Endopyelotomy has been widely used for the management of selected patients with ureteropelvic junction (UPJ) obstruction. Endopyelotomy, which is associated with a 10%–15% failure rate, is based on the principle of Davis’s intubated ureterotomy. The steep learning curve with laparoscopic suturing has restricted laparoscopic pyeloplasty to centers with high volume. Percutaneous endopyeloplasty consists of horizontal suturing of a standard vertical endopyelotomy incision performed through a percutaneous renal tract via a nephroscope. Our technique of percutaneous endopyeloplasty incorporates the use of a novel laparoscopic suturing device (SewRite SR5, LSI Solutions, Victor, NY) that was modified to enable use with a 26-French nephroscope (Karl Storz, Culver City, CA) for meticulous intrarenal suturing.
Technique
The SewRite 5SR (SewRite SR5, LSI Solutions, Victor, NY) is a 5-mm suturing instrument used for placing interrupted sutures ( Fig. 21.1A and B ). The device was modified in length and diameter to enable its use through the working channel of a 26-French Storz nephroscope.
Step 1. Retrograde contrast study and placement of ureteral catheter. Retrograde ureteral access is obtained cystoscopically by placing a 6-French open-ended ureteral catheter into the pelvicalyceal system.
Step 2. Renal access. Percutaneous renal access is obtained through an upper or midpole calyx, which provides direct access to the UPJ ( Fig. 21.2 ). A 30-French Amplatz sheath is positioned within the renal pelvis.
FIGURE 21.2
( A – C ) Percutaneous renal access is obtained through the left middle calyx.
Step 3. Conventional endopyelotomy. A laterally placed, full-thickness endopyelotomy incision is made using cutting current and a bugbee electrode ( Fig. 21.3 ). The incision is made across the stricture segment and extends for approximately 1 cm into the normal ureter distally and normal pelvis proximally. Care is taken to ensure a clean and sharp cut to facilitate subsequent endopyeloplasty suturing.
FIGURE 21.3
( A , B ) A laterally oriented, full-thickness, endopyelotomy button-hole incision is made using a hook electrode and cutting current. This incision is extended toward the ureteropelvic junction with a “cold” Endoshears.
Step 4. Mobilizing the distal ureteral lip. This is an important step for suturing ( Fig. 21.4 ). The periureteral fibroareolar tissue is carefully dissected away from the incised ureteral margin and the adjacent unincised ureter. This is performed carefully under vision using a 5-mm laparoscopic Endoshears (USSC, Norwalk, CT). Recently we have used the 3-mm MicroEndoshears (USSC, Norwalk, CT), which enables even more precise dissection. Care is taken not to excessively thin out the ureteral wall during this step. The entire dissection is performed “cold,” without cautery. Only specific spot coagulation of bleeding points is carried out as required. Occasionally one can encounter a vessel of significant size, which can be gently dissected away from the ureteral wall. This step serves three important purposes. First, it provides space for the suturing device while placing the distal bites. Second, it defines the distal ureteral lip enabling precise full-thickness suturing. Third, it releases tension on the horizontal suture line.
