DISMEMBERED V-FLAP PYELOPLASTY

Abstract

We present a modified technique of pyeloplasty that seems ideally suited for reoperative as well as primary repair of ureteropelvic junction obstruction due to high ureteral insertion. This repair combines the dismembered technique with creation of a V-flap of renal pelvis by dividing and incising through the ureteropelvic junction superolateral onto the pelvis to a height above the most dependent portion of the pelvis just exceeding the length of ureteral spatulation. The V-flap is completed by an inferolateral incision directed toward the lateral aspect of the pelvis at its most dependent portion. The tip of the V-flap is then flipped down and approximated to the apex of the posterior ureteral spatulation. Of the 12 cases managed by this procedure 2 were reoperative and 10 involved select primary repair with high ureteral insertion at the ureteropelvic junction. Patient age was 3 months to 17 years (median 11 months). Two procedures were performed via a dorsal lumbar incision in the oldest patients and 10 were done via the standard anterior extraperitoneal approach. Radiological evaluation, including mercaptoacetyltriglycine renal scan and/or excretory urography, was performed in all patients preoperatively and postoperatively. In all patients postoperative mercaptoacetyltriglycine renal scan and/or excretory urography at 3 months and 1 year showed excellent drainage after dismembered V-flap pyeloplasty. Dismembered V-flap pyeloplasty has proved to be successful with a number of advantages over the Anderson-Hynes dismembered technique in select patients. These advantages include the avoidance of tissue tension that make mobilization of the kidney and ureter unnecessary, aggressive ureteral spatulation, creation of a dependent, funneled configuration and automatic tapering of a redundant pelvis in the routine course of closure without excision of tissue. This technique also has the advantage of being simpler than other flap repairs and it combines the physiological virtues of dismembered repair with the anatomical advantages of flap pyeloplasty.