Introduction
Pyeloplasty is a surgical procedure performed to repair a blockage or obstruction in the ureteropelvic junction (UPJ), the point where the ureter meets the renal pelvis. This blockage can cause urine to flow back into the kidney, leading to infections, kidney damage, and other complications. Pyeloplasty is typically performed as an open surgery or with minimally invasive techniques such as laparoscopy or robotic-assisted surgery. Open pyeloplasty remains the gold standard for correcting ureteropelvic junction (UPJ) obstruction in pediatric and adult age groups. In recent series, the success rate after open pyeloplasty exceeds 90 %. In order to avoid the pain and prolonged recovery associated with open surgery, several minimally invasive techniques for repairing the obstructed UPJ have been developed. While pyeloplasty is generally safe and effective, it is not suitable for everyone. In this article, we will discuss the indication and contraindication of the pyeloplasty.
What Is Pyeloplasty?
Pyeloplasty is a surgical procedure that is performed to correct a blockage or narrowing of the renal pelvis, which is the area at the center of the kidney where urine collects before it is carried to the bladder. The blockage or narrowing, known as ureteropelvic junction (UPJ) obstruction, can lead to a buildup of pressure in the kidney and cause damage to the kidney tissue over time. During a pyeloplasty, the surgeon will make an incision in the abdomen or flank and access the affected kidney. The ureter, the tube that carries urine from the kidney to the bladder, is then disconnected from the renal pelvis, and the narrowed area is removed. The healthy ends of the ureter and renal pelvis are then reconnected with sutures or staples to create a wider opening and improve urine flow from the kidney to the bladder. Pyeloplasty can be performed using traditional open surgery, laparoscopic surgery, or robotic surgery. The choice of technique will depend on various factors, including the location and severity of the blockage, the patient's overall health, and the surgeon's experience and preference. Pyeloplasty is typically a highly effective procedure that can help restore kidney function and alleviate symptoms associated with UPJ obstruction.
How Is Pyeloplasty Performed?
There are two types of pyeloplasty:
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Open Pyeloplasty - Open pyeloplasty is performed in the following ways:
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Patients are administered with anesthesia (a substance that makes patients insensitive to pain). The surgeon will make incisions in the abdomen.
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The surgeon makes an incision in the abdomen to access the kidney. The size and location of the incision will depend on the surgeon's preference and the patient's anatomy (abdomen structure).
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The ureter is disconnected from the renal pelvis, and the narrowed or obstructed area is removed.
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The healthy ends of the ureter and renal pelvis are then reconnected with sutures or staples to create a wider opening.
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A stent may be inserted to ensure the proper flow of urine and to prevent the ureter from narrowing during the healing process.
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The incision is closed with sutures or staples, and the patient is sent to the recovery room.
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Laparoscopic Pyeloplasty - Laparoscopic pyeloplasty offers a higher success rate than incisional techniques. Laparoscopic pyeloplasty is performed in the following ways:
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The patient is placed under general anesthesia, and several small incisions are made in the abdomen to allow the surgeon to access the kidney.
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A laparoscope, which is a thin tube with a camera attached to it, is inserted into one of the incisions to provide the surgeon with a visual guide.
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The ureter is disconnected from the renal pelvis, and the narrowed or obstructed area is removed using specialized laparoscopic instruments.
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The healthy ends of the ureter and renal pelvis are then reconnected with sutures or staples to create a wider opening.
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A stent may be inserted to ensure the proper flow of urine and to prevent the ureter from narrowing during the healing process.
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The incisions are closed with sutures, and the patient is sent to the recovery room.
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What Are the Indications and Contraindications of Pyeloplasty?
The following are the indications of pyeloplasty:
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UPJ Obstruction: Pyeloplasty is primarily performed to treat UPJ obstruction, which can occur due to a variety of reasons, such as congenital anomalies, scarring, or tumors.
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Chronic UTIs: Chronic urinary tract infections (UTIs) can cause kidney damage, and pyeloplasty can help prevent further damage and reduce the risk of recurrent infections.
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Hydronephrosis: When urine backs up into the kidney, it can cause a condition called hydronephrosis, leading to kidney damage. Pyeloplasty can help relieve this condition and improve kidney function.
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Recurrent Stone Formation: When kidney stones cause UPJ obstruction, pyeloplasty can help prevent recurrent stone formation and alleviate symptoms such as pain and infection.
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Alternative Techniques: Laparoscopic pyeloplasty can be offered as a reasonable minimally invasive alternative for patients with crossing vessels at the UPJ or an extremely dilated renal pelvis, who are frequently poor candidates for incisional or endoscopic techniques.
The following are the contraindications of the pyeloplasty:
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Advanced Renal Failure: If the patient has advanced renal failure, pyeloplasty may not be recommended as it may not be effective in improving kidney function.
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Severe Medical Conditions: Patients with severe medical conditions such as heart disease or lung disease may not be suitable candidates for pyeloplasty as they may be at increased risk for complications during surgery.
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Pregnancy: Pyeloplasty is generally not recommended during pregnancy unless the obstruction is severe and poses a significant risk to the mother or baby.
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Active Infections: If the patient has an active infection, pyeloplasty may need to be postponed until the infection has been treated and resolved.
What Is Postoperative Care After Pyeloplasty?
Postoperative care refers to the care and follow-up of the patients after the surgery.
The following are the essential postoperative care that patients need after surgery:
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On postoperative days, patients are started on a clear liquid diet and progress to a regular diet before discharge.
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Patients are kept on a broad-spectrum antibiotic prophylactic regimen during surgery.
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The Foley catheter is removed on the second postoperative day, and if drainage has been minimal, the drain is removed before discharge.
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The ureteral stent is removed in the outpatient clinic one month after surgery.
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Six months after surgery, a diuretic renal scan is performed. Regular diagnostic scans such as an intravenous pyelogram, diuretic renal scan, or renal ultrasound are obtained annually.
Conclusion:
Laparoscopic pyeloplasty is a minimally invasive technique that produces long-lasting clinical and radiographic results. However, it is still a technically difficult procedure, laparoscopic pyeloplasty addresses and corrects all potential causes of UPJ obstruction while posing little risk of hemorrhagic complications. Laparoscopic pyeloplasty is an effective, minimally invasive treatment option for many patients with primary or secondary UPJ obstruction when performed by a skilled surgeon.
