Pujo- endopyelotomy

1. ENDOUROLOGIC MANAGEMENT OF PUJO
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai 1

2. 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.
2

3. INTRODUCTION
• Endourologic management of UPJO was introduced by Ramsay and
colleagues in 1984 as a “percutaneous pyelolysis”
• Popularized in the United States by Badlani and colleagues (1986),who
coined the term endopyelotomy
3

4. The basic concept of the endopyelotomy
• A full-thickness lateral incision through the obstructing proximal
ureter, from the ureteral lumen out to the peripelvic and periureteral
fat
• A stent is placed across the incision and is left to heal
(based on the concept of Davis“intubated ureterotomy” )
4

5. • The advantages of endourologic approaches - reduced hospital stays and early postoperative
recovery.
• The success rate does not approach that of open, laparoscopic,or robotic pyeloplasty.
• consideration of any of the endourologic approaches requires the surgeon take into account
• the degree of hydronephrosis,
• ipsilateral renal function,
• concomitant calculi,
• presence of crossing vessels
5

6. INDICATIONS FOR INTERVENTION
• 1. Presence of symptoms associated with the obstruction
• 2. Impairment of overall renal function or progressive impairment of ipsilateral function
• 3. Development of stones or infection,or, rarely, causal hypertension.
The primary goal of intervention is relief of symptoms and preservation or improvement
of renal function
6

7. ENDOSCOPIC APPROACHES
• Percutaneous Antegrade Endopyelotomy
• Percutaneous Endopyeloplasty
• Retrograde Ureteroscopic Endopyelotomy
• Retrograde CauteryWire Balloon Endopyelotomy
7

8. PERCUTANEOUS ANTEGRADE ENDOPYELOTOMY
Indications
• Historically - PUJO with associated stones or
- failed open pyeloplasty
• Primary therapy for almost any patient with UPJO - encouraging results
8

9. Contraindications
• Long segment (>2 cm) of obstruction, active infection,and untreated coagulopathy
• The impact of crossing vessels is controversial
• The mere presence of crossing vessels is not a contraindication to an endopyelotomy
• Significant entanglement of the UPJ by crossing vessels may render any
endourologic approach unsuccessful
• When such entanglement is suggested by intravenous or retrograde pyelography,
it can be reliably verified with 3D helical CT
CROSSING VESSEL
9

10. Patient Preparation
• Sterile urine should be ensured at the time of definitive intervention
• If upper tract infection cannot be cleared because of obstruction - internal stenting or percutaneous
nephrostomy drainage
• Counselling - risks and benefits of the procedure
• success rate of any endourologic approach,including percutaneous endopyelotomy,may be less than that of
formal reconstruction.
• Risk of bleeding requiring transfusion,urinary leak, drainage-related complications,and hydropneumothorax,
particularly if upper pole access is used
10

11. Technique
• Access across the UPJ is established – In retrograde fashion cystoscopically or in an
antegrade manner percutaneously
• For retrograde access,the UPJ can be traversed using a hydrophilic wire passed through an open-end
catheter
• the open-end catheter is advanced over it into the renal pelvis
• The wire is withdrawn and contrast material is injected through the open-end catheter to guide
subsequent percutaneous access
11

12. • With the patient in the prone position,the site for percutaneous access is chosen to allow
straightforward access to the UPJ
• In general,a midposterior or superolateral calyx is chosen,and occasionally an inferolateral calyx
may be used
• The tract is initially established with fluoroscopic control
12

13. • Nephroscopy is performed,a wire can again be passed in a retrograde fashion through the
open-end catheter and grasped from above so that through-and-through access is
reestablished.
• Pass a second wire as a safety wire, so a working and a safety wire are now both in place
• At this point, percutaneous access is complete and the endopyelotomy may be performed
13

14. • The hook-shaped cold knife (endopyelotome) is used to
completely incise the UPJ in a full-thickness manner,
from the ureteral lumen to periureteral and peripelvic
fat
• The holmium laser or the cutting balloon catheter may
also be used to perform an antegrade endopyelotomy
14

15. • Stent is placed
• There remains no consensus as to the optimal stent size or duration for endopyelotomy
• A No.14/7-Fr endopyelotomy stent may be used,passed in an antegrade fashion with the larger-
diameter end of the stent positioned across the UPJ
• when the patient has not been prestented,passage of this large-caliber stent may be difficult
• In those instances,a No.10/7-Fr endopyelotomy stent or even a standard No.8-Fr internal stent may be
used
15

16. • In the setting of a high insertion,the incision can often be extended to the
dependent portion of the renal pelvis under direct vision, bridging the gap
between the lateral wall of the ureter and the medial wall of the pelvis, across the
periureteral and peripelvic fat
• Once the incision is complete, the stent is already in place and nephrostomy
drainage is instituted for 24 to 48 hours.
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18. Postoperative Care
• Avoidance of strenuous activity for 8 to 10 days after the procedure is recommended
• The ideal stent size,duration of stent placement,and radiographic follow-up after endopyelotomy
remain unclear
• Once the stent is removed,the patient returns 1 month later for clinical follow-up and radiographic
evaluation.
• This includes a history,physical examination,urinalysis,and diuretic renography
18

19. • If the patient remains asymptomatic and the diuretic renography reveals normal drainage,
reevaluation is performed at 6 months and then at 12-month intervals
• Majority of endopyelotomy failures occur within the first year of the procedure;
• For most adults,2- to 3-year follow-up is justified because studies indicate that even at 36 months
some late failures are identified, but relatively few are identified at 60 months
19

20. Results
• Success rates - 85% to 90% at experienced centers,with little difference in outcome noted in primary versus
secondary UPJO
• When percutaneous endopyelotomy fails,
• Retrograde endopyelotomy;
• Repeat percutaneous endopyelotomy;
• Laparoscopic, robotic, or open operative intervention
• In failed endopyelotomy - spiral CT angiography done to rule out a crossing vessel
• If a significant vessel is found,repeat endopyelotomy is usually not recommended
20

21. Complications
• Analogous to those associated with percutaneous nephrolithotomy
• Hemorrhage is a risk of any percutaneous upper tract procedure including
endopyelotomy
21

22. • Acute management of hemorrhage is usually conservative to start:bed rest,hydration,and
transfusion if necessary.
• The nephrostomy tube should not be irrigated acutely - it is preferable to allow the
pyelocalyceal system to tamponade the bleeding.
• Selective angiographic embolization - When continued bleeding does not respond to these
conservative measures
22

23. • Infection is a risk of any urinary tract manipulation including percutaneous
endopyelotomy – sterilise the urine preoperatively
• Persistent obstruction is rare in the early postoperative period because of the
internal stent
• Occasionally the stent can be obstructed from blood clots, and continued
nephrostomy drainage for a few days typically allows the problem to resolve
spontaneously
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25. PERCUTANEOUS ENDOPYELOPLASTY
• A hybrid technique - combines percutaneous endopyelotomy and an endoscopic Fenger plasty
• Endoscopic Fenger plasty - endoscopic Heineke-Mikulicz repair performed through a
percutaneous tract
• Percutaneous endopyeloplasty consists of horizontal suturing of a standard vertical
endopyelotomy incision performed through a percutaneous renal tract via a nephroscope
25

26. TECHNIQUE
Step 1. Retrograde contrast study and placement of ureteral catheter
• Retrograde ureteral access is obtained cystoscopically by placing a 6-French open-ended ureteral
catheter into the pelvicalyceal system
26

27. Step 2. Renal access
• Percutaneous renal access is obtained through an upper or midpole calyx,which provides
direct access to the UPJ
• A 30-F Amplatz sheath is positioned within the renal pelvis.
27

28. Step 3. Conventional endopyelotomy
• A laterally placed,fullthickness endopyelotomy incision is made using cutting current and a bugbee electrode
• The incision is made across the stricture segment and extends for approximately 1 cm into the normal ureter
distally and normal pelvis proximally
• Care is taken to ensure a clean and sharp cut to facilitate subsequent endopyeloplasty suturing
28

29. Step 4. Mobilizing the distal ureteral lip
• An important step for suturing
• The periureteral fibroareolar tissue is carefully dissected away from the incised ureteral margin and the adjacent
unincised ureter.
29

30. Step 5. Endopyeloplasty suturing
• The loaded SewRite SR5 is passed through the
working channel of the 26-F nephroscope
• The initial suture approximates the distal and
proximal angles of the endopyelotomy incision,
thereby dividing the horizontal suture-line into 2
equal halves
30

31. • Additional sutures are placed on either side of the initial stitch to complete the procedure
• The number of sutures depends on the length of the endopyelotomy incision
• Typically, 3 sutures are required,one on either side of the initial stitch
31

32. Step 6. Placement of a JJ stent and nephrostomy tube
• After obtaining precise mucosa-to-mucosa coaptation,a JJ ureteral stent is placed
antegradely,and a 20-French nephrostomy tube is placed.
32

33. • Percutaneous endopyeloplasty is technically feasible and safe.
• The initial clinical experience with percutaneous endopyeloplasty is encouraging.
• These data need to be validated by further studies from multiple centers with longer
follow-up
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35. RETROGRADE URETEROSCOPIC ENDOPYELOTOMY
The main advantage of a ureteroscopic approach
• It allows direct visualization of the UPJ and assurance of a properly situated,full-thickness
endopyelotomy incision without the need for percutaneous access
• Decrease in cost compared with the use of the cautery wire balloon,assuming
ureteroscopic equipment and electroincision or holmium laser are already available
35

36. Indications
• Functionally significant obstruction
Contraindications
• Long areas of obstruction and upper tract stones, which are best managed simultaneously with
alternative approaches,usually percutaneously or laparoscopically
• In patients with significant hydronephrosis,the evidence indicates an antegrade endopyelotomy may be more
efficacious
36

37. Technique
• General anesthesia - minimize patient movement
• Retrograde pyelogram is performed under fluoroscopic control
• A hydrophilic guide wire is passed cystoscopically under fluoroscopic
control and coiled in the pyelocalyceal system
37

38. • The ureteroscope is passed alongside the guide wire to the level of the UPJ
• 200- or 365-μm holmium laser fiber , 0.8 to 1.2 J and a frequency of 10 to 15 Hz, the
UPJ is incised in a posterolateral direction
• contrast material - extravasation confirms adequate depth
• JJ Stenting
38

39. Success rate
- 80%
Complications
• Most complications are minor and relate primarily to urinary leak, stent migration,
and infection
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40. 40

41. RETROGRADE CAUTERY WIRE BALLOON
ENDOPYELOTOMY
• No.7 Fr catheter on which was mounted an 8-mm balloon with a 150-μm-wide, 2.8-cm-long
electrosurgical cutting wire
• standard cystoscopic techniques and real-time fluoroscopy are used
• contraindications –
• stricture greater than 2 cm, upper tract stones.
• crossing vessels- increase the risk of hemorrhage
41

42. Technique
• Retrograde pyelogram under fluoroscopic control,
with C-arm imaging
• Stiff, nonconducting guide wire is passed and coiled
within the pyelocalyceal system
• The cautery wire balloon catheter is then passed
with the cutting wire positioned laterally
42

43. The renal pelvis should be drained via the cautery wire balloon catheter
and filled with dilute contrast material
- Balloon is partially inflated- waist will be visualized
- C-arm fluoroscopy -cutting wire is placed in position.
-75 W of pure cutting current is applied for 2 to 3 seconds
- waist resolve and extravasation of contrast material
43

44. Complications
• Major- hemorrhagic- crossing vessels
• strict adherence to lateral incision principles minimizes this risk
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45. THANK YOU
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