Making Laparoscopic Pyeloplasty Easier: A Novel Technique

Abstract

Introduction: Laparoscopic pyeloplasty (LP) remains a technically challenging procedure with few changes made during the past decade. The 7-minute video describes our current technique for LP that involves several facilitating steps performed on the externalized ureter. Bringing the dismembered ureteral end to skin level and performing several surgical steps on the externalized ureter can significantly simplify LP, shorten operative time, and make it a more attractive procedure. Surgical Procedure: Transperitoneal laparoscopy is performed through three 5-mm ports. Special attention is addressed to the placement of the lower trocarpositioned as cranial as possible to allow externalization of the ureter with minimal traction as well as comfortable triangulation for laparoscopy. The colon is medially dissected; the ureter, ureteropelvic junction (UPJ), renal pelvis, and eventual crossing vessels are identified and dissected. Distal dissection of the ureter should be kept to a minimum to avoid ureteral devascularization. In obese patients, where excessive dissection or traction of the ureter is necessary, a regular pyeloplasty is preferred. This occurred in two patients, who were excluded from the present study. Alternatively, on the left side, in selected cases, these steps can be performed through a transmesocolic window, obviating extensive medial colonic dissection. The UPJ is dismembered at the renal pelvis followed by (1) dessuflating the abdomen; (2) externalizing the dismembered ureter at skin level at the lower trocar site; (3) spatulation of the ureter and antegrade stent insertion are performed on the externalized ureter as open surgery; and (4) initiation of the anastomosis is also performed on the externalized ureter using a double needle vicryl 4/0 suture placed at the corner of the spatulation. If possible different color sutures should be used to facilitate orientation during the anastomosis. Pneuomoperitoneum is restored; the spatulated, stented ureter is returned into the abdomen. The anastomosis is achieved with two running sutures by using the two preplaced sutures. Special attention should be given to avoid twisting of the ureter. Materials and Methods: The described technique has been implemented in 43 consecutive patients. Success of the procedure was defined as disappearance of symptoms and improved renal function on postoperative diuretic renal scan. Results: Success rate was 96%, similar to other studies.1 The median operative time, 95 minutes (range: 80–115 minutes), was significantly shorter than that reported in these studies. Complications related to antegrade stent insertion occurred in two patients (4%): in one patient the stent protruded through the urethra; in the other it did not reach the bladder and was removed by ureteroscopy. No complications related to devitalization or excessive traction of the ureter were recorded. Conclusions: In our opinion, the described modified technique of LP facilitates this procedure, making it more accessible for a wider array of urologists. This technique may not be feasible in obese patients. Excessive traction on the externalized ureter and excessive distal dissection of the ureter should be avoided. No competing financial interests exist. Runtime of video: 7 mins