Pediatric urology pujo- pyeloplasty

 Dept of Urology
 Govt Royapettah Hospital and Kilpauk Medical College
 Chennai
1

MODERATORS:
Professors:
 Prof.Dr.G. Sivasankar, M.S., M.Ch.,
 Prof.Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr.J. Sivabalan,M.S., M.Ch.,
 Dr.R. Bhargavi,M.S., M.Ch.,
 Dr.S. Raju, M.S., M.Ch.,
 Dr.K. Muthurathinam,M.S., M.Ch.,
 Dr.D.Tamilselvan, M.S., M.Ch.,
 Dr.K. Senthilkumar,M.S., M.Ch.
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
2

HISTORY
 1891 - Kuster- divided the ureter and re-anastomosed it to pelvis
 1892 - Fenzer – principle of Heineke-Mikulicz – transverse closure of longitudinal incision
 1916- Schwyzer – flap technique
 1937 – Foley –V-Y plasty
 1943- Davis – intubated ureterotomy
 1949 - Anderson & Hynes anastomosis of spatulated ureter to a projection of lower aspect
of renal pelvis
 1951-Culp & Deweerd – spiral flap
 1953-Scardino &Prince - vertical flap
3

INDICATIONS
 Presence of symptoms from obstruction
 Impairment of overall renal function
 More than 10 % difference in the split renal function
 Progressive loss of function
 Development of stones, infection or hypertension with obstruction
4

GOALS
 Relief of symptoms
 Preservation and improvement of renal function
5

FACTORS TO BE CONSIDERED BEFORE
 Presence or absence of crossing vessels
 Degree of hydronephrosis
 Renal pelvis size
 Level of ipsilateral and overall function
 Presence of anomalies
 Stones
6

PRINCIPLES OF PYELOPLASTY
 Widely patent
 Watertight
 Tension free
 Funnel shaped transition between pelvis and ureter
 Dependent drainage
7

PREOPERATIVE PREPARATION
 Contrast CT urogram & Diuretic renogram
 Preoperative antibiotics
 Preoperative drainage – infection, azotemia
8

PREOPERATIVE RGP
 Identify precisely the position of the UPJ
 Aide in the placement of the incision
 Rules out concomitant distal obstruction
9

SURGICAL APPROACHES
 Open
 Standard flank incision
 Anterior subcostal incision
 Posterior lumbotomy approach
 Laparoscopic
 Robotic
10

ANTERIOR EXTRAPERITONEAL APPROACH
POSITION: Supine with a roll
placed transversely beneath the
patient to elevate the flank
Subcostal incision - Made from
the edge of the rectus muscle to
just below the tip of the 12th rib
11

ANTERIOR EXTRAPERITONEAL APPROACH
 Minimal mobilization of renal pelvis and proximal ureter
 Valuable in bilateral disease
 Valuable in previous flank incision
 Other congenital anomalies
12

POSTERIOR LUMBOTOMY APPROACH
POSITION: Prone with rolled towels to elevate chest
and abdomen with legs and arms lying lower than the
back
INCISION:
Vertical incision lateral to the paraspinal muscles
with the 12th rib and bony pelvis as the upper and
lower limits.
Curvilinear / horizontal incision midway between
the two bony structures made parallel to the skin
lines 13

POSTERIOR LUMBOTOMY APPROACH
 Direct exposure to PUJ
 Thin patients
 No previous surgery
14

FLANK APPROACH
 Incision made from the tip of
12th rib anteriorly to the lateral
edge of the rectus muscle
following the skin lines
15

FLANK APPROACH
 Subcostal approach through bed of 12th rib
 Avoid injury to subcostal nerve
 Advantages:
 Familiar
 Excellent exposure
16

SURGICAL EXPOSURE
 Skin incision
 Dissection through three muscle/fascial layers: External oblique, Internal
oblique and transversus abdominis
 Protect Intercostal nerves
 Transversalis fascia dissected from underlying Gerota’s fascia and peritoneum
 Peritoneum medialised
 Gerota’s fascia opened vertically as far posteriorly as possible
 Expose renal hilum
 No need for complete mobilisation of the kidney
 Pelvis cleaned of the fat to expose UPJ
17

OPEN SURGICAL TECHNIQUES
 Anderson Hynes Dismembered pyeloplasty
 Foley’sV-Y plasty
 Culp DeeWerd spiral flap plasty
 Scardino Prince vertical flap plasty
 Davis intubated ureterotomy
 Ureterocalicostomy
 Fenger’s plasty 18

BASIC SURGICAL PRINCIPLES
 Identification of proximal ureter
 Preserve Blood Supply
 Ureter dissected cephalad to renal pelvis leaving a large amount of
periureteral tissue
 Ensure orientation
 Marking stitch of fine suture placed on lateral aspect of the proximal
ureter below obstruction
 Medial and lateral aspects of the dependent portion of the renal pelvis
marked with sutures 19

BASIC SURGICAL PRINCIPLES
 Excise pathologic UPJ tissue
 Proximal ureter is spatulated on its lateral aspect
 Watertight anastomosis - Full thickness fine interrupted or running
absorbable sutures, through the ureteral and renal pelvis
 Anastomoses over a stent
 Reduction pyeloplasty if renal pelvis is exceptionally redundant
20

ANDERSON HYNES DISMEMBERED PYELOPLASTY
Borne out of necessity in the repair of a retrocaval ureter
(Anderson and Hynes,1949)
21

DISMEMBERED PYELOPLASTY
ADVANTAGES:
 The ureteral insertion is high on the pelvis or already dependent.
 Excision of the pathologic UPJ and appropriate repositioning
 Permits reduction of a redundant pelvis or straightening of a tortuous proximal
ureter.
 Transposition of the UPJ can be achieved when the obstruction is due to accessory
or aberrant lower pole vessels.
 Complete excision of the anatomically or functionally abnormal UPJ 22

NOT IDEAL IN CASES OF
 Lengthy strictures
 Multiple proximal ureteral strictures
 Small pelvis
 Inaccessible intrarenal pelvis.
23

Traction sutures are placed to maintain
proper orientation for the subsequent
repair.
Medial and lateral aspects of the
dependent portion of the renal pelvis
Lateral aspect of the proximal
ureter, below the level of obstruction.
24

 Ureteropelvic junction is excised
25

 Proximal ureter is spatulated on its lateral aspect.
 The apex of this lateral, spatulated aspect of the
ureter is then brought to the inferior border of the
pelvis
 The medial side of the ureter is brought to the
superior edge of the pelvis.
26

 Anastomosis performed with fine interrupted
or running absorbable sutures placed full
thickness through the ureteral and renal pelvis
walls in a watertight fashion.
27

REDUCTION PYELOPLASTY
Excising the redundant portion
between traction sutures.
Cephalad aspect of the pelvis is then
closed with running absorbable suture
down to the dependent portion
Dependent aspect of the pelvis is then
anastomosed to the proximal ureter.
28

When aberrant or
accessory lower
pole vessels are
present,
dismembered
pyeloplasty allows
transposition of the
UPJ in relation to
the vessels
29

FOLEYV-Y PLASTY
 Indication
 High insertion of ureter
 Contra indications
 Crossing vessels
 Redundant pelvis
30

Base of theV is
positioned on the
dependent, medial aspect
of the renal pelvis and the
apex at the UPJ.
The incision from the
apex of the flap, which
represents the stem of
the y, is then carried along
the lateral aspect of the
proximal ureter well into
an area of normal caliber.
FOLEYV-Y PLASTY
31

• The apex of the pelvic flap is brought
to the most inferior aspect of the
ureterotomy incision.
• The posterior walls are then
approximated using interrupted or
running fine absorbable suture &
anastomosis is completed with
approximation of the anterior walls of
the pelvic flap and ureterotomy. 32

CULP-DEWEERD SPIRAL FLAP
 Large readily accessible extra renal pelvis
 Dependent ureteral insertion
 Long segment proximal ureteral narrowing or stricture
 Contraindications
 In cases of high ureteral insertion
 Aberrant vessel crossing
33

Base situated obliquely on the dependent aspect of the
renal pelvis.
Base of the flap is positioned anatomically lateral to the
UPJ, between the ureteral insertion and the renal
parenchyma.
The flap is spiraled posteriorly to anteriorly or vice
versa.
The anatomically medial line of incision is carried down
completely through the obstructed proximal ureteral
segment into normal-caliber ureter. 34

Once the flap is developed, the apex is rotated down to
the most inferior aspect of the ureterotomy.
The anastomosis is then completed, usually over an
internal stent.
35

 The site of the apex for the flap is determined by the length of flap
required to bridge the obstruction.
 The longer the segment of proximal ureteral obstruction, the farther
away is the apex because this will make the flap longer.
 To preserve vascular integrity of the flap, the ratio of flap length to width
should not exceed 3 : 1. 36

SCARDINO PRINCEVERTICAL FLAP
 Used when a dependent ureteropelvic
junction (UPJ) is situated at the medial margin
of a large, box-shaped extrarenal pelvis
37

 Base of the vertical flap is situated on the dependent aspect of
the renal pelvis, between the UPJ and the renal parenchyma.
 The flap is formed by two straight incisions converging from
the base vertically up to the apex on either the anterior or the
posterior aspect of the renal pelvis.
 The position of the apex determines the length of the flap
 The medial incision of the flap is carried down the proximal
ureter completely through the strictured area into normal-
caliber ureter 38

 The apex of the flap is rotated down
to the most inferior aspect of the
ureterotomy.
 The flap is then closed by
approximating the edges with
interrupted or running fine
absorbable sutures.
39

DAVIS INTUBATED URETEROTOMY
 Lengthy or multiple ureteral strictures
associated with PUJ obstruction
40

INTUBATED URETEROTOMY
Spiral flap is
developed
The apex of the flap is then
brought as far down as
possible
The distal aspect of the
ureterotomy is left open
to heal secondarily by
ureteral regeneration
41

INTUBATED URETEROTOMY
 Require routine nephrostomy tube
drainage to prevent postoperative
urinoma
 Antegrade nephrostogram after 6 weeks
 Ureteral stent removed after 6 weeks if
no extravasation
42

URETEROCALICOSTOMY
 Small Intrarenal pelvis
 Rotational anomalies – Horseshoe kidney etc
 Salvage technique for failed pyeloplasty
43

URETEROCALICOSTOMY
 Ureter is first identified
 Dissected proximally with a generous amount
of periureteral tissue
 Attempt to identify pelvis may be difficult
 Kidney mobilised to gain access to lower pole
44

URETEROCALICOSTOMY
 Parenchyma overlying the lower pole
calyx resected
 Proximal ureter spatulated &
ureterocalyceal anastomosis done
over an internal stent
 First suture at the apex of ureteral
spatulation and lateral wall of calyx
 Second suture 180 degrees away
45

URETEROCALICOSTOMY
 Remainder by interrupted open suture
technique
 Nephrostomy tube can also be
considered
46

URETEROCALICOSTOMY
 Renal capsule closed over cut surface
 But not over the anastomosis
 Anastomosis covered with
perinephric fact or peritoneal or
omental flap
47

FENGER’S PYELOPLASTY
 Small renal pelvis and no crossing
vessels.
 Heineke-Mikulicz principle
 Long incision along the anterior
renal pelvis and proximal ureter,
ending about 1 cm below the
obstructed area.
 Apex of the incision on the renal
pelvis to the inferior apex of the
incision on the proximal ureter
48

SPLASH PYELOPLASTY
 Few multiple small cuts on convex border of pelvis
 To relieve tension on anastomosis
 Heal by secondary intention
49

HELLSTROM OPERATION
Redundant pelvis wrapped around the crossing vessel
50

NEPHROPLICATION
 Plicating sutures through anterior, lateral and
posterior surface
 For efficient drainage of collecting system
51

NEPHROPEXY
 Lower pole sutured to posterolateral
abdominal muscles
 Infero-pelvicalyceal angle ≈ 90 degrees
 Pelvi-ureteric angle ≈180 degree
52

LAPAROSCOPIC APPROACH
 First introduced in 1993 by Schuessler and colllegues
 Techniques:
 Standard transperitoneal
 Retroperitoneal
 Anterior extraperitoneal
 Laparoendoscopic single site surgery (LESS)
 Robotic assisted approach
53

ADVANTAGES
 Lower patient morbidity
 Shorter hospitalization
 Faster convalescence
 Reported success rates matches that of open pyeloplasty(≥90%)
54

 DISADVANTAGES
 Greater technical complexity
 Steeper learning curve
 Absolute contraindications
 Uncorrected coagulopathy
 Active urinary tract infection
 Presence of cardiopulmonary compromise 55

 UPJO
 Failed endopyelotomy
 Anatomical abnormalities
 Crossing vessels
 Extremely dilated pelvis
 Small intra renal pelvis
 Multiple intra abdominal surgeries
IDEAL IN UNFAVOURABLE CONDITIONS
56

 Cystoscopy with RGP
 Placement of ureteral stent and urethral Foley catheter
 45 degree lateral decubitus position
57

TROCAR PLACEMENT
Conventional three midline trocars
A 10/12-mm trocar is placed at the umbilicus.
The second port (5 mm) is placed midway
between the xiphoid process and the umbilicus.
A third trocar is located midway between the
umbilicus and the symphysis pubis
In obese individuals – all trocars placed laterally
58

TROCAR PLACEMENT
A 10/12-mm trocar is placed at the
umbilicus.
The second port (5 mm) is placed
midway between the xiphoid process and
the umbilicus.
A third trocar in anterior axillary line at
the level of umbilicus
59

TRIANGULATION
60

TRANSPERITONEAL APPROACH
 Patient is placed in 70° lateral position without kidney bridge elevation
 A 30° telescope may be preferable for better view from different angles
 Additional port (5–10 mm convertible) is inserted in the epigastrium or
flank for the retraction or suction if the redundant bowel disturbs the
vision or there is collection
61

The line ofToldt is incised with
either a hook dissector or
ultrasonic shears.
Colon is reflected medially
until the ureteropelvic junction
and part of the pelvis is well
seen
Pelvis and UPJ are adequately
mobilised.
Stay suture is taken through the pelvis
to stabilise it and avoid frequent
unwanted movements of the
instrument
A nylon suture on a straight needle is
used for this purpose.The suture is
brought out through the flank.
62

TRANSMESOCOLIC APPROACH
 In left sided UPJ obstruction in children and in thin adults
 Once the mesocolon is incised, the bulging pelvis can be pulled into the
peritoneal cavity provided that the mesocolic arterial arcade is wide
 ADVANTAGES
 No need for colonic mobilisation.
 Very good illumination as there is not much of raw area with blood clots
 UPJ can be quickly accessed.
 The mean operative time is reduced by about 15–20 min.
 Occasional problem in this approach is injury to left colic vessel.
63

TRANSMESOCOLIC APPROACH
Bulging pelvis seen through
the mesocolon
Incision of the mesocolon over
the bulge, preserving the
mesocolic vessels
Pelvis seen through the
mesocolic window
64

RETROPERITONEAL APPROACH
 With the patient in the 90° lateral positions, and without the kidney bridge elevated, the
primary (camera) port is inserted by open technique in the renal angle i.e. lateral to erector
spinae just below the tip of 12th rib.
 A 1.5 cm long incision is made.
 A haemostat is introduced to split the muscles and the lumbodorsal fascia.
 The index finger is introduced through the wound into the retroperitoneal space to push
away the peritoneum anteriorly, thus enlarging the potential space.
 The space is inflated to the required volume (150–600 ml according to the built and age of
patient) using balloon technique.
 Alternatively commercially available balloon trocars can be used directly.
65

Initial retroperitoneal dissection anterior to psoas
Port placement (Right PUJ obstruction)
Ureter and gonadal vein seen in the retroperitoneum Pelvis dissected and pevi ureteric junction delineated
66

RETROPERITONEOSCOPIC APPROACH
 The first landmark to be identified is the psoas muscle.
 Dissection along this plane easily leads to the ureter.
 If the Gerota’s fascia with perinephric fat is extensive over the UPJ, it
may be incised (or excised) for free movement of the hand instruments.
 A preplaced stent or guidewire in ureter makes identification of ureter
easier (gonadal vessel may be mistaken for ureter).
67

POSTOPERATIVE CARE
 Urethral foley removed after 48 hrs
 External drain removed after 12 - 24 hrs following catheter removal
 Internal ureteral stents : 4-6 weeks after surgery
 If nephrostomy tube – nephrostogram 7-10 days postoperatively
68

COMPLICATIONS
 Anastomotic urine leak
 Retroperitoneal urinoma formation
 Postoperative ileus – laparoscopic
 Bleeding
 Infection
 Failure – 15% for secondary 5% for primary
69

 Can occur within the 24hrs
 Observation
 Drain lasting more than 5-7 days should be
investigated
POST PYELOPLASTY LEAK
70

INCREASED DRAIN OUTPUT
 Anastomotic leak
 Malpositioned drain
 Obstructed or malpositioned
stent
 CT scan can help in assessment of
stent positioning
 Creatinine level of the drain fluid
is higher than the plasma
creatinine
71

POST PYELOPLASTY LEAK
 Maintain the foley catheter - reduces chance of reflux and thereby reduces leak
 First be sure position of drain is not in contact with pelvis - Withdraw or shorten
the drain
 If drain lasts more than a week investigate - CT UROGRAM
 Done to demonstrate the site of leak
 Position of the stent and drain
 Additional Drainage – Nephrostomy is placed
 STENT MALPOSITION – Repositioning of stent 72

FOLLOW UP
 Stent removal 6 weeks after surgery
 Diuretic renal scan 1 month following stent removal
 Every 4 to 6 months for 2 years.
 Failures usually occur within the first year postoperatively.
73

POORLY FUNCTIONING KIDNEY
Differential function < 20%
PCN
Assess for recoverability
Function improves > 20%
Pyeloplasty
Differential function < 20% or
deteriorates
Nephrectomy 74

“SALVAGE” PROCEDURES
 Failed open pyeloplasty is a challenging problem
 Initial approach should be an endourological procedure
 Flap or dismembered techniques could be attempted if endoscopic
approach fails
 Technically toughest
 Wide mobilisation as much as possible is required
75

“SALVAGE” PROCEDURES
 Other options :
 Ileoureteral
 Pyelovesicostomy
 Autotransplantation
 In extreme cases where the opposite kidney is normal – Nephrectomy
can be considered.
76

 HORSE SHOE KIDNEY
 ECTOPIC KIDNEY
 DUPLICATED COLLECTING SYSTEM
PUJO IN ANOMALOUS KIDNEYS
77

HORSESHOE KIDNEY - PUJO
High insertion of ureter
Increased likelihood of crossing
aberrant vessels
But not all dilatation is due to
PUJO
 Ureter course anterior to
isthmus -mild increased resistance
to urine flow
78

HORSESHOE KIDNEY - PUJO
 IVU/CT UROGRAM
 3-D CT is very useful in planning
 Calyceal orientation
 Vascular relationships
79

 Anterior subcostal extraperitoneal approach.
 Dismembered usually done
 Non - dismembered (foleyY-V ) -Easy
 Isthmus division – Rarely indicated
 Allows both kidneys to be rotated into normal position for improved
drainage from pelvis.
PYELOPLASTY IN HORSE SHOE KIDNEY
80

VASCULAR
RELATION
 Venteromedially
related
 Posterior or
posterolateral incision
of UPJ is safe
81

ECTOPIC KIDNEYWITH PUJO
 50% of ectopic kidneys are hydronephrotic
 40% of cases due to PUJO
 IVU/CT UROGRAM
 RGP
 DIURETIC RENOGRAM
82

PUJO IN PARTIAL DUPLICATED SYSTEM
 MC – Lower moiety
 PYELOURETEROSTOMY
83

COMPLETE DUPLICATION WITH PUJO
PYELOPLASTY
84

 When there is marked
hydronephrosis of the lower-
pole moiety, particularly if the
UPJ is difficult to expose, then a
ureterocalicostomy may be
performed
85

 Ureteropyelostomy
 Ureter which needs to be
excised is dissected till the
bladder or as low as possible
and divided.
 Refluxing ureters need
complete excision to prevent
stump syndrome.
 Single sheath reimplantation
86

DUPLICATION WITH PUJO
NONFUNCTIONING MOIETY
 If the lower pole is poorly
functioning, a lower-pole
heminephrectomy is appropriate.
87

DUPLICATION WITH PUJO
NONFUNCTIONING MOIETY
 If a dysplastic upper pole segment
is present, owing to an ectopic
ureter or ureterocele, it may be
excised at the time of the lower
pole repair.
 Alternatively, an upper to lower
pole ureteropyelostomy may be
performed at the time of the lower
pole pyeloplasty 88

SECONDARY PUJO
SEVEREVUR (grade 4,5)
Kinking of tortous ureter at
relatively fixed PUJ
Stone related scarring
Iatrogenic instrumentation
89

FACTORS
LEADINGTO
SECONDARY
PUJO IN HIGH
GRADEVUR
 High grade reflux result in kinking of
upper ureter and adjacent UPJ
 Chronic reflux may stretch the renal
pelvis and result in atonicity of pelvis
 UTI – result in inflammation and
ureteritis and contribute to transient
or chronic obstruction at UPJ
90

VUR ASSOCIATEDWITH PUJO
91

VUR ASSOCIATEDWITH PUJO
 Correct upper tract obstruction first
 InitialVUR correction - Amplifies the upper tract dilatation during the
phase of post operative edema in lower ureter
 Simultaneous management ofVUR & PUJO have negative impact on
ureter vascularity
 Pyeloplasty can be combined with endoscopic injection of bulk agents
inVUJ 92

OUTCOME & PROGNOSIS
 Degree of obstruction
 Duration of obstruction
 Primary or secondary obstruction
 Function of the affected kidney
 Anatomic considerations
 Expertise of the treating surgeon
Overall success
rate > 90%
93

94

Pediatric urology pujo- pyeloplasty

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