Laparoscopic and Robotically Assisted Pyeloplasty in Adults

J. STUART WOLF JR.

Pyeloplasty is a first-line option for the management of ureteropelvic junction (UPJ) obstruction. The reconstructive techniques have evolved over the years, and most recently, the laparoscopic approach (with or without robotic assistance) has been introduced. In properly selected cases and with requisite expertise, laparoscopic pyeloplasty provide the same technical success as open surgical laparotomy and is associated with a shorter and less intense convalescence. The technique is well-established and reproducible, although there are situations that might prompt consideration of the open surgical approach such as extensive tissue deficit in the setting of prior surgery. Laparoscopic suturing is the most technically demanding portion of the procedure, such that manual suturing devices or robotic assistance can facilitate the procedure. This chapter summarizes the pre-, intra-, and postoperative considerations for laparoscopic pyeloplasty.

DIAGNOSIS

UPJ obstruction can present symptomatically, or it can be detected incidentally. Flank pain is the most common presenting symptom. Infection, urolithiasis, and/or impaired renal function can result as well. The radiographic finding of unilateral hydronephrosis and a normal ureter (on computerized tomography, magnetic resonance imaging, or ultrasonography) together with ipsilateral flank pain (classically episodic and related to fluid or alcohol intake) is sufficient to make the diagnosis. When the diagnosis is uncertain or if surgery is considered, however, further information such as estimation of differential renal function and quantification of outflow obstruction might be desirable and can be obtained with nuclear medicine renal scintigraphy. At the time of pyeloplasty, or in some cases as a separate procedure, retrograde ureteropyelography is recommended to confirm the diagnosis and determine the UPJ anatomy.

INDICATIONS AND CONTRAINDICATIONS

Indications for pyeloplasty include symptomatic UPJ obstruction or UPJ obstruction resulting in pyelonephritis, urolithiasis, and/or impaired renal function. Repair of asymptomatic UPJ obstruction that has not led to these sequelae can be offered, with the intention of preventing future problems. There are no absolute contraindications to the laparoscopic approach to pyeloplasty except the usual surgical contraindications (untreated coagulopathy, active infections, etc.). Significant prior infections, intrarenal pelvis, or prior pyeloplasty will make the laparoscopic approach more challenging, but with experience, these
cases can be managed laparoscopically. The combination of any of these with extensive tissue deficit, however, should prompt consideration of open surgery. In the absence of significant urinary leakage, prior endopyelotomy is not usually problematic.

ALTERNATIVE THERAPIES

The most common alternative to pyeloplasty is endopyelotomy, which is the endoscopic incision of the obstructed UPJ and intended healing of the ureter over a stent to provide a wider lumen. Following initial enthusiasm, there is now recognition that endopyelotomy for primary UPJ obstruction does not have favorable long-term results (1,2,3,4,5,6). Its best role may be in the management of pyeloplasty failures (secondary UPJ obstruction). In ill patients, chronic ureteral stenting may be considered as an alternative to definitive surgery.

PREOPERATIVE PREPARATION

Treat bacteriuria prior to surgery. Bowel preparation is not necessary. After the patient has taken nothing by mouth for 6 hours, and after administering intravenous antibiotics effective against skin and genitourinary organisms, place the patient under general anesthesia with oral endotracheal intubation.

INSTRUMENTATION FOR NONROBOTIC LAPAROSCOPY

The following list includes all of the instrumentation needed for all of the surgical steps described. Not all equipment is needed in all cases, and a variety of preferences will alter the list.

Nondisposable
- Laparoscope, 30- or 45-degree lens
- Video instrumentation and light source
- Surgical instruments
  - Scissors: standard and microscissors (right-angle scissors are helpful but not necessary)
  - Needle holders
  - Graspers: Maryland, bowel, and bipolar
  - Fascial closure device
  - Needle-suture passer
Disposable
- Laparoscopic ports, 5- and 12-mm
- Veress needle or other abdominal access device
- Insufflation tubing
- Irrigator-aspirator
- Dissection device (monopolar or bipolar cautery, ultrasonic, others)
- Endo Stitch (Covidien, Norwalk, Connecticut)
- Umbilical tape or vessel loop
- Sutures
  - 4-0 Polysorb for Endo Stitch
  - 4-0 braided, monofilament, or barbed suture for freeneedle suturing
  - Keith needle for retraction
  - Skin closure suture (or wound glue)
- 10Fr round closed suction drain catheter
- Internal ureteral stent
- Urethral catheter

SURGICAL STEPS

Cystoscopy, Retrograde Ureterography, and Ureteral Stent Placement

Confirm ureteral and renal pelvic anatomy with cystoscopy and retrograde ureterography (can be omitted if retrograde ureterography has already been performed) and place a ureteral stent. Some surgeons place the stent in an antegrade fashion laparoscopically. Insert a urethral catheter to drainage.

Position for Laparoscopy

Place the patient in a modified lateral decubitus position, 45 degrees from horizontal, with the ipsilateral side up on a flat table without flexion. Pad all pressure points well. Bring the ipsilateral arm over the chest and fix it in a neutral position.

Laparoscopic Entry and Port Placement

The transperitoneal route is most popular because it provides more room for suturing and better angles for transposition of the UPJ anterior to crossing vessels when felt necessary. Figure 10.1 illustrates typical port placement for a right-sided laparoscopic pyeloplasty. The midline ports are for the laparoscope (middle port) and the surgeon (working through the umbilical port and the most cephalad port). The fourth port is in a lateral position, in line with the umbilicus, for the assistant surgeon. In an obese patient, displace the ports laterally and cephalad. All ports are 5 mm initially, assuming a 5-mm laparoscope is available. The umbilical port is placed directly through the base of the umbilicus. If the Endo Stitch device is used for the repair, then increase the umbilical port from 5 to 12 mm. Obtain access at the lateral port site using your preferred method and place the remaining ports. Consider infiltrating all port sites with 0.5% bupivacaine (7).

Exposure of Operative Field

If the UPJ is visible under the colonic mesentery when performing a left-sided pyeloplasty, consider a transmesenteric route, which is more expedient. In most cases, however, reflect the colon and mesentery, staying outside Gerota fascia until reflection is complete. Liver or splenic retraction usually is not needed. Bowel mobilization is complete when the medial aspect of the lower pole of the kidney, up to the renal hilum, can be seen without active retraction of bowel (in obese patients, a bowel retractor may be required). Then, incise Gerota fascia to expose the renal pelvis, UPJ, and proximal ureter.

Dissection of Ureteropelvic Junction

Expose the UPJ either by identifying the renal pelvis and dissecting caudally or by identifying the ureter and proceeding
cephalad. Free up the lower aspect of the renal pelvis, UPJ, and proximal ureter from surrounding tissue. The degree of mobilization required depends on the selected repair. Preserve any lower pole crossing vessels. Stabilize the ureter and/or renal pelvis as needed with a vessel loop placed through the abdominal wall with a needle-suture passer or a suture on a Keith needle.