureter can be identified by its peristalsis and by its color, which is less bluish than the vein’s.
Dissection of the ureter should be sufficient. It is performed only in the direction of the ureteropelvic junction. A dissection that is too extensive and performed too close to the ureter involves a risk of ureteral necrosis due to devascularization.
• Dissection of the ureteropelvic junction
Progressive freeing of the ureter, caudad to cephalad, leads progressively to the ureteropelvic junction. A polar vessel crossing the ureteropelvic junction anteriorly may be found during dissection. The ureter and the junction are dissected free on either side of the pedicle.
• Pyelic dissection
Dissection of the renal pelvis is generally easy when it is dilated. The pyelic dissection is performed on its anterior and posterior surfaces.
Whenever possible, we avoid placing a double-J stent into the ureter before the operation as it causes a periureteral inflammatory reaction that interferes with the dissection. The emptying of the renal pelvis induced by the stent also makes the dissection more difficult.
Nevertheless, for inexperienced surgeons, a ureteral double-J stent may facilitate identification of the ureter.
• Division of the ureter
The ureter is divided just below the ureteropelvic junction. A ureteral incision made on its anterior surface gives the limb of the ureter a spatulated aspect that makes it possible to perform a wide ureteropelvic junction anastomosis.

13. Pyelic resection
Any excess renal pelvis is trimmed off and the ureteropelvic junction is removed following a straight or L-shaped incision. Care must be taken not to remove part of the calices. Division of these calices exposes the patient to the risk of subsequent stenosis.
The superior boundary of the divided edge of the renal pelvis is suspended to the overhanging abdominal wall using a wire. This wire used for exposure avoids retraction of the free border of the renal pelvis and aids anastomosis. This is very helpful when the surgeon is not experienced in the technique.
14. Ureteropelvic anastomosis
• Ureteropelvic anastomosis
The ureteral spatulation is anastomosed to the renal pelvis, starting by fixing the tail of the spatulation to the free inferior border of the divided edge of the renal pelvis. Interrupted suture or two 180° running sutures with 4.0 absorbable monofilament are used.
When the ureter is fixed to the renal pelvis by five interrupted stitches or a posterior running suture, a double-J stent is placed in the ureter.
• Double-J ureteral stent
The double-J ureteral stent is inserted through the subcostal trocar. It is possible to first insert a flexible guidewire into the ureter and to slide the stent into place over the guidewire. It is also possible to take a closed tip stent mounted on the stiff end of a guidewire and to insert both elements together into the ureter with the help of two graspers or a needle holder, or both.
To avoid gas leakage during passage of the stent or guidewire through the trocar, a plastic-coated tip (usually used in the openings of a cystoscope) may be placed in the trocar opening. When the double-J stent is placed in the bladder, the guide is removed and the upper extremity of the stent is placed in the renal pelvis.
• End of anastomosis
Once the double-J stent is in place, the anastomosis of the ureter to the renal pelvis is completed with 2 to 4 additional interrupted sutures. The remaining portion of the renal pelvis or “racket handle” is closed with a running suture. If a posterior running suture was performed, a second, anterior running suture completes the anastomosis. It begins at the most caudal stitch, and progressively fixes the anterior border of the ureter to the corresponding border of the renal pelvis. This second running suture then closes the remaining pyelic opening, resulting in a suture line resembling a tennis racket.
• Other techniques
• Foley Y-V plasty
In this chapter, we have described the Anderson-Hynes (dismembered) pyeloplasty. Other techniques are used to treat UPJ obstruction in traditional open surgery that may also be performed laparoscopically. These include the Foley Y-V pyeloplasty, which is performed by incising in a Y fashion and closing in a V fashion.
• Fenger plasty
Fenger (non-dismembered) pyeloplasty is performed by incising the UPJ longitudinally and closing the incision transversally.
15. End of the procedure
The suspension wire attached to the renal pelvis is clipped and removed.
Hemostasis is checked.
A Redon drain may be placed in the colonic gutter and withdrawn through the trocar situated close to the anterior superior iliac spine.
Trocars are removed under visual control. The optical trocar opening is closed using absorbable suture.
All trocar openings are reapproximated with staples.
The urinary catheter is removed as soon as bowel function is restored.
The Redon drain is removed when the drainage stops.
Hospital discharge is possible from POD 3 to POD 5.
The ureteral double-J stent is removed in an outpatient setting under local anesthesia between POD 21 and POD 30.
16. Reference