Pyeloplasty

Pyeloplasty is a surgical procedure to correct a ureteropelvic junction obstruction (UPJO), a condition where the connection between the kidney’s renal pelvis and the ureter is narrowed or blocked, impeding the flow of urine from the kidney to the bladder. This condition can lead to pain, infection, kidney stones, and progressive kidney damage if untreated. Pyeloplasty is most commonly performed in children and adults with congenital or acquired UPJO.

Indications

Pyeloplasty is indicated for:

1. Symptomatic UPJO:
   • Flank pain, especially after fluid intake or diuresis.
2. Recurrent Kidney Infections:
   • Due to stagnant urine flow.
3. Hydronephrosis:
   • Progressive swelling of the kidney detected on imaging studies.
4. Declining Kidney Function:
   • Documented by functional imaging such as diuretic renography.
5. Kidney Stones:
   • Caused by urine stasis in the renal pelvis.

Types of Pyeloplasty

1. Open Pyeloplasty:

   • Traditional surgical method with an incision in the flank or abdomen.
   • High success rate, but longer recovery time.

2. Minimally Invasive Pyeloplasty:

   • Laparoscopic Pyeloplasty:
     • Performed through small incisions using a laparoscope.
   • Robot-Assisted Laparoscopic Pyeloplasty:
     • Advanced technique offering greater precision and faster recovery.
   • Benefits: Shorter hospital stay, reduced pain, and faster return to activities.

3. Endopyelotomy:

   • A minimally invasive approach using an endoscope to incise the obstruction.
   • Suitable for select cases with less severe obstruction.

Preoperative Preparation

1. Diagnostic Workup:

   • Ultrasound: To assess the degree of hydronephrosis.
   • CT Urogram or MRI: To visualize the anatomy and identify the obstruction.
   • Diuretic Renography (MAG3 or DTPA scan):
     • To evaluate kidney function and confirm the severity of obstruction.
   • Urinalysis: To check for infection.
   • Blood Tests: To assess kidney function (creatinine, BUN).

2. Counseling:

   • Discuss the procedure, risks, benefits, and postoperative recovery expectations.

3. Anesthesia:

   • General anesthesia is used for pyeloplasty.

Surgical Procedure

1. Access:

   • Open or minimally invasive techniques are chosen based on the case.
   • For laparoscopic or robotic approaches, small incisions are made in the abdominal or flank area.

2. Ureteropelvic Junction (UPJ) Exposure:

   • The kidney’s renal pelvis and the ureter are carefully dissected to expose the narrowed junction.

3. Excision of the Obstructed Segment:

   • The narrowed or scarred segment of the UPJ is removed.

4. Reconnection (Anastomosis):

   • The healthy ends of the renal pelvis and ureter are reconnected to restore normal urine flow.
   • A tension-free, watertight repair is ensured.

5. Stent Placement:

   • A double-J stent is inserted into the ureter to maintain patency and support healing.

6. Closure:

   • The surgical area is checked for leaks, and incisions are closed.

Postoperative Care

1. Hospital Stay:

   • Open Surgery: 3-5 days.
   • Minimally Invasive Surgery: 1-2 days.

2. Pain Management:

   • Analgesics are prescribed for postoperative discomfort.

3. Hydration:

   • Adequate fluid intake is encouraged to promote urine flow.

4. Activity Restrictions:

   • Avoid heavy lifting and strenuous activities for 4-6 weeks.

5. Stent Removal:

   • The stent is usually removed 4-6 weeks after surgery, often under local anesthesia.

Benefits

• Relief from pain and urinary symptoms.
• Preservation or improvement of kidney function.
• Resolution of hydronephrosis and prevention of long-term kidney damage.