Laparoscopic pyeloplasty can be performed via either a transperitoneal or retroperitoneal approach. The transperitoneal approach involves mobilizing the colon to access the retroperitoneum. Trocar placement is typically in a triangular configuration. The procedure involves dissecting the ureter and renal pelvis, transecting the UPJ, spatulating the ureter, placing a stent, and performing an anastomosis with absorbable sutures to create a tension-free repair. Variations include a transmesenteric approach and retroperitoneal approach via a flank position. Success rates of laparoscopic pyeloplasty match those of open surgery.

1. BY : Dr. Ghanshyam Kumawat
Moderator : Dr Neeraj Agarwal (Associate prof...)

2. INTRODUCTION
 Laparoscopicapproach to pyeloplastywas first introduced
in 1993 by Schuessler andcolleagues (Kavoussi and
Peters )
 This has developed worldwide as aviable minimally
invasive alternative to open pyeloplasty .
 Relativeto open pyeloplasty , laparoscopic pyeloplasty is
associated with greater technical complexityand a
steeper learning curve .


3.  It Follows the similar surgical principlesof anatomic dissection
and repair used in open pyeloplasty.
 In the hands of experienced laparoscopic surgeons, it has been
reported success rates matching those of open pyeloplasty
(≥90%).
The objective of the laparoscopic pyeloplasty
 Provide a tension-free, watertight repair with a funnel-
shaped drainage to relieve clinicalsymptoms and to preserve
renalfunction.

4. INDICATIONS .
 Presence of clinical symptoms of UPJO.
 Progressive impairmentof renal function.
 Developmentof ipsilateral upper tractcalculi or
infection .
 Hypertension associated with UPJO.

5. CONTRAINDICATIONS OF LAP PYELOPLASTY
 Uncorrected
coagulopathy
 Presence of
cardiopulmonary
compromise unsuitable
forsurgery.
 Peritonitis.
 Extensive prior surgery.
 Intrarenal pelvic.
 Abdominal wall
cellulitis.
 Ascitis.
 Obesity.
 Organomegaly
Absolute Relative

6. Pre operative evaluation
 Evaluation to confirm diagnosis of UPJO in an adequately
functioning kidney.
 Various Radiological investigations
 X –ray KUB.
 USG abdomen.
 DDIVP /Computed tomography (CT)scan .
 Renal scan (MAG3/DTPA).
 These radiological tests evaluate the severity of
obstruction, degree of hydronephrosis, renal pelvic size,
any associated stones the anatomical configuration of
the UPJ, crossing vessels, and differential renal function.
 Urineroutineandculture
 Evaluation for fitness for surgery

7. VARIOUS INSTUMENTS REQUIRED
1- Access imstruments
Veress needle:
 Discovered by Hungarian physician janos veress in 1932
 Disposable/nondisposable-70 to 120 mm, 14 guage and 2
mm outer diameter.
 Max capacity 2 L/min
 Itconsists of an outersharpcutting needleand inner blunt
spring-loaded obturator.
Hasson’scannula:
 used forgaining initial access to theabdominal cavitywith
 an open cut downtechnique.

8. VERESS NEEDLE

9.  Trocars:
 Available in various diameters and sizes according
to requirements, 10 mm,12 mm and 5 mm being
commonly used.
 Trocar consists of outer hollow sheath
(cannula/port) and inner obturator.

10. INSTRUMENTS FOR
VISUALISATION
Telescope:
 This endoscope is made of surgical stainless steel
containing an optical lens train comprised ofprecisely
aligned glass lensesand spacers (Rod lens system).
 Telescopes or laparoscopes come in various sizes
ranges from 2.7 mm to 10 mm with 0 or 30 degree
lenses (range, 0 to 45 degree ).
 Recently devleoped laparoscopes has the tip which
can deflect in four directions up to 90 degree.

11.  Light source:
 White light illumination is provided from a high-
intensity xenon,mercury, or halogen lamp and
delivered via a fiberopticbundle.

12.  Gas insufflation:
1.CO2 Insufflator: The creation of working space in the
abdominal cavity is generally done using CO2 delivered via an
automatic, high flow, pressure regulatedinsufflator.
 CO2 iscurrently theagentof choicedue to low risk of gas
embolism,low toxicity to peritoneal tissues, rapid
reabsorption, low cost and inhibitscombustion.
 The insufflatordelives gas at a flow rateof up to 20 liters /
min.
 Presure maintained between 12 to 15 mm Hg.

14. INSTRUMENT FOR DISSECTION
 Maryland Dissector has long, curved jaws withfine-
tapered tips. Ideal for precise dissection (resembles
the atery forceps used in open surgeries).

15.  There are a variety of scissors for dissecting, mobilizing and cutting
tissues, which include straight and curved types .
Hook scissors are used to cut sutures, tough fibrous tissues.
Most dissecting scissors have adapters fordiathermy.
Repeated use of diathermy at the sharp edge may tend to blunt
the scissors.
SCISSORS:

16.  Ultrasonic Energy: (The Harmonicscalpel)
 Uses ultrasonic technology, the unique energy form thatallows
bothcutting and coagulationat the precise point of impact,
resulting in minimal lateral thermal tissuedamage.
 Cutsand coagulates byusing lowertemperatures than those
used byelectrosurgeryor lasers.
 Coagulation occurs by means of proteindenaturation when the
blade, vibrating at 55,500 Hz, couples with protein, denaturing
it to form a coagulum that seals small vessels.
 It offers greater precision in tight spaces near vital structures,
f ewer instrument changes are needed, less tissuecharring and
desiccationoccur, and visibility in the surgical field isimproved.

17. HARMONIC SCALPEL

18. DIFFERENT PROCEDURES OF LAP
PYELOPLASTY
 Anderson-hynes (most
commonly performed )
 Foley v –y plasty
 Culp-DeWeerd spiral
flap
 Scardino –prince
vertical flap
 Fenger pyeloplasty
Dismembered Non Dismembered

19. TYPES OF LAPAROSCOPIC TECHNIQUES FOR
PYELOPLASTY
 Standard transperitoneal approach (including
transmesenteric).
 Retroperitoneal approach.
 Laparoendoscopic single-site surgery (LESS)approach.
 Robotic-assisted approach.
 For each approach, adismembered Anderson-Hynes
pyeloplasty is preferred by most surgeons.

20. TRANSPERITONEAL LAPAROSCOPIC
APPROACH
 Was first described by Schuessler and colleagues
(1993)
( Kavoussi and Peters ).
 Most widely used laparoscopic method owing to
its associated largeworking space and familiar
anatomy.
.

21.  position
 For transperitoneal procedures, including robotic-
assisted laparoscopy surgery and LESS, patients are
positioned in a 30- to 45-degree flank-upposition.
 Care is taken to pad all pressure points to minimize
risk of nerve injury and reduce the incidence of
tissuebreakdown and rhabdomyolysis.
 The patient is secured to theoperating table toallow
lateral tilting of thetable.
 Tilting the tableaway from theaffected kidney
will help move bowel out of the operativefield.
 There is no need to flex the tableorelevate the
kidney rest as there is with open surgery.

23. Trocar placement
 Access to the peritoneal cavity isobtained viaeither the
Veress needleor the Hasson access technique.
 After creation of pneumoperitoneum Intraabdominal pressure
maintained between 12-15 mm Hg.
 There are various configurations for trocar placement as per
surgeon “s choice
.

24. 1 - Conventional 3 midline trocar – 12-mm
trocar is placed in the midline, halfway
between the umbilicus andpubis.
 This trocar is used for instrumentationand the
passage of sutures.
 A 10/12-mm trocar is placed at the umbilicus for
camera manipulation
 A5- or 10-mm port is inserted in the midline 2 cm
below the xiphoid process.
 In obese patients, all trocarsites are shifted laterally.
 Additional trocar for assistance may be placed at
level of at level of umblicus at anterior or mid
axillary line

25. Instead of midline
2 –Trigonal or rhomboidal arrangement of trocar can be
done.
One port 10 mm at umblicus for camera.
Two 5 mm port in mid clavicular line one at subcostal
level and another on the line joining between umblicus
and ASIS repctectively.
or
Two 5mm port with one subxephoid and another at
midclavicular line on the line joining between umblicus
and ASIS repctectively.

26. Port position figures

27.  Colonic mobilisation from white line of toldt ,to
expose theretroperitoneal structures .
 After medial mobilizationof thecolon, the ureter is
identified and dissected in the cephalad direction to
achieve mobilization of the ipsilateral proximal
ureter, UPJ, and renal pelvis.
STEPS OF PROCEDURE

28.  Transection of UPJ and redundant pelvic excision after stay
suture placement
 Spatulation of lateral end of ureter (1.5 -2 cm ) is done.
 stent placement..

29.  Posterior layer of ureteropelvic anastomosis is done followed
by anterior layer.

30.  Completion of anastomosis.

31.  Extensivedissection of the ureterand excessive
electrocautery use in close proximity to the ureter
should be avoided to minimize injury to its vascular
supply.
 At this time, the anatomy of the proximal ureter,
renal pelvis, and nearby vasculature are carefully
examined to determine the causeof the UPJO and the
appropriate typeof surgical repair
 If crossing vessel is present , renal pelvisand proximal
ureterare then transposed to the opposite side of the
crossing vessel, and the ureteropelvic anastomosis is
then completed with intracorporeal suturing
techniques.

32.  In the presence of redundant renal pelvis, reduction
pelvioplasty may be performed by excisingredundant renal
pelvic tissueand closing the pyelotomy.
 .
 Suturing can be Eithercontinuous running orsimple
interrupted sutures typically with 4-0 absorbable suture.
 Aim: widely patent anastomosis ,the reconstructed UPJ
should be funnel shaped, watertight, tension free & with
dependent drainage.
 A surgical drain is placed afterthecompletionof the
anastomosis, and one of the trocar sites is typically used as
thedrain exitsite.

33. TRANSMESENTERIC MODIFICATION OF THE
TRANSPERITONEAL APPROACH
 In select cases(childrens and thin young adults with less
mesentric fat) it may be possible to omit the initial stepof
colonic mobilization to reveal the UPJ by instead carefully
opening the mesocolonic mesentery directly over the UPJ.
 After incision of the mesentery, the UPJ is mobilizedand
reconstructed in the same fashion as the standard
retrocolicapproach.
 To use the transmesenteric approach, the dilated renal
pelvis must be well visualized.
 Advantages –less operative time
 Disadvantage –damage to middle colic artery.

34. RETROPERITONEAL LAPAROSCOPIC APPROACH
 The initial retroperitoneoscopic approach to
pyeloplasty was first reported byJanetschek and
and colleagues (1996).
 In this method Cystoscopy withureteral stent
placement may be firstperformed so ureteric
identificatons becomes easy during intraoperatively
as (as gonadal vessel sometimes look like ureter ).

35. POSITION OF PATIENT AND PORT PLACEMENT

36. Patient Positioning and Trocar Placement
 With this approach, patientsare placed in a full-flank
position.
 Modest table flexion can help increase the distance between
the ribs and iliaccrest to facilitate trocar placement.
 A 15-mm transverse incision is made below tip of 12th rib .
 After the dissection is deepened downward through the
lumbodorsal fascia, the retroperitoneum is entered, and a
working space may be developed using blunt dissection with
the tip of a finger in the space between the psoas muscle and
the kidney.

37.  A simple ballooncreated from two fingersof a size 8 or 9
glove may then be inserted and filled with CO2 or saline, or
alternatively, a purpose-built trocar with an integrated
balloon may be used to dissect the fat away from the
overlying musculature.
 Instillation of 800 ml of air in the baloon will create adequate
space (400 ml is sufficient for childrens )

 A Blunt Tip Trocar is then passed through the incision, and
the trocar cuff is expanded and cinched to the skin to prevent
leakage of CO2.

38.  Entry into the retroperitoneum may be confirmed by the
appearance of the characteristic yellow retroperitoneal fat.
 insufflation is initiated, and blunt dissection using only the
laparoscope is performed to develop a workingspace.
 Caution must be used not to enter too anteriorly because
inadvertent peritoneal entry or colon injury mayoccur.

40.  Once the working space has been established secondary
ports are placed in following manner
 one at anterior axillry line two to three finger breadths
above ASIS and another at lateral border of sacrospinalis
along inferior border of 12th rib.
 The ureter is usually identified early in the procedure,
and the dissection, mobilization, and UPJ repair steps
are identical to those described for the transperitoneal
approach
 Disadvantage –suturing is difficult due to crowding of
instruments

41. CONTD…
 Post operative care
 Prophylactic antibiotic coverage perioperatively.
 Day 1: clear liquid diet.
 Foleys catheter- 24-36 hours.
 Surgical drain removal: @ discharge or 4-6 days.
 If thedrain output increases afterthe Foleycatheterremoval, the
Foley catheter should be replaced for 7 days to eliminate urinary
reflux along the stent in the treated ureter and decrease urinary
extravasation at the ureteropelvicanastomosis
 Stent removal : 4-6 weeks.

42. FLAP PROCEDURES
 Foley Y-V Plasty
 Indication
 High insertion of ureter.
 Contra indication
 If lower pole vessels transposition is necessary or excision of
redundant pelvic is necessary.
 Technique
 Base of the V – toward kidney side of renal pelvis.
 Apex – UPJ.

43. FOLEY Y-V PLASTY BASIC CONFIGURATION
UPJO With high
insertion of
ureter

44. CULP- DEWEERD SPIRAL FLAP
 Indications
 Large extra renal pelvis with dependent an ureteral insertion.
 UPJ obstruction with long segment of proximal ureteral
narrowing.
 Ratio of flap length width should not exceed 3:1.
Long areas of
proximal ureteral
obstruction

45. SCARDINO- PRINCE VERTICAL FLAP
 Scardino- Prince vertical flap
 Indication
 Dependent UPJ with box shaped extra renal pelvis.
Dependent UPJ
situated at medial
margin of large box
shaped extra renal
pelvis

46.  The mostwidely used robotic system in theclinical
setting today is thedaVinci Robotic System .
 First robotic pyeloplasty in experimental setting
was performed by sung and gill (1999)
 Gettman and colleagues( palese and mufrrij) in
2002 performed first robotic pyeloplasty on
humans.
 Reported benefits of the robotic system include
enhanced 3D vision, motion scaling, tremorreduction,
improved dexterity, and increased range of motion.
 Typically the procedure is performed in a
transperitoneal manner providing a largerworking
space for the roboticarms.
 All steps are similar to lap pyeloplasty.
Robotic-Assisted Laparoscopic Approach

47.  In both transperitoneal and retroperitoneal
approaches, at least fourtrocars are used in a robotic-
assisted procedure, including three for the robotic
arms (including one for the camera) and one for the
surgical assistant to perform suction, irrigation,
retraction, and sutureintroduction.

49. LAPAROENDOSCOPIC SINGLE-SITE SURGERY APPROACH
 LESS approach mayofferpatients improved cosmeticoutcomes
by decreasing the number of ports from three, four, or five to a
single periumbilical incision that is oftenhidden.
 In LESS, all the instrumentsare inserted through a single
location.
 This approach abandons the common laparoscopic principle of
triangulation of the ports and results in challenge of clashing of
instrumentsas theycompete forspace in a limited working area.
 Although this approach increases the level of complexity in
performing the procedure, in experienced hands,complication
rates of LESS pyeloplasty are similar to those with other
minimally invasiveapproaches.

51. COMLICATIONS OF LAP PYELOPLASTY
 Acess related
complications-
bowel/vessal injury
 Complication of
pneumoperitoneum
 Conversion to open
 DVT/PE
 Atelectasis /pneumonia
 Subcutaneous
emphysema
 1-Early post op
 Urine leakage : heals
spontaneously in 1-2 weeks
if still persist –percutaneous
drainage –if still persists –
PCN
 Hematoma
 illeus
 Infection at port site
 Colon injury
 2-Late post op
 Stone formation
 Reccurent UPJ stenosis
 Port site hernia
General Complications due to
laparoscopic surgery
Surgery specific complications

52. FOLLOW UP AFTER SURGERY
 DJ stent removal after 4-6 weeks.
 IVP after 6 weeks of stent removal.
 Nuclear scan at 3 and 6 months followed by yearly
for 2 years .

53. COMPARASION OF LAP/OPEN PYELOPLASTY
Decrease need of
analgesia
Decrease hospital stay
Faster recovery
Cosmotically better
Less incisional hernia
 Increase operative time
 Long learning curve
 Increase cost
Advantage of lap surgery Drawbacks of lap surgery

54. ROBOTIC VS. LAPAROSCOPY
 Enhanced three-
dimensional vision
 motion scaling
 Tremor reduction
 Improved dexterity
 Increased range of motion
 Longer operative time
 Costlier (2.7 times)
 Limited instrumentation
 Need for experienced
bedside laparoscopic
assistance
 Success rate of open vs.
lap.vs robotic are
comparable- ≥ 90%
Advantages Disadvantages