[DISMEMBERED PYELOPLASTY

(Anderson-Hynes)

2
A, Expose the ureter below the UPJ, taking care not to interfere with the segmental blood supply
to this area that enters the ureter from the medial side. Placing a small Penrose drain or vessel loop
around the ureter may help mobilization but risks interfering with the ureteral blood supply. For
secondary operations, locate the normal part of the ureter distally, and dissect proximally from normal
to abnormal. Dissect as short a length of the ureter as possible, and preserve all its adventitial vessels. It
is better to mobilize the kidney than the ureter.

B, Palpate and look for an aberrant lower-pole vessel, which is common with this anomaly. It can
usually be moved out of the way after the ureter is divided because sacrificing it could result in
segmental renal ischemia and systemic hypertension.

Selection of Technique. After exposure of the UPJ, make a decision about what type of operation to use.
Obstructions are located (1) at the UPJ from a high insertion anomaly with or without stricture, the most
common finding (2) just below the UPJ owing to stricture; or (3) in the upper segment ureter as a
stricture or ureteral valve. It is necessary to ask whether the ureter is long enough to allow
dismemberment and excision of the UPJ. If it is, a modified Anderson-Hvnes dismembered pyeloplasty is
most often suitable, although a Foley Y-plasty works well with high insertions of the ureter. For a long,
dependent obstruction of the UPJ, the Culp or Scardino technique may solve the problem of insufficient
ureter for approximation. If the site of the obstruction is in doubt, fill the pelvis with saline through a
scalp vein needle and observe the site of hold-up.

3
Place a stay suture in the ureter at its junction with the pelvis. Divide the ureter obliquely, and
spatulate its less vascularized lateral surface for a distance equal to the length of the proposed V-
shaped flap, a step often more accurately done after the pelvic flap is formed.

Alternatively, divide the ureter transversely, insert a traction suture, and spatulate the end;
excise the pelvis and form a V-flap at the caudal rim; insert the V-flap into the spatulated ureter to
provide a tapered junction.

If distal ureteral obstruction was not ruled out by preoperative sonography, checking for
narrowing of the upper ureter by passing a 5 F infant feeding tube distally may not be wise because it
could instigate a stricture. Instead, insert an infant feeding tube attached to an open syringe filled with
saline into the ureter for a short distance. Flow at an elevation of 10 cm indicates adequate ureteral
patency.

4
 Caution: Do not place the stay sutures too far apart and thus remove too much pelvis, especially
in a bifid system. Keep the incision well away from the caliceal necks, which With the pelvis full, dissect
it free and map out the proposed diamond-shaped incision with a skin marking pen, angling the caudal
triangle medially to form a V-flap. The kidney can be brought up into the wound with vein or Gil-Vernet
retractors or rotated with a sponge stick. Place stay sutures of 5-0 silk at the angles of the diamond.
Because considerable pyelectasis is the rule, the diamond should include a portion of the pelvis for
reduction pyeloplasty as part of the repair.

can be surprisingly close to its edge after pelvic excision; otherwise, closure is difficult and
infundibular stenosis may result. Start dismemberment by incising for a short distance along one of the
planned lines with a #11 hooked blade.

5
Complete the resection with Lahey or Potts scissors, cutting from inside one stay suture to inside
the next. Remove the specimen.

6
Insert an infant feeding tube of suitable size into the ureter to prevent catching the far wall in a
suture. Using binocular loupes, place one 6-0 or 7-0 SAS adjacent to the apex of the V-shaped flap from
outside in, then out through the apex of the ureteral slit. Place a second suture 2 mm away from the
first. Tie both sutures with four knots, and cut the short ends. Use the ureteral stay suture for
manipulation; do not use forceps. Alternatively, place a mattress stitch with a double-armed suture, and
run one end up the back wall from inside the lumen and the other up the front wall.

B, Catch minimal epithelium; include more muscularis and adventitia in the stitch.

7
A, Continue the first suture on the far side to the tip of the ureter as a continuous stitch, locked
at every four or five bites. Do the same for the second suture on the near side. Irrigate the pelvis and
calyces free of clots, an especially important precaution with an anterior approach.

B, Tie the two sutures together, cut one, and continue with the other to close the rest of the
pelvic defect, if the infant feeding tube is to be used as a stent, bring it out through the renal
parenchyma. If a nephrostomy tube is needed, place it before the pelvis is closed.

8
Alternatively, form a purse-string opening around the central defect by starting a third suture
from the upper end.

9
 Inject saline with a fine needle through the pelvic wall to test for watertightness and for patency
of the anastomosis. Alternatively, if the infant feeding tube was left in place, withdraw it until the tip lies
in the renal pelvis, and allow saline to flow through it by gravity at an elevation of 10 cm. Add a suture or
two if needed to close a leak. Use an omental wrap (see page 74) if the tissues appear poorly
vascularized or if the operation is a second one.

10
Insert a Penrose drain, and fasten it near but not touching the anastomosis or the ureter below
it. Use the long suture technique (see page 12) to ensure that contact is not made. Alternatively, use a
suction drain. Accurate drainage is important. If the kidney has been mobilized, hold it up into normal
position with nephropexy stitches (Step 19); otherwise the lower pole falls forward against the ureter.
Such fixation is more often needed with a flank approach. Tack the preserved posterior edge of Gerota's
fascia to the anterior edge with fine plain catgut (PCG) to hold the perirenal fat around the kidney and
isolate the repair from the body wall. Close the wound in layers, leading the drain laterally so that the
patient does not lie on it.

11
Stenting: In general, avoid placing a stent, although it may prevent kinking by a large floppy
pelvis. A good compromise may be to place a nephrostomy tube in an infant and to use both a tube and
a double-J stent in any difficult repair.

A, If the repair has been difficult, as after previous pyeloplasty, and appears tenuous or if the
kidney is infected, insert a nephrostomy tube (see page 928) before closing the pelvis. Alternatively,
insert a nephrostomy tube along with a double-J stent, or use a grooved KISS catheter that stents and
exits through the pelvic wall or a perforated length of soft silicone tubing.

B, A Cummings tube, combining nephrostomy and stent, is an alternative. If such a stent is too
long, it may enter the bladder and siphon off the bladder contents, an event that can be very disturbing.

Unless a stent or nephrostomy tube has been placed, insert a balloon catheter into the bladder
to prevent back pressure on the repair, and remove it in 24 to 48 hours. This is especially important in
infants, who may not void for 12 to 24 hours. Consider giving suppressive antibiotic therapy. Avoid
irrigating a nephrostomy tube. Discharge the patient with the drain in place. Shorten the drain 2 days
after drainage stops, and then remove it. If a stent has been placed, take it out in 10 to 12 days unless
the repair was tenuous. Remove the nephrostomy tube when nephrostography shows no extravasation
and ready drainage of the contrast medium when the pelvis is filled. Little residual urine should remain
after a trial of intermittent clamping. Perform intravenous urography after 3 months, 1 year, and 5
years.
LAPAROSCOPIC DISMEMBERED PYELOPLASTY
(Schuessler)

Caution the patient about the limited data on the results of the procedure. Insert a 6 F or 7 F double-J
stent in the affected ureter at operation or, preferably, 2 to 3 weeks before, with fluoroscopic guidance
if necessary.

Insert a 16 F balloon catheter in the bladder. Position: Place the patient in the lateral decubitus
position at a 75-degree angle, held with a vacuum bean bag. Induce a pneumoperitoneum, Place one 10-
mm trocar two fingerbreadths below the costal margin in the midclavicular line. Place a second trocar
caudad to the first and a third in the anteroaxillary line. Remember that veins injured by trocar insertion
do not bleed during pneumoperitoneum but do so copiously at the end of the procedure.

Mobilize the appropriate part of the colon, and reflect it medially. Place one or two more 10-
mm trocars more laterally in the midaxillary line if needed for renal traction. Two or three stay sutures in
the pelvis, either supported transabdominally or exiting transcutaneously and manipulated outside the
body, expand and support the pelvis during the dissection and anastomosis and reduce the need for
extra ports (Recker et al, 1995).

Identify the proximal ureter as far as the UPJ, and dissect it free. Look for crossing vessels; if any
are found, clip and divide them. Dissect the entire renal pelvis free on both aspects.

Mark the proposed incision with the electrocautery. To excise the anterior part of the pelvis,
make diverging incisions with the rotating endoscopic scissors, starting from the superior medial aspect
of the pelvis. As the incisions progress, close the opening left behind them with a running 4-0 SAS on a
straight or ski needle. Before either spatulating the UPJ or detaching the ureter, insert a suture between
the apex of the ureter and the lowest part of the pelvis and leave it untied. Cut the ureter 1.5 cm above
the apex of the spatulation, and cut the pelvis through the posterior layer, excising the UPJ. Insert a
second suture anteriorly near the first, and tie the two sutures. Place one additional interrupted suture
anteriorly; then close the posterior wall with a running suture, held at the end with a resorbable clip.
Alternatively, spatulate the ureter and start two 4-0 SAS at the apex. Run two sutures lines in opposite
directions to close the UPJ. In some cases, rather than excision of the defect, the simpler Heinecke-
Mikulicz incision and closure can be applied.

Insert a 7-mm suction drain retroperitoneally through a trocar site with grasping forceps using
two trocars. Replace the colon and hold it with hernia staples. Leave the stent in place for at least 6
weeks. The procedure may also be done extraperitoneally by inflating a balloon in the retroperitoneum
(see page 994).
YV-PLASTY
(Foley)

The Foley Y-plasty can be used for a high insertion of the ureter, especially when the pelvis has a
box shape. It requires more ability to visualize the rearrangement than does the dismembered
operation.

12
A, Free the ureter but preserve the adventitia. B, Draw the ureter cephalad with a Penrose
drain. Mark a long Y-shaped incision between stay sutures. Incise the pelvis between the stays with a
#11 hooked blade, and open it with Potts scissors, forming a V with arms equal to the length of the
ureteral incision. At this point, consider placing a nephrostomy tube with or without a ureteral stent.

13
Suture the apex of the flap to the apex of the ureteric incision by placing a 7-0 SAS in through
the apex of the V and out through the apex of the ureteral incision, and tie it. Include a minimal amount
of epithelium.

14
A and B, Place interrupted 4-0 SAS down both sides of the V to make a watertight anastomosis.
Alternatively, two sutures may be run continuously, as in the dismembered technique in Steps 6 and 7.
Pad the area with perirenal fat, and provide drainage accurately.

PELVIC FLAP PYELOPLASTY

15
A, Mark a spiral (Culp) lap running obliquely around the enlarged pelvis, and extend the incision down
the ureter for a distance equal to the length of the flap.

B, Incise the flap, and deflect it down with a stay suture.

C, Approximate the posterior edge of the flap to the lateral ureteral edge with a running 4-0 or 5-0 SAS.

D, Close the anterior edge of the flap and pelvis with similar sutures. It helps to place the sutures over a
small infant feeding tube (not shown).
INTUBATED URETEROTOMY

(Davis)

Intubated ureterotomy is used for scarred defects near the URI, but endoscopic incision is usually
preferred unless the defects are very long.

16
With a 11 knife blade, incise the pelvis just 16 above the URJ between two stay sutures. Open
the ureter with Potts scissors until normal caliber is reached.

17
Insert an 8 F silicone double-J stent and a neph- rostomy tube. Tack the edges of the defect to-
gether loosely with 5-0 SAS.

18
For a lower defect, incise it laterally over a small- caliber double-J stent. Place a few fine sutures
to hold the ureter loosely against the stent, being sure not to constrict it.

Close the pelvic defect after placing a nephrostomy tube. Tack retroperitoneal fat around the
defect, or bring the omentum through the posterior peritoneum and wrap it around the ureter (see
page 74) (not shown) Perform a nephropexy (see Step 19).

Drain the area of the repair very accurately with the long suture technique (see page 917),
taking care that the end of the drain neither touches the repair nor is so far away that urine can
accumulate in a pocket. Leave the stent in place at least 6 weeks, testing for sealing with
nephrostography before and after removing it.

NEPHROPEXY

19
To prevent the lower pole of a kidney that has been extensively mobilized from sliding medially
and making contact with or angulating the repair, fix it to the posterior body wall.

Place two mattress sutures in the renal capsule on the posterolateral aspect of the lower portion
of the kidney, and tie them over bolsters of fat or absorbable sponge so that they do not cut through the
capsule. Adherence is greater if a square of renal capsule removed between the stay sutures.

Insert the sutures with mattress stitches into an appropriate area on the quadratus lumborum.
Rotate the kidney into proper orientation, and tie the sutures.
[08:08, 5/4/2021] dr. Filandy Pai: Surgery for the Horseshoe Kidney

The horseshoe kidney retains parts of its developmental blood

supply from the pelvic vessels. The isthmus and lower poles

frequently receive blood from the common iliac arteries. The

gonadal vessels pass over the lower renal vessels. Also, the

ureters lie closer to the midline than normal. Realize that the

isthmus itself is rarely obstructive; consequently, symphysi-

otomy is seldom indicated.

The approach to the horseshoe kidney depends on

the objective of the operation. For correction of

unilateral ureteropelvic junction (UPJ) obstruction or for

nephrectomy, an anterior subcostal extraperitoneal inci-

sion provides good access (see page 871). In order to

operate on both pelves and divide the isthmus as well,

make a longer supraumbilical transverse incision, going

transperitoneally and then reflecting the ascending and

descending colon to reach the retroperitoneum. This

gives excellent exposure and is recommended for a child.

In an adult, a long midline incision is required.

PYELOPLASTY

Approach the pelvis through an anterior subcostal

incision. Mobilize the colon, and move Gerota's fas-

cia and perirenal fat medially to provide cover for the

repair later.

A modified Anderson-Hynes pyeloplasty is usually suitable

(see page 914), although a Foley YV-plasty (see page 919) may

occasionally be easier to perform.