Abstract
Introduction:
Minimally invasive pyeloplasty for redo cases or after recurrent attacks of pyelonephritis is a challenging procedure and requires extensive surgical experience and a prolonged learning curve. 1 –4 The objective of this video is to provide technical tips to improve the suturing technique and the outcome of complex pyeloplasty using the laparoscopic approach. In addition, these maneuvers could be applied to robotic pyeloplasty.
Patients and Methods:
Video recordings of laparoscopic pyeloplasty (LP) procedures for patients with complex ureteropelvic junction (UPJ) obstruction done between May 2017 and May 2019 were revised. A complex case was defined as LP after previous episodes of pyelonephritis requiring hospital admission and/or redo surgery. Surgical steps, technical difficulties, and potential solutions were reviewed and presented.
Results:
In 10 patients, the median (range) age was 26 years (19–50), and the mean (standard deviation) body mass index was 23 kg/m2 (3.4). First, our standard in situ ureteral spatulation technique is demonstrated, which involves ureteral spatulation while it is still attached to the UPJ to avoid ureteral twist or malrotation. Second, in redo cases, extensive fibrosis is expected, and compete ureterolysis is warranted to ease future anastomosis. In the case wherein the anastomosis is under tension, excessive ureteral and renal mobilization are required, then the application of the first suture might be on the sidewall of the ureter, rather than at the apex, for tissue approximation followed by suturing of the spatulated apex. Finally, a too small renal pelvis to be anastomosed with the spatulated ureter is overcome by a renal pelvis flap. The median (interquartile range [IQR]) operative time was 3.5 (2.5–5) hours. In one patient, a percutaneous nephrostomy was required for urinary leakage until complete healing was confirmed by antegrade nephrostogram. In another patient, a fluid collection was aspirated. All patients underwent Double-J stent fixation for 3 to 4 weeks and retrograde ureteropyelography was performed to document UPJ patency at the time of removal. At a median (IQR) follow-up of 6 months (6–14), all patients were asymptomatic with static split renal function by diuretic renography.
Conclusions:
During LP for complex cases, nondismembered ureteral spatulation, adequate ureterolysis, the need for excessive ureteral and renal mobilization, and a renal pelvis flap might be necessary steps to optimize the outcome. In addition, buccal mucosal graft substitution should be considered as a potential rescue procedure.
Patient Consent:
Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
No competing financial interests exists.
Runtime of video: 6 mins, 54 secs
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