Pediatric urology pujo- pyeloplasty

pujo- pyeloplasty

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

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2. MODERATORS:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
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3. HISTORY
1891 - Kuster- divided the ureter and re-anastomosed it to pelvis
1892 - Fenzer – principle of Heineke-Mikulicz – transverse closure of longitudinal incision
1916- Schwyzer – flap technique
1937 – Foley – V-Y plasty
1943- Davis – intubated ureterotomy
1949 - Anderson & Hynes anastomosis of spatulated ureter to a projection of lower aspect
of renal pelvis
1951-Culp & Deweerd – spiral flap
1953-Scardino &Prince - vertical flap
3 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

4. INDICATIONS
Presence of symptoms from obstruction
Impairment of overall renal function
More than 10 % difference in the split renal function
Progressive loss of function
Development of stones, infection or hypertension with obstruction
4 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

5. GOALS
Relief of symptoms
Preservation and improvement of renal function
5 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

6. FACTORS TO BE CONSIDERED BEFORE
Presence or absence of crossing vessels
Degree of hydronephrosis
Renal pelvis size
Level of ipsilateral and overall function
Presence of anomalies
Stones
6 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

7. PRINCIPLES OF PYELOPLASTY
Widely patent
Watertight
Tension free
Funnel shaped transition between pelvis and ureter
Dependent drainage
7 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

8. PREOPERATIVE PREPARATION
Contrast CT urogram & Diuretic renogram
Preoperative antibiotics
Preoperative drainage – infection, azotemia

8 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

9. PREOPERATIVE RGP
Identify precisely the position of the UPJ
Aide in the placement of the incision
Rules out concomitant distal obstruction
9 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

10. SURGICAL APPROACHES
Open
Standard flank incision
Anterior subcostal incision
Posterior lumbotomy approach
Laparoscopic
Robotic
10 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

11. ANTERIOR EXTRAPERITONEAL APPROACH
POSITION: Supine with a roll
placed transversely beneath the
patient to elevate the flank
Subcostal incision - Made from
the edge of the rectus muscle to
just below the tip of the 12th rib
11 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

12. ANTERIOR EXTRAPERITONEAL APPROACH
Minimal mobilization of renal pelvis and proximal ureter
Valuable in bilateral disease
Valuable in previous flank incision
Other congenital anomalies
12 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

13. POSTERIOR LUMBOTOMY APPROACH
POSITION: Prone with rolled towels to elevate chest
and abdomen with legs and arms lying lower than the
back
INCISION:
Vertical incision lateral to the paraspinal muscles
with the 12th rib and bony pelvis as the upper and
lower limits.
Curvilinear / horizontal incision midway between
the two bony structures made parallel to the skin
lines 13 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

14. POSTERIOR LUMBOTOMY APPROACH
Direct exposure to PUJ
Thin patients
No previous surgery
14 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

15. FLANK APPROACH
Incision made from the tip of
12th rib anteriorly to the lateral
edge of the rectus muscle
following the skin lines
15 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

16. FLANK APPROACH
Subcostal approach through bed of 12
th
rib
Avoid injury to subcostal nerve
Advantages:
Familiar
Excellent exposure
16 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

17. SURGICAL EXPOSURE
Skin incision
Dissection through three muscle/fascial layers: External oblique, Internal
oblique and transversus abdominis
Protect Intercostal nerves
Transversalis fascia dissected from underlying Gerota’s fascia and peritoneum
Peritoneum medialised
Gerota’s fascia opened vertically as far posteriorly as possible
Expose renal hilum
No need for complete mobilisation of the kidney
Pelvis cleaned of the fat to expose UPJ
17 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

18. OPEN SURGICAL TECHNIQUES
Anderson Hynes Dismembered pyeloplasty
Foley’s V-Y plasty
Culp DeeWerd spiral flap plasty
Scardino Prince vertical flap plasty
Davis intubated ureterotomy
Ureterocalicostomy
Fenger’s plasty
18 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

19. BASIC SURGICAL PRINCIPLES
Identification of proximal ureter
Preserve Blood Supply
Ureter dissected cephalad to renal pelvis leaving a large amount of
periureteral tissue
Ensure orientation
Marking stitch of fine suture placed on lateral aspect of the proximal
ureter below obstruction
Medial and lateral aspects of the dependent portion of the renal pelvis
marked with sutures
19 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

20. BASIC SURGICAL PRINCIPLES
Excise pathologic UPJ tissue
Proximal ureter is spatulated on its lateral aspect
Watertight anastomosis - Full thickness fine interrupted or running
absorbable sutures, through the ureteral and renal pelvis
Anastomoses over a stent
Reduction pyeloplasty if renal pelvis is exceptionally redundant

20 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

21. ANDERSON HYNES DISMEMBERED PYELOPLASTY
Borne out of necessity in the repair of a retrocaval ureter
(Anderson and Hynes,1949)

21 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

22. DISMEMBERED PYELOPLASTY
ADVANTAGES:
The ureteral insertion is high on the pelvis or already dependent.
Excision of the pathologic UPJ and appropriate repositioning
Permits reduction of a redundant pelvis or straightening of a tortuous proximal
ureter.
Transposition of the UPJ can be achieved when the obstruction is due to accessory
or aberrant lower pole vessels.
Complete excision of the anatomically or functionally abnormal UPJ
22 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

23. DISMEMBERED PYELOPLASTY
NOT IDEAL IN CASES OF
Lengthy strictures
Multiple proximal ureteral strictures
Small pelvis
Inaccessible intrarenal pelvis.
23 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

24. DISMEMBERED PYELOPLASTY
Traction sutures are placed to maintain
proper orientation for the subsequent
repair.
Medial and lateral aspects of the
dependent portion of the renal pelvis
Lateral aspect of the proximal
ureter, below the level of obstruction.
24 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

25. DISMEMBERED PYELOPLASTY
Ureteropelvic junction is excised
25 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

26. DISMEMBERED PYELOPLASTY
Proximal ureter is spatulated on its lateral aspect.
The apex of this lateral, spatulated aspect of the
ureter is then brought to the inferior border of the
pelvis
The medial side of the ureter is brought to the
superior edge of the pelvis.
26 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

27. DISMEMBERED PYELOPLASTY
Anastomosis performed with fine interrupted
or running absorbable sutures placed full
thickness through the ureteral and renal pelvis
walls in a watertight fashion.
27 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

28. REDUCTION PYELOPLASTY
Excising the redundant portion
between traction sutures.
Cephalad aspect of the pelvis is then
closed with running absorbable suture
down to the dependent portion
Dependent aspect of the pelvis is then
anastomosed to the proximal ureter.
28 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

29. When aberrant or
accessory lower
pole vessels are
present,
dismembered
pyeloplasty allows
transposition of the
UPJ in relation to
the vessels
29 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

30. FOLEY V-Y PLASTY
Indication
High insertion of ureter


Contra indications
Crossing vessels
Redundant pelvis

30 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

31. Base of the V is
positioned on the
dependent, medial aspect
of the renal pelvis and the
apex at the UPJ.
The incision from the
apex of the flap, which
represents the stem of
the y, is then carried along
the lateral aspect of the
proximal ureter well into
an area of normal caliber.
FOLEY V-Y PLASTY
31 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

32. •The apex of the pelvic flap is brought
to the most inferior aspect of the
ureterotomy incision.
•The posterior walls are then
approximated using interrupted or
running fine absorbable suture &
anastomosis is completed with
approximation of the anterior walls of
the pelvic flap and ureterotomy. 32 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

33. CULP-DEWEERD SPIRAL FLAP
Large readily accessible extra renal pelvis
Dependent ureteral insertion
Long segment proximal ureteral narrowing or stricture
Contraindications
In cases of high ureteral insertion
Aberrant vessel crossing
33 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

34. CULP-DEWEERD SPIRAL FLAP
Base situated obliquely on the dependent aspect of the
renal pelvis.
Base of the flap is positioned anatomically lateral to the
UPJ, between the ureteral insertion and the renal
parenchyma.
The flap is spiraled posteriorly to anteriorly or vice
versa.
The anatomically medial line of incision is carried down
completely through the obstructed proximal ureteral
segment into normal-caliber ureter.
34 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

35. CULP-DEWEERD SPIRAL FLAP
Once the flap is developed, the apex is rotated down to
the most inferior aspect of the ureterotomy.

The anastomosis is then completed, usually over an
internal stent.
35 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

36. CULP-DEWEERD SPIRAL FLAP
The site of the apex for the flap is determined by the length of flap
required to bridge the obstruction.

The longer the segment of proximal ureteral obstruction, the farther
away is the apex because this will make the flap longer.

To preserve vascular integrity of the flap, the ratio of flap length to width
should not exceed 3 : 1.
36 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

37. SCARDINO PRINCE VERTICAL FLAP
Used when a dependent ureteropelvic
junction (UPJ) is situated at the medial margin
of a large, box-shaped extrarenal pelvis
37 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

38. SCARDINO PRINCE VERTICAL FLAP
Base of the vertical flap is situated on the dependent aspect of
the renal pelvis, between the UPJ and the renal parenchyma.
The flap is formed by two straight incisions converging from
the base vertically up to the apex on either the anterior or the
posterior aspect of the renal pelvis.
The position of the apex determines the length of the flap
The medial incision of the flap is carried down the proximal
ureter completely through the strictured area into normal-
caliber ureter
38 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

39. SCARDINO PRINCE VERTICAL FLAP
The apex of the flap is rotated down
to the most inferior aspect of the
ureterotomy.
The flap is then closed by
approximating the edges with
interrupted or running fine
absorbable sutures.
39 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

40. DAVIS INTUBATED URETEROTOMY
Lengthy or multiple ureteral strictures
associated with PUJ obstruction
40 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

41. INTUBATED URETEROTOMY
Spiral flap is
developed
The apex of the flap is then
brought as far down as
possible
The distal aspect of the
ureterotomy is left open
to heal secondarily by
ureteral regeneration
41 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

42. INTUBATED URETEROTOMY
Require routine nephrostomy tube
drainage to prevent postoperative
urinoma
Antegrade nephrostogram after 6 weeks
Ureteral stent removed after 6 weeks if
no extravasation
42 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

43. URETEROCALICOSTOMY
Small Intrarenal pelvis
Rotational anomalies – Horseshoe kidney etc
Salvage technique for failed pyeloplasty
43 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

44. URETEROCALICOSTOMY
Ureter is first identified
Dissected proximally with a generous amount
of periureteral tissue
Attempt to identify pelvis may be difficult
Kidney mobilised to gain access to lower pole
44 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

45. URETEROCALICOSTOMY
Parenchyma overlying the lower pole
calyx resected
Proximal ureter spatulated &
ureterocalyceal anastomosis done
over an internal stent
First suture at the apex of ureteral
spatulation and lateral wall of calyx
Second suture 180 degrees away
45 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

46. URETEROCALICOSTOMY
Remainder by interrupted open suture
technique
Nephrostomy tube can also be
considered
46 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

47. URETEROCALICOSTOMY
Renal capsule closed over cut surface
But not over the anastomosis
Anastomosis covered with
perinephric fact or peritoneal or
omental flap
47 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

48. FENGER’S PYELOPLASTY
Small renal pelvis and no crossing
vessels.
Heineke-Mikulicz principle
Long incision along the anterior
renal pelvis and proximal ureter,
ending about 1 cm below the
obstructed area.
Apex of the incision on the renal
pelvis to the inferior apex of the
incision on the proximal ureter
48 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

49. SPLASH PYELOPLASTY
Few multiple small cuts on convex border of pelvis
To relieve tension on anastomosis
Heal by secondary intention
49 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

50. HELLSTROM OPERATION
Redundant pelvis wrapped around the crossing vessel
50 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

51. NEPHROPLICATION
Plicating sutures through anterior, lateral and
posterior surface
For efficient drainage of collecting system
51 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

52. NEPHROPEXY
Lower pole sutured to posterolateral
abdominal muscles
Infero-pelvicalyceal angle ≈ 90 degrees
Pelvi-ureteric angle ≈180 degree
52 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

53. LAPAROSCOPIC APPROACH
First introduced in 1993 by Schuessler and colllegues
Techniques:
Standard transperitoneal
Retroperitoneal
Anterior extraperitoneal
Laparoendoscopic single site surgery (LESS)
Robotic assisted approach
53 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

54. ADVANTAGES
Lower patient morbidity
Shorter hospitalization
Faster convalescence
Reported success rates matches that of open pyeloplasty(≥90%)
54 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

55. LAPAROSCOPIC APPROACH
DISADVANTAGES
Greater technical complexity
Steeper learning curve

Absolute contraindications
Uncorrected coagulopathy
Active urinary tract infection
Presence of cardiopulmonary compromise
55 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

56. LAPAROSCOPIC APPROACH
UPJO
Failed endopyelotomy
Anatomical abnormalities
Crossing vessels
Extremely dilated pelvis

Small intra renal pelvis
Multiple intra abdominal surgeries
IDEAL IN UNFAVOURABLE CONDITIONS
56 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

57. LAPAROSCOPIC APPROACH
Cystoscopy with RGP
Placement of ureteral stent and urethral Foley catheter
45 degree lateral decubitus position
57 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

58. TROCAR PLACEMENT
Conventional three midline trocars
A 10/12-mm trocar is placed at the umbilicus.
The second port (5 mm) is placed midway
between the xiphoid process and the umbilicus.
A third trocar is located midway between the
umbilicus and the symphysis pubis
In obese individuals – all trocars placed laterally
58 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

59. TROCAR PLACEMENT
A 10/12-mm trocar is placed at the
umbilicus.
The second port (5 mm) is placed
midway between the xiphoid process and
the umbilicus.
A third trocar in anterior axillary line at
the level of umbilicus
59 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

60. TRIANGULATION
60 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

61. TRANSPERITONEAL APPROACH
Patient is placed in 70° lateral position without kidney bridge elevation
A 30° telescope may be preferable for better view from different angles
Additional port (5–10 mm convertible) is inserted in the epigastrium or
flank for the retraction or suction if the redundant bowel disturbs the
vision or there is collection
61 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

62. The line of Toldt is incised with
either a hook dissector or
ultrasonic shears.

Colon is reflected medially
until the ureteropelvic junction
and part of the pelvis is well
seen
Pelvis and UPJ are adequately
mobilised.
Stay suture is taken through the pelvis
to stabilise it and avoid frequent
unwanted movements of the
instrument

A nylon suture on a straight needle is
used for this purpose. The suture is
brought out through the flank.

62 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

63. TRANSMESOCOLIC APPROACH
In left sided UPJ obstruction in children and in thin adults
Once the mesocolon is incised, the bulging pelvis can be pulled into the
peritoneal cavity provided that the mesocolic arterial arcade is wide
ADVANTAGES
No need for colonic mobilisation.
Very good illumination as there is not much of raw area with blood clots
UPJ can be quickly accessed.
The mean operative time is reduced by about 15–20 min.
Occasional problem in this approach is injury to left colic vessel.
63 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

64. TRANSMESOCOLIC APPROACH
Bulging pelvis seen through
the mesocolon
Incision of the mesocolon over
the bulge, preserving the
mesocolic vessels
Pelvis seen through the
mesocolic window
64 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

65. RETROPERITONEAL APPROACH
With the patient in the 90° lateral positions, and without the kidney bridge elevated, the
primary (camera) port is inserted by open technique in the renal angle i.e. lateral to erector
spinae just below the tip of 12th rib.
A 1.5 cm long incision is made.
A haemostat is introduced to split the muscles and the lumbodorsal fascia.
The index finger is introduced through the wound into the retroperitoneal space to push
away the peritoneum anteriorly, thus enlarging the potential space.
The space is inflated to the required volume (150–600 ml according to the built and age of
patient) using balloon technique.
Alternatively commercially available balloon trocars can be used directly.
65 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

66. Initial retroperitoneal dissection anterior to psoas Port placement (Right PUJ obstruction)
Ureter and gonadal vein seen in the retroperitoneum Pelvis dissected and pevi ureteric junction delineated
66 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

67. RETROPERITONEOSCOPIC APPROACH
The first landmark to be identified is the psoas muscle.
Dissection along this plane easily leads to the ureter.
If the Gerota’s fascia with perinephric fat is extensive over the UPJ, it
may be incised (or excised) for free movement of the hand instruments.
A preplaced stent or guidewire in ureter makes identification of ureter
easier (gonadal vessel may be mistaken for ureter).
67 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

68. POSTOPERATIVE CARE

Urethral foley removed after 48 hrs
External drain removed after 12 - 24 hrs following catheter removal
Internal ureteral stents : 4-6 weeks after surgery
If nephrostomy tube – nephrostogram 7-10 days postoperatively
68 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

69. COMPLICATIONS
Anastomotic urine leak
Retroperitoneal urinoma formation
Postoperative ileus – laparoscopic
Bleeding
Infection
Failure – 15% for secondary 5% for primary
69 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

70. Can occur within the 24hrs
Observation
Drain lasting more than 5-7 days should be
investigated


POST PYELOPLASTY LEAK
70 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

71. INCREASED DRAIN OUTPUT
Anastomotic leak
Malpositioned drain
Obstructed or malpositioned
stent
CT scan can help in assessment of
stent positioning
Creatinine level of the drain fluid
is higher than the plasma
creatinine


71 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

72. POST PYELOPLASTY LEAK
Maintain the foley catheter - reduces chance of reflux and thereby reduces leak

First be sure position of drain is not in contact with pelvis - Withdraw or shorten
the drain

If drain lasts more than a week investigate - CT UROGRAM
Done to demonstrate the site of leak
Position of the stent and drain

Additional Drainage – Nephrostomy is placed
STENT MALPOSITION – Repositioning of stent
72 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

73. FOLLOW UP
Stent removal 6 weeks after surgery
Diuretic renal scan 1 month following stent removal
Every 4 to 6 months for 2 years.
Failures usually occur within the first year postoperatively.

73 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

74. POORLY FUNCTIONING KIDNEY
Differential function < 20%
PCN
Assess for recoverability
Function improves > 20%
Pyeloplasty
Differential function < 20% or
deteriorates
Nephrectomy
74 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

75. “SALVAGE” PROCEDURES
Failed open pyeloplasty is a challenging problem
Initial approach should be an endourological procedure
Flap or dismembered techniques could be attempted if endoscopic
approach fails
Technically toughest
Wide mobilisation as much as possible is required
75 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

76. “SALVAGE” PROCEDURES
Other options :
Ileoureteral
Pyelovesicostomy
Autotransplantation

In extreme cases where the opposite kidney is normal – Nephrectomy
can be considered.
76 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

77. HORSE SHOE KIDNEY
ECTOPIC KIDNEY
DUPLICATED COLLECTING SYSTEM
PUJO IN ANOMALOUS KIDNEYS
77 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

78. HORSESHOE KIDNEY - PUJO
High insertion of ureter
Increased likelihood of crossing
aberrant vessels
But not all dilatation is due to
PUJO
 Ureter course anterior to
isthmus -mild increased resistance
to urine flow

78 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

79. HORSESHOE KIDNEY - PUJO
IVU/CT UROGRAM
3-D CT is very useful in planning
Calyceal orientation
Vascular relationships

79 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

80. Anterior subcostal extraperitoneal approach.
Dismembered usually done
Non - dismembered (foley Y-V ) -Easy
Isthmus division – Rarely indicated
Allows both kidneys to be rotated into normal position for improved
drainage from pelvis.
PYELOPLASTY IN HORSE SHOE KIDNEY
80 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

81. VASCULAR
RELATION
Venteromedially
related

Posterior or
posterolateral incision
of UPJ is safe
81 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

82. ECTOPIC KIDNEY WITH PUJO
50% of ectopic kidneys are hydronephrotic
40% of cases due to PUJO

IVU/CT UROGRAM
RGP
DIURETIC RENOGRAM

82 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

83. PUJO IN PARTIAL DUPLICATED SYSTEM
MC – Lower moiety
PYELOURETEROSTOMY
83 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

84. COMPLETE DUPLICATION WITH PUJO
PYELOPLASTY
84 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

85. COMPLETE DUPLICATION WITH PUJO
When there is marked
hydronephrosis of the lower-
pole moiety, particularly if the
UPJ is difficult to expose, then a
ureterocalicostomy may be
performed
85 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

86. COMPLETE DUPLICATION WITH PUJO
Ureteropyelostomy
Ureter which needs to be
excised is dissected till the
bladder or as low as possible
and divided.
Refluxing ureters need
complete excision to prevent
stump syndrome.
Single sheath reimplantation
86 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

87. DUPLICATION WITH PUJO
NONFUNCTIONING MOIETY
If the lower pole is poorly
functioning, a lower-pole
heminephrectomy is appropriate.
87 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

88. DUPLICATION WITH PUJO
NONFUNCTIONING MOIETY
If a dysplastic upper pole segment
is present, owing to an ectopic
ureter or ureterocele, it may be
excised at the time of the lower
pole repair.

Alternatively, an upper to lower
pole ureteropyelostomy may be
performed at the time of the lower
pole pyeloplasty
88 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

89. SECONDARY PUJO
SEVERE VUR (grade 4,5)
Kinking of tortous ureter at
relatively fixed PUJ
Stone related scarring
Iatrogenic instrumentation
89 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

90. FACTORS
LEADING TO
SECONDARY
PUJO IN HIGH
GRADE VUR
High grade reflux result in kinking of
upper ureter and adjacent UPJ

Chronic reflux may stretch the renal
pelvis and result in atonicity of pelvis

UTI – result in inflammation and
ureteritis and contribute to transient
or chronic obstruction at UPJ
90 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

91. VUR ASSOCIATED WITH PUJO
91 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

92. VUR ASSOCIATED WITH PUJO
Correct upper tract obstruction first

Initial VUR correction - Amplifies the upper tract dilatation during the
phase of post operative edema in lower ureter

Simultaneous management of VUR & PUJO have negative impact on
ureter vascularity

Pyeloplasty can be combined with endoscopic injection of bulk agents
in VUJ
92 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

93. OUTCOME & PROGNOSIS
Degree of obstruction
Duration of obstruction
Primary or secondary obstruction
Function of the affected kidney
Anatomic considerations
Expertise of the treating surgeon
Overall success
rate > 90%
93 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

94. 94 DEPT OF UROLOGY, GRH AND KMC, CHENNAI.