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Retroperitoneoscopic pyeloplasty: some technical tricks

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Abstract

This didactic video describes the key points in performing a pyeloplasty using the retroperitoneal approach. It is applicable for advanced laparoscopic surgeons.

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Duration

05'25''

Publication

2007-04

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E-publication

WeBSurg.com, Apr 2007;7(04).
URL: http://www.websurg.com/doi-vd01en2112.htm

Retroperitoneoscopic pyeloplasty: some technical tricks

1. Stay suture of ureteropelvic junction 00'18''

The goal of minimal access repair is similar to that of open pyeloplasty, which is to create a wide tension-free water-tight anastomosis. In this video, our retroperitoneoscopic approach in a lateral position is explained step by step. Three trocars are inserted. The kidney is left attached to the peritoneum and the pelvis is approached posteriorly. The ureteropelvic junction (UPJ) is freed with a minimal dissection. A 5/0 stay suture is placed at the level of the UPJ and anterior to the psoas muscle for a presentation and stabilization using an extracorporeal slipping knot. The ureter is opened and spatulated on its internal part leaving its proximal stenotic portion attached to the stay suture. In the same way, the dilated pelvis is partially incised leaving the external portion tied to the stay suture.

2. Ureteropelvic anastomosis 01'25''

The 1st point to re-approximate the ureter and the pelvis is placed at the lowest point of the ureter and pelvis. In case of some traction, it could be an extracorporeal slipping knot. For the next most changing step, the anastomosis, the crucial point is to get a stable image, especially in small children with a small working space. A Scamera holder is needed. You can now see the installation for a right-sided UPJ and now for a left-sided case. The anterior part of the ureteropelvic anastomosis is performed using an absorbable running suture passed by inside. In case of fragile tissue, it’s better not to grasp the pelvic and ureteric edges. If needed, a double J stent is inserted at that time through the upper port. The entry of the stent into the bladder is confirmed by the backflow of the urine from the bladder, which is filled with methylene blue. Then the posterior part of the anastomosis is completed using also a running suture passed from outside.

3. Excess renal pelvis excised and closed 03'30''

The UPJ is completely excised. The excess renal pelvis is then resected. It should be trimmed in a straight line without jagged margins. The stay suture is removed. The renal pelvis is closed with running sutures. A drain is left in place for 2 days. The UPJ is extracted through the 5mm hole. In case of aberrant lower pole vessels, the same principles are applied.

4. Technique for aberrant vessels 04'30''

The junction is attached to the psoas muscle but it must be completely divided. The pelvis is uncrossed so that the vessel can be placed posterior to the anastomosis. In conclusion, this technique has been used in more than 50 patients, 4 months to 18 years old with the same results as in open surgery but with all the advantages of a minimal access surgery.

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