Page 9 - World Journal of Laparoscopic Surgery

Laparoscopic Dismembered Pyeloplasty: Our Experience in 15 Cases

15 pyeloplasties with an average follow-up of 10.6 months was used for telescope. The second port was placed at the mid
(ranging from 4 to 16 months). spino umbilical line. 5 mm or 10 mm port was used. The third
port (5 mm) was placed subcostally so as to make on equilateral
METHODS triangle with the previous ports and a diamond with the renal
angle. The fourth port was placed in the loin at a later time as
Patients
and when required. The fourth port (5 mm) was used mainly to
From May 2006 to September 2007, a total of 15 laparoscopic retract the kidney laterally.
pyeloplasties were performed at our center. Patients included 8 All patients had dismembered Anderson Hynes pyeloplasty
males and 7 females aged 8 to 57 years (mean age 29.8 years). The colon was mobilized by incising the peritoneum laterally.
9 out of 15 patients had right sided PUJ obstruction whereas The ureter was identified and dissected in cephalad direction to
only 6 patients had left sided lesion. Flank pain was the achieve mobilization of the ipsilateral proximal ureter, UPJ and
commonest presentation (9 patients, 60%). Other symptoms renal pelvis. One trans cutaneous stay suture was taken on the
were dysuria (6 patients, 40%), fever (2 patients, 13.3%) hematuria anterior wall of pelvis to spread it which also helped in suturing.
(1 patient, 6.6%). One patient (6.6%) was asymptomatic. All The anterior wall of renal pelvis was incised. Spatulation of the
patients had radiographic evidence of UPJ obstruction on ureter was done on the lateral aspect with the posterior wall
diuretic renography or HN with delayed function on excretory intact. Subsequently the posterior wall was divided. In cases
urography. All patients had primary PUJ obstruction. Four out where direction of the scissors could not be brought in line
of 15 patients had stones present in the ipsilateral kidneys. with the ureter, the spatulation was done after the circumferential
Retrograde pyelography with DJ stenting on the ipsilateral side transection of the pelvis. In that case, a marking suture was put
was done in cases where the pelvis was hugely dilated and if on the medial aspect of the ureter before complete transaction.
the patients presented with fever and loin pain and when the Suturing was done intracorporeally with vicryl 4-0 suture on a
anatomy was not properly delineated. Radiographic success 20 mm needle. First the posterior half of the uretero pelvic
was defined as improved drainage on diuretic renography. IVP anastomosis was done with a running suture beginning at the
was done at 1 year of follow-up mainly to compare the anatomy apex of the spatulated ureter. Then the DJ stent was placed and
of the PUJ preoperatively and postoperatively in our initial cases then the anterior wall suturing performed. Reduction of pelvis
of laparoscopic pyeloplasty. wherever required was done. If a crossing vessel was present,
the ureter was transposed anterior to the crossing vessel.
PROCEDURE Removal of any associated calculus was tried. In case of calyceal
calculi, rigid ureteroscope was used through a 10 mm working
All patients were kept on liquid diet for 1 day and T. Dulcolax port. 20 Fr drain was placed through a 5 mm trocar site.10 mm
was given in a dose of 2 tablets HS for 2 days. Patients were
given parenteral cephalosporin and Amikacin at the time of port sites were closed in 2 layers and 5 mm ports were closed
with only skin sutures. The steps of surgery are illustrated in
induction of anesthesia and these antibiotics were continued Figures 1A and B.
postoperatively till the time of drain removal. All procedures Postoperatively, clear liquid diet was initiated on the post
were performed under general anesthesia. A Foley’s catheter operative day 1. The Foley’s catheter was removed after 2 days
was placed in the bladder and a nasogastric tube was inserted
to decompress bladder and stomach. All patients were placed and the drain was removed once it was less than 50 cc. Tramadol
was used routinely in the postoperative period for pain relief.
in lateral decubitus position with proper padding of pressure Skin sutures were removed on 10th postoperative day.
areas. The kidney rest was elevated and table flexed to stretch Cystoscopy and DJ stent removal was done at 6 weeks
the flank. Compression crepe bandages were applied to legs. after surgery. DTPA renogram was done at 3 months and one
All procedures were carried out by the transperitoneal
approach. The access to the peritoneal cavity was obtained year. IVP was done at 1 year after surgery to look for patent
PUJ, reduction in the grade of hydronephrosis and redundant
with open technique. Pneumoperitoneum was created with an pelvis and improved drainage. Patients were examined clinically
insufflation rate of 5 l/min and the insufflation continued till an at 3, 6 and 12 months.
abdominal pressure of 15 mm Hg. 30° telescope was used. The
first port (10 mm) was introduced at the lateral border of rectus
muscle above the umbilicus. The exact level of the port was RESULTS
decided by the configuration of the pelvis and the anatomical Only one out of 15 patients required conversion to open
position of PUJ and the body habitus of the patient. This port approach where the pelvis and ureter were friable and not

7