This document discusses urinary tract obstruction, specifically ureteropelvic junction obstruction (UPJO). It covers the causes, evaluation, and surgical treatment options for UPJO, with a focus on laparoscopic pyeloplasty. Key points include that UPJO can be congenital or acquired, and indications for intervention include symptoms, impaired renal function, stones or infection. Laparoscopic pyeloplasty is a less invasive alternative to open surgery that provides comparable success rates while reducing morbidity. The procedure involves mobilizing the colon, dissecting the ureter, and performing a dismembered pyeloplasty reconstruction.

1. BY : Dr Sumit Gupta
Moderator : Prof AK.Kaku Singh

2. Introduction
 Urinary tract obstruction is a major clinical problem that
affects both children and adults and can result in
permanent renal damage.
 The degree of injury to the kidney and the effect on overall
renal function depends on:
 the severity of the obstruction (partial or complete,
unilateral or bilateral),
 The chronicity of the obstruction (acute vs. chronic),
 The baseline condition of the kidneys,
 And the presence of other mitigating factors such as
urinary tract infection (UTI).

3.  The cause of urinary tract obstruction can be
congenital or acquired and benign or malignant.
 Obstructive uropathy accounts for approximately 10%
of all cases of renal failure.

4. URETEROPELVIC JUNCTION OBSTRUCTION
 The diagnosis of ureteropelvic junction (UPJ) obstruction
(UPJO) describes a functionally significant impairment of
urinary transport from the renal pelvis to the ureter.
 Although most cases are congenital, the problem may not
become clinically apparent until much later in life.
 Acquired conditions such as stone disease, postoperative or
inflammatory stricture, or urothelial neoplasm may also
manifest clinically with symptoms and signs of obstruction
at the level of the UPJ.
 Similarly, extrinsic obstruction can occur at this level as
well.

5.  Controversy persists regarding the potential role of
“aberrant” vessels in the etiology of UPJO.
 Significant crossing vessels have been noted in up to
63% of patients with UPJO but in as little as 20% of
individuals with normal kidneys.
 UPJO may also result from vesicoureteral reflux which
can lead to upper tract dilation with subsequent
elongation, tortuosity, and kinking of the ureter.

6. Indications for intervention for
UPJO
 The presence of symptoms associated with the
obstruction,
 Impairment of overall renal function or progressive
impairment of ipsilateral function,
 Development of stones or infection, or,
 Rarely , causal hypertension.

7. The primary goal of intervention is
 Relief of symptoms and preservation or improvement
of renal function.
 Such intervention should be a reconstructive
procedure aimed at restoring nonobstructed urinary
flow.

8.  When intervention is indicated, the procedure of
choice has historically been dismembered
pyeloplasty;.
 However , less invasive endourologic approaches have
a role as an alternative.
 Moreover, laparoscopic and robotic pyeloplasty has
gained acceptance as primary therapy at centers with
appropriate experience

9. Pre operative evaluation
 The patient undergoes the usual preoperative evaluation to
confirm a functionally significant UPJO in an adequately
functioning kidney, as well as evaluation for fitness for
surgery.
 Radiological investigations include intravenous
pyelography, diuretic isotope renal scan (MAG3/DTPA),
and a three-dimensional computed tomography (CT) scan
to rule out crossing anomalous vessels.
 These radiological tests evaluate the severity of
obstruction, degree of hydronephrosis, renal pelvic size,
the anatomical configuration of the UPJ, crossing vessels,
and differential renal function

10.  Renography can provide quantitative measures of
renal function, and, in general, kidneys with less than
15% differential function are nonsalvageable in adults.

11. Laparoscopic and Robotic
Intervention.
 Laparoscopic approach to pyeloplasty was first introduced
in 1993 by Schuessler and colleagues
 This has developed worldwide as a viable minimally
invasive alternative to open pyeloplasty and
endopyelotomy.
 Relative to both open pyeloplasty and endopyelotomy,
laparoscopic pyeloplasty is associated with greater
technical complexity and a steeper learning curve .
 In the hands of experienced laparoscopic surgeons, it has
been shown to provide lower patient morbidity, shorter
hospitalization, and faster convalescence, with the
reported success rates matching those of open pyeloplasty
(≥90%).

12.  Following the similar surgical principles of anatomic
dissection and repair used in open pyeloplasty,
laparoscopic pyeloplasty has been shown to provide
the success rates surpassing those of endopyelotomy
by approximately 10% to 30%

13. Indications and Contraindications.
 The indications and contraindications for a
laparoscopic repair are similar to those for either an
endourologic or an open operative procedure.
 Indications to intervene include the presence of
clinical symptoms of UPJO, the progressive
impairment of renal function, and the development of
ipsilateral upper tract calculi or infection.
 Cases requiring the transposition of crossing vessels
obstructing the UPJ or the size reduction for massively
dilated renal pelvis are also suitable for the
laparoscopic approach.

14. Absolute contraindications
 Uncorrected coagulopathy,
 Active urinary tract infection,
 Presence of cardiopulmonary compromise unsuitable
for surgery.
The objective of the laparoscopic surgery
 Provide a tension-free, watertight repair with a
funnel-shaped drainage to relieve clinical symptoms
and to preserve renal function

15. Types of laparoscopic techniques
for pyeloplasty
 Standard transperitoneal approach (including
transmesenteric),
 Retroperitoneal approach,
 Anterior extraperitoneal approach,
 Laparoendoscopic single-site surgery (LESS) approach,
and
 Robotic-assisted approach.
 For each approach, a dismembered Anderson-Hynes
pyeloplasty is preferred by most surgeons.

16. Transperitoneal Laparoscopic
Approach
 Was first described by Schuessler and colleagues (1993)
and Kavoussi and Peters (1993).
 This approach has been the most widely used
laparoscopic method owing to its associated large working
space and familiar anatomy.
 Before the laparoscopic portion of the procedure,
cystoscopy with retrograde pyelography may be first
performed to define the anatomy and confirm the
diagnosis, followed by placement of a ureteral stent and a
urethral Foley catheter.
 Alternatively, the surgeon may place a stent
laparoscopically in an antegrade fashion after incising the
UPJ.

17. Position
 For transperitoneal procedures,including robotic-assisted
laparoscopy surgery and LESS, patients are positioned in a
30- to 45-degree flank-up position.
 Care is taken to pad all pressure points to minimize risk of
nerve injury and reduce the incidence of tissue breakdown
and rhabdomyolysis.
 The patient is secured to the operating table to allow lateral
tilting of the table.
 Tilting the table away from the affected kidneywill help
move bowel out of the operative field.
 There is no needto flex the table or elevate the kidney rest
as there is with open surgery.

20. Trocar placement
 A 12-mm trocar is placed in the anterior axillary line at the level of the
umbilicus.
 This trocar is used for instrumentation and the passage of sutures,
bulldog clamps, or staplers to secure and divide hilar vessels.
 In shorter patients, this may be placed in the midline, halfway between
the umbilicus and pubis.
 A 10-mm trocar is placed at the umbilicus for camera manipulation
 A 5- or 10-mm port is inserted in the midline 2 cm below the xiphoid
process.
 In obese patients, all trocar sites are shifted laterally.
 Additional trocars for retraction may be needed for visualization or
assistance with organ entrapment.
 Additional low midline 10- or 12-mm trocars can be used for assistants
to retract or use clamps or stapler device.

23.  Access to the peritoneal cavity is obtained via either
the Veress needle or the Hasson access technique.
 Colonic mobilization to expose the retroperitoneal
structures is the initial step of the laparoscopic
procedure
 In a nontransmesenteric approach, after medial
mobilization of the colon, the ureter is identified and
dissected in the cephalad direction to achieve
mobilization of the ipsilateral proximal ureter, UPJ,
and renal pelvis .

24.  Extensive dissection of the ureter and 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
cause of the UPJO and the appropriate type of surgical repair.
 The general methods and principles of various types of surgical
repair for laparoscopic pyeloplasty are identical to those
described for open pyeloplasty.
 If dismembered pyeloplasty is to be performed, which is suitable
for the presence of crossing vessels, the renal pelvis is first
transected circumferentially above the UPJ and the lateral aspect
of the proximal ureter is spatulated .

26.  The renal pelvis and proximal ureter are then transposed to
the opposite side of the crossing vessel, if such vessel is
present, and the ureteropelvic anastomosis is then
completed with intracorporeal suturing techniques.
 If the surgeon opted for antegrade laparoscopic stent
placement, this can be accomplished by passing a wire
down the ureter though either the upper quadrant port or a
14-gauge angiocatheter passed through the subcostal
region.
 Clamping the Foley catheter and allowing the bladder to
fill before wire passage can facilitate this process.

27.  After the wire has been placed, a stent can be inserted
over the wire using the pusher.
 In the presence of redundant renal pelvis, reduction
pelvioplasty may be performed by excising redundant
renal pelvic tissue and closing the pyelotomy.
 Suturing can be Either continuous running or simple
interrupted sutures typically with 4-0 absorbable
suture.
 A surgical drain is placed after the completion of the
anastomosis, and one of the trocar sites is typically
used as the drain exit site.

29. Transmesenteric Modification of
the Transperitoneal Approach
 In select cases, it may be possible to forgo the initial step of
colonic mobilization to reveal the UPJ by instead carefully
opening the mesocolonic mesentery directly over the UPJ,
being careful not to damage any mesenteric or crossing
vessels.
 After incision of the mesentery, the UPJ is mobilized and
reconstructed in the same fashion as the standard
retrocolic approach.
 To use the transmesenteric approach, the dilated renal
pelvis must be well visualized, and this is more often
possible in thinner, younger patients with less adipose in
their mesenteries.

30. Retroperitoneal Laparoscopic
Approach
 The initial retroperitoneoscopic approach to
pyeloplasty was first reported by Janetschekand
colleagues (1996).
 Cystoscopy with retrograde pyelography and ureteral
stent placement are first performed.

31. Patient Positioning and Trocar Placement
 With this approach, patients are placed in a full-flank position.
 Modest table flexion can help increase the distance between the
ribs and iliac crest to facilitate trocar placement.
 A 15-mm transverse incision is made in the posterior axillary
line, midway between the tip of the 12th rib and the iliac crest.
 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.

32.  A simple balloon created from two fingers of 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.
 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.

33.  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 working space.
 Caution must be used not to enter too anteriorly
because inadvertent peritoneal entry or colon
injurymay occur; entering too posteriorly may result in
bleeding from entry into the quadratus lumborum or
psoas muscles.

34.  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.
 Once the working space has been established a 5-mm
trocar is placed just off the tip of the 12th rib, and a 12-
mm trocar is placed posteriorly and superiorly relative
to the camera port.

38. Anterior Extraperitoneal
Laparoscopic Approach
 Cystoscopy with retrograde pyelography and ureteral
stent placement are first performed
 For the anterior extraperitoneal approach, medial
mobilization of the peritoneal sac containing the
bowel contents en bloc is performed.
 Subsequently, full exposure of the anterior aspects of
the retroperitoneal structures including the ipsilateral
ureter and kidney comes into view.
 The proximal ureter, UPJ, and renal pelvis are
identified, dissected, mobilized, and repaired as in the
transperitoneal laparoscopic pyeloplasty.

39. Robotic-Assisted Laparoscopic
Approach
 The most widely used robotic system in the clinical
setting today is the da Vinci Robotic System .
 Reported benefits of the robotic system include
enhanced 3D vision, motion scaling, tremor reduction,
improved dexterity, and increased range of motion.
 Typically the procedure is performed in a
transperitoneal manner providing a larger working
space for the robotic arms.

40.  A ureteral stent may be placed in a cystoscopic
retrograde or laparoscopic antegrade manner.
 In both transperitoneal and retroperitoneal
approaches, at least four trocars 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 suture introduction.

43. Laparoendoscopic Single-Site
Surgery Approach
 LESS approach may offer patients improved cosmetic outcomes
by decreasing the number of ports from three, four, or five to a
single periumbilical incision that is often hidden.
 In LESS, all the instruments are inserted through a single
location.
 This approach abandons the common laparoscopic principle of
triangulation of the ports and results in challenge of clashing of
instruments as they compete for space 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 invasive approaches.

46. Postoperative Care and
Complications
 Typically, a clear liquid diet is initiated on postoperative day 1
and advanced rapidly after minimally invasive pyeloplasty.
 Perioperative prophylactic antibiotic coverage is maintained.
 The Foley catheter is usually removed 24 to 36 hours
postoperatively, and the surgical drain is removed before
hospital discharge if the drain output remains negligible.
 If the drain output increases after the Foley catheter removal, 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 ureteropelvic anastomosis.
 The ureteral stent is typically removed 4 to 6 weeks later in an
outpatient setting, and follow-up including the use of imaging
studies such as diuretic renal scan is performed as for an open
pyeloplasty.

47.  Most of the complications of laparoscopic pyeloplasty
are similar to those of general laparoscopic procedures
including colonic injury,hemorrhage,ileus,pneumonia,
congestive heart failure, thrombophlebitis,and
urinoma formation

48. Results
 Most of the published laparoscopic pyeloplasty reports have
used the classic Anderson-Hynes dismembered technique.
 In the experienced hands, the entire procedure can be
consistently performed in less than 3.5 hours.
 Perioperative complication rates are low, ranging from 2% to
15.8%, demonstrating the safety of the laparoscopic procedure.
 Open conversion rates are also low, in the range of 0% to 5.5%.
 Furthermore, blood transfusion risks are low.
 Postoperative analgesic use is typically minimal.
 Mean length of hospital stay is in the range of 2.2 to 2.8 days

49.  Most failures from laparoscopic pyeloplasty occur in
the first 2 years, although up to 30% of failed cases
may occur after 2 years postoperatively .
 For the patients in whom laparoscopic pyeloplasty
fails, open surgery has been used as a salvage
procedure, with success rates of approximately 86%
 However, most patients can be well managed with
endoscopic intervention such as endopyelotomy, with
success rates of approximately 70%

51. Laparoscopic Dismembered
Tubularized Flap Pyeloplasty.
 Presence of a significant upper ureteral defect after the
excision of UPJ stricture may also be managed
laparoscopically with success.
 Using a four-port transperitoneal approach, a wide-
base renal pelvic flap was created and tubularized to
bridge the defect,

52. Dismembered Pyeloplasty
Indications.
 This approach can be used regardless of whether the
ureteral insertion is high on the pelvis or already
dependent.
 It also permits reduction of a redundant pelvis or
straightening of a tortuous proximal ureter.
 Anterior or posterior transposition of the UPJ can be
achieved when the obstruction is the result of accessory or
aberrant lower pole vessels.
 Only a dismembered pyeloplasty allows complete excision
of the anatomically or functionally abnormal UPJ itself.

53.  It is important to note that a dismembered pyeloplasty
is not well suited to UPJO associated with lengthy or
multiple proximal ureteral strictures or to patients in
whom the UPJO is associated with a small, relatively
inaccessible intrarenal pelvis.

54. Technique
 Surgical exposure to the UPJ is achieved by first identifying
the proximal ureter in the retroperitoneum.
 The proximal ureter is then dissected cephalad to the renal
pelvis, leaving a large amount of periureteral tissue to
preserve the ureteral blood supply.
 A marking stitch of fine suture can be placed on the lateral
aspect of the proximal ureter, below the level of the
obstruction for proper orientation for the subsequent
repair.
 The UPJ tissue is typically excised, and the proximal ureter
is then spatulated on its lateral aspect.

55.  The apex of this lateral, spatulated aspect of the proximal ureter
is brought to the inferior border of the renal pelvis, and the
medial side of the ureter is brought to the superior aspect
 The anastomosis is then performed with fine interrupted or
running absorbable sutures, placed full thickness through the
ureteral and renal pelvic walls, in a watertight manner.
 If the renal pelvis is exceptionally redundant, a
“reduction”pyeloplasty can be performed by excising the
redundant portion of the pelvis.
 The cephalad aspect of the pelvis is then closed with running
absorbable sutures down to the dependent portion, which will
subsequently be anastomosed to the ureter.

56. THANK YOU