Pelviureteral Junction Obstruction (PUJO) - Laparoscopic and robotic surgery

1. Pelvi-Ureteral Junction
Obstruction (PUJO)
Laparoscopic / Robotic Surgical
Management
Dr Abhishek Pandey
Senior Resident, Urology

2. Learning Objectives
By the end of seminar, you are expected to learn about
1. Various Lap & Robotic approaches to Pyeloplasty
2. Basic technique of Dismembered Pyeloplasty
3. Specific maneuvers used in Lap/Robotic Pyeloplasty
4. Critical steps of Lap/Robotic Pyeloplasty
5. Outcomes & Complications of Lap/Robotic Pyeloplasty

3. Introduction
• Schuessler 1993 – Laparoscopic Pyeloplasty
• Gettman 2002 – Robotic-Assisted Pyeloplasty
• >90% success rate, as with open pyeloplasty
• Less incisional morbidity & shorter hospitalization
• Robotic approach – wristed movements → easier
suturing; more expensive

4. Indications - Same as for open surgery
• Ipsilateral flank pain
• Deterioration of renal function
• Stones
• Infections
Goals of Intervention
provide resolution to clinical symptoms
conserve renal function

5. APPROACHES
TRANSPERITONEAL
• Most common
• Large working space
• 45-90° lateral decubitus
• Port placement – similar for lap / robotic
Lateral Shifting of ports in Obese patients & Downward Shifting in Large PUJO.

6. RETROPERITONEAL
• Steep learning curve
• Faster access
• No bowel handling
• 80-90° Flank position with surgeon operating
dorsally
• Port –
Laparoscopic Robotic – Cranial docking

7. TRANSMESENTERIC
• Modification of Transperitoneal approach
• Faster access with minimal bowel handling
• Incision over mesocolon
• Preffered approach on left side

8. ANTERIOR EXTRAPERITONEAL
• Large working space
• Extraperitoneal
• Familiar anatomy
• No bowel handling

9. LAPAROENDOSCOPIC SINGLE-SITE SURGERY (LESS)
• Feasible both lap & robotic
• Technically demanding
• Instrument clashing
• Cosmetic benefit
Right angle adapter
Multichannel port

10. Dismembered Pyeloplasty
• Most commonly done
• Versatile procedure
• Better results than non-dismembered

11. Ureteropelvic junction (UPJ) dissection

12. Transection of UPJ and spatulation of
proximal ureter along lateral aspect

13. Initial suture at UPJ

14. Posterior anastomosis closure

15. Antegrade ureteral stent placement

16. Anterior anastomosis closure

17. Ureteral Spatulation
&
Apical Stitch Placement

18. Extracorporeal Ureteral Spatulation
Spatulation
Initial suture at apex

19. Transabdominal Hitch Stitch

20. Double Hitch Technique

21. Spatulation & Suturing before dismembering

22. First cut on Ureter
Spatulation
Initial suture at apex

23. Handle of UPJ tissue

24. Lap Scissors for Spatulation
Articulating
Scissors
Single action straight scissors
Laparoscopic Hook scissors

25. Pelviureteral Anastomosis

26. Posterior layer done first
Anterior layer to finish anastomosis
Continuous Suturing
most commonly used
Faster
Economical
Some prefer interrupted
esp. for posterior layer

27. • Barbed sutures – Knotless Pyeloplasty
– Increased risk of recurrence reported in early series
– Newer studies
 same results
 same speed
 no added benefit

28. • 3-0 to 6-0 polyglactin suture on an RB-1 needle
• First knot at apex or slightly posterior to apex
• Endo-Stitch may be used for speed

29. Postanastomotic Dismemberment
Better alignment & orientation for suturing

30. DJ – Stent
• Antegrade placement preffered
– Retrograde stent may decompress pelvis
– Less chance of cutting stent & up-migration
– Reduces surgery time – no position change
• Stent introduction
– Initial puncture needle
– Lap Instrument Sheath
– Suction Cannula

32. Complex PUJO Scenarios
1. Intra-renal/Posterior pelvis
2. Duplex System with PUJO
3. Horseshoe & Pelvic kidney
4. Retrocaval Ureter
5. Redo-cases & long strictures

33. Intra-renal/Posterior pelvis
• Mobilization & retraction of lower pole of kidney
• Latero-medial Renal Pedicle Rotation
• Foley V-Y plasty easier
• Ureterocalicostomy

34. Duplex System with PUJO
• Retroperitoneal approach preferred
• Incidence – 2-7%; Usually of lower moeity
• Incomplete duplication
– Ureterotomy + end to side
– Lateral ureterotomy for lower
• Complete duplication
– Dismembered pyeloplasty

35. Horseshoe & Pelvic kidney
• Transperitoneal / Anterior Extraperitoneal approach
• HSK – Isthumectomy may not be required
– Vascular anatomy variable – meticulous dissection
• Pyelovesicostomy or Calicovesicostomy can be done

36. Retrocaval Ureter
Upper ureter transected
Retrocaval segment
•Mobilized
•Anteriorly transposed

37. Re-do Pyeloplasty
• Dense fibrosis, & long segment strictures
• Scardino-Prince Vertical Flap
• Culp-DeWeerd Spiral Flap
• Ureterocalycostomy
Spiral flap
Vertical flap

38. Laparoscopic vs Robotic-assisted
Open Laparoscopic Robotic
Duration 70-180min 120-250min 100-300 min
Complications 3-14% 2-16% 3-24%
Conversion --- 0–5.5% 0–6.8%
Mean stay 4.2 days 2.7 days 2.2-2.8 days
Success 90-100% 87-99% 95 to 100%
Cost 2.7×Lap

39. • Success rates >95% in most contemporary series
• 70% failures present in first 2yrs postoperatively
• Patients with Failed repair
– Endopyelotomy success rate – 70%
– Redo Lap/Robotic Success rate – 78-88%
– Open surgery success rate – 86%

40. Thank You

41. A
• A