Laparoscopic Management of Complex Ureteropelvic Junction Obstruction

Abstract

Ureteropelvic junction (UPJ) obstruction is associated with complex anatomic problems, such as pelvic kidneys, giant hydronephrosis, crossed fused ectopia with L-shaped kidneys, and poses a real challenge in management. In this paper, we describe simple laparoscopic techniques for the management of these cases of atypical and complex UPJ obstruction. From 2004 to 2008, 9 cases of UPJ obstruction with atypical anatomic problems were operated on laparoscopically at PGIMER (Chandigarh, India). The different surgical procedures performed lap-aroscopically were pyelovesicostomy (5 cases), ureterocalicostomy (1 case), calicovesicostomy (1 case), heminephrectomy (1 case), and ureteropyelostomy (1 case) as per the merits of each case. The four-port technique was followed for pyelovesicostomy, calicovesicostomy, and ureterocalicostomy (two 10-mm ports, one each at the umbilicus and lateral border of the ipsilateral rectus, and two 5-mm ports, one each at the lateral border of the contralateral rectus and midway between the umbilicus and symphysis pubis). Pyelovesicostomy and calicovesicostomy were stented with a suprapubically placed Foley catheter. Mean operating time was 140 minutes, with an average intraoperative blood loss of 50 mL. There were no intraoperative complications. The patients recovered well from the surgery. Postoperative nephrostograms confirmed anastomotic patency and good drainage. On follow-up, patients are asymptomatic with normal renal functions. Patients with calicovesicostomy and pyelovesicostomy were advised double voiding, and they need to be on long-term, perhaps lifelong, follow-up. In pelvic kidneys with UPJ obstruction and in select cases of giant hydronephrotic kidneys, anastomosis of the bladder with the most dependent part of the pelvicalyceal system ensures adequate drainage. Ureterocalicostomy is the choice of treatment in cases of UPJ obstruction with an intrarenal pelvis where calicovesicostomy is not feasible. Laparoscopic performance of these procedures is feasible and simple.