This document discusses open pyeloplasty (OP) for ureteropelvic junction obstruction (UPJO). It covers indications for OP, technical aspects of the procedure, and outcomes and costs. OP is the standard surgical treatment for UPJO as it has good outcomes. The technical aspects section discusses the open incision, use of magnification and traction sutures, debate around prestenting, and judging renal anatomy. Training and a learning curve are required to properly perform the procedure. Studies have found that while laparoscopic and robotic procedures have longer operative times, outcomes are generally equivalent to OP. Complications are rare for all procedures. Costs are higher for minimally invasive approaches due to longer OR times.

3. Ahmed M Eliwa
MD UROLOGY AND ANROLOGY

4. • Symptomatic obstruction (recurrent flank
pain, UTI) requires surgical correction
using a pyeloplasty, according to the
standardised open technique of
Hynes and Anderson [492]
• There does not seem to be any clear
benefit of minimal invasive procedures in
a very young child but current data is
insufficient to defer a cut-off age

7. • Indications
• Technical aspects
• Outcomes and Cost

8. • Open pyeloplasty is the standard
surgical TTT for the PUJO
• Universal treatment for universal
pathology
Indications
Training
Outcomes
and Cost

9. LP
• Technically challenging patients [morbidly
obese , children less than 1year]
• failed open pyeloplasty [perinephric
scarring and the potential for
devascularization of the proximal ureter]
Indications
Training
Outcomes
and Cost

10. • small intrarenal pelvis
• Long stricture in the upper ureter
Indications
Training
Outcomes
and Cost

11. TECHNICAL ASPECTS

12. • Incision
• Magnification
• Traction sutures
• Prestenting
• The surgical procedure and judgment on
renal parenchyma or pelvic dimension
• Excellent assessment of secondary
pathologies
• Training and learning curve
Indications
Technical
Outcomes
and Cost

13. OPEN PYELOPLASTY
• Incision in open pyeloplasty is not long
Indications
Technical
Outcomes
and Cost

14. Indications
Technical
Outcomes
and Cost

15. Indications
Technical
Outcomes
and Cost

16. Indications
Technical
Outcomes
and Cost
A muscle-splitting dissection was done to reach the
Gerota’s fascia and expose the UPJ,

17. Traction sutures and orientation
• Traction sutures are crucial part of
pyeloplasty
• In open pyeloplasty they are easily
done
• Orientation and good judgment on the
dimension
Indications
Technical
Outcomes
and Cost

18. Magnification
Indications
Technical
Outcomes
and Cost

19. Prestenting
• Technical highlights include initial
placement of an internal ureteral stent
Laparoscopic dismembered pyeloplasty.
Schuessler WW , Grune MT , Tecuanhuey LV , Preminger GM
The Journal of Urology [1993, 150(6):1795-1799]
Indications
Technical
Outcomes
and Cost

20. Indications
Technical
Outcomes
and Cost
• previous ureteral stenting subjectively
complicated the surgical dissection.

21. Indications
Technical
Outcomes
and Cost
• Yurkanin JP, Fuchs GJ (2004) Laparoscopic dismembered pyeloureteroplasty: a single
institution’s 3-year experience. J ndourol 18: 765–769.
• Siqueira TM, Jr., Nadu A, Kuo RL, Paterson RF, Lingeman JE, et al. (2002) Laparoscopic
treatment for ureteropelvic junction obstruction. Urology 60: 973
–
978
.
• Moon DA, El-Shazly MA, Chang CM, Gianduzzo TR, Eden CG (2006) Laparoscopic
pyeloplasty: evolution of a new gold tandard. Urology 67: 932
–
936
.
• Dissection and full mobilization difficult owing to
the decompression of the renal pelvis by the
stent.
• The stent can be cut accidentally [migration]

22. • impede the identification of the extent of the
stenosis and hinder trimming of the ureter
and suturing of the posterior anastomosis
• Gaitonde K, Roesel G, Donovan J (2008) Novel technique of retrograde ureteral stenting during
laparoscopic pyeloplasty. JEndourol 22: 1199–1202
• Arumainayagam N, Minervini A, Davenport K, Kumar V, Masieri L, et al. (2008) antegrade versus
retrograde stenting in laparoscopic pyeloplasty. J Endourol 22: 671–674.
Indications
Technical
Outcomes
and Cost

23. Procedure
• In OP a plethora of procedures are
available for the surgeon to deal with
UPJO however A-H dismembered
pyeloplasty is the most commonly
practiced procedure for repair
Indications
Technical
Outcomes
and Cost

24. Suturing
• In open pyeloplasty is very easy
Indications
Technical
Outcomes
and Cost

25. Indications
Technical
Outcomes
and Cost
laparoscopic suturing
Laparoscopic suturing is a difficult skill to master but can
be acquired with extensive training outside the operating
room

26. Indications
Technical
Outcomes
and Cost
Robotics eliminated the early learning curve for
novices, which was present when they used standard
laparoscopic tools

27. Simulators
Indications
Technical
Outcomes
and Cost

28. Indications
Technical
Outcomes
and Cost
• The EndoStich gives the
surgeon the advantage
of being able to easily
pass sutures

29. Training and learning curve
Indications
Technical
Outcomes
and Cost

30. Lets make it more difficult

32. Retro

33. Single port

36. Outcomes, complications and costs

37. • OR time
• LOS
• COSTS
• Complications
Indications
Technical
Outcomes
and Cost

39. Indications
Technical
Outcomes
and Cost

40. Retroperitoneal Laparoscopic Pyeloplasty Series
Indications
Technical
Outcomes
and Cost

41. Indications
Technical
Outcomes
and Cost
Hong Mei, Jiarui Pu, Chunlei Yang, Huanyu Zhang, Liduan Zheng, and
Qiangsong Tong.
Journal of Endourology. May 2011, 25(5): 727-736.
doi:10.1089/end.2010.0544.
Published in Volume: 25 Issue 5: May 25, 2011
• October 2010 were searched from Medline,
Embase, Web of Science, Ovid, and Cochrane
databases.
• Laparoscopic Versus Open Pyeloplasty for
Ureteropelvic Junction Obstruction in
Children: A Systematic Review and Meta-
Analysis

42. Of 1403 studies,
• one randomized controlled trial (RCT)
• two prospective comparative studies,
• six retrospective observational studies
were eligible for inclusion criteria,
comprising 694 cases of LP and 7334
cases of OP.
Indications
Technical
Outcomes
and Cost

43. The OP has
• significantly reduced operative time
P<0.00001
• Higher stent placement rate
P<0.00001
Indications
Technical
Outcomes
and Cost
• Because of the publishing bias, a series of
RCTs are necessary to explore the efficiencies
of LP in the management of UPJ obstruction in
children.

44. Indications
Technical
Outcomes
and CostLaparoscopic vs Open Pyeloplasty in Children: Results of a
Randomized, Prospective, Controlled Trial.
Gatti JM1, Amstutz SP2, Bowlin PR1, Stephany HA3, Murphy JP1.
J Urol. 2016 Oct 17. pii: S0022-5347(16)31528-2. doi: 10.1016/j.juro.2016.10.056
-mean operative time, which was 139.5 minutes (range 94 to
213) in the laparoscopic group and 122.5 minutes (83 to 239)
in the open group (p <0.01)
-mean length of stay, which was 25.9 hours (18 to 143) in the
laparoscopic group and 28.2 hours (16 to 73) in the open
group (p = 0.02).
• the clinical significance of these variables is
questionable.
The approach to repair may best be
based on family preference for incision
aesthetics and surgeon comfort with
either approach, rather than more
classically objective outcome measures

45. Complications
• TRANSPERITONEAL
Indications
Technical
Outcomes
and Cost

46. Indications
Technical
Outcomes
and Cost

47. Indications
Technical
Outcomes
and Cost

48. Indications
Technical
Outcomes
and Cost
National Trends of Perioperative Outcomes and Costs
for Open, Laparoscopic and Robotic Pediatric
Pyeloplasty
Briony K. Varda Emilie K. Johnson , Curtis Clark , Benjamin I. Chung , Caleb P. Nelson
, Steven L. Chang
JOURNAL OF UROLOGY . 2014 Apr;191(4):1090-5.
• Operative time was longer for minimally
invasive pyeloplasty compared to open pyeloplasty
• Laparoscopic and robotic pyeloplasty had longer
median operative times (240 minutes, p <0.0001 and
270 minutes, p <0.0001, respectively].
• Length of stay was equivalent across all procedures.

50. Indications
Technical
Outcomes
and Cost

51. Korede Bello

52. One-trocar-assisted pyeloplasty: An attractive alternative to open
pyeloplasty. African Journal of Paediatric Surgery:Marte A,
Papparella A. AJPS. 2015;12(4):266-269. doi:10.4103/0189-
6725.172569.
November 2010Volume 184, Issue 5, Pages 2109–2115
One-Port Retroperitoneoscopic Assisted Pyeloplasty Versus Open
dismembered Pyeloplasty in Young Children: Preliminary Experience.
Paolo Caione, Alberto Lais, Simona Ger