Laparoscopic Pyeloplasty

Jaime Landman, MDAssistant Professor of Urology

Columbia University Department of Urology

Patient Selection Indications

− Symptomatic UPJ obstruction− Asymptomatic UPJ obstruction with documented

deterioration of renal function

Contraindications− Intra-renal pelvis− Multiple prior abdominal surgeries (relative)

Equipment Required Veress needle (14G) Knife with #15 blade Dilating trocars: 12 mm (1), 5 mm (2 or 3) 10 mm laparoscope with 30 Lens 5 mm laparoscope with 0 Lens Harmonic Shears-5 mm curved [Ethicon] Macrobipolar grasper [Aesculap] Endoshears with disposable tip (Microline) 5 mm suction irrigation device Endoholder (self-retaining retractor) [Codman] Padron Endoscopic Retractor (PEER) [J Jamner] Suture: 4-Vicryl on an SH needle Lapra-Ty clip applier and clips [Ethicon] 7 mm Jackson Pratt drain

Patient Positioning

Standard full flank, ventral surface on edge of table

Lower (left) leg bent, 3 pillows supporting upper (right) leg

Table flexed 15 Axillary roll OR table covered with gel pad (never bean bag) Arm draped over chest, supported by 2 pillows Arms, hips, and lower leg secured by tape No kidney rest

Patient Positioning

= Areas that are carefully padded

Trocar Placement

Veress needle placed medial and superior to the anterior superior iliac spine, followed by 5 mm trocar that will be the right hand working site

5 mm trocar beneath costal margin in anterior axillary line for left hand working site

12 mm trocar in midline between the two working trocars for the laparoscope

Optional 5 mm trocar in posterior axillary line between the working trocars for lateral retraction

Port Placement

=12mm trocar

=5 mm trocar

=5 mm trocar (optional)

Port Placement (post-operative)

7mm Jackson Pratt drainin retractor site

12mm laparoscope site

5mm right hand working site5mm left hand working site

Head Feet

Steps of the procedure

1. Deployment of trocars*

2. Mobilization of Colon and Kocherizing the duodenum (right side)

3. Identification and limited mobilization of ureter and the renal pelvis with preservation of crossing vessels when present

*If not done pre-operatively, cystoscopy, retrograde ureteropyelogram, and JJ stent deployment can be done before laparoscopy OR a JJ stent can be deployed laparoscopically after transection of the UPJ

Steps of the procedure

4. Transection of the UPJ and spatulation of the ureter. Reduction of renal pelvis (when redundant)

5. Anastomosis (anterior to crossing vessels when present) and deployment of drain

Step 1. Deployment of Trocars

Step 2. Mobilization of Colon and Kocherizing the duodenum (right side)

Step 3. Identification and limited mobilization of the ureter

Step 4. Transection of the UPJ and spatulation of the ureter

Step 5. Anastomosis

Technical points: Tips

Pre-operative CT angiogram is reliable in the detection of crossing vessels and can warn of the existence of crossing vessels

Patients with JJ stents placed prior to surgery will have thickened reactive ureters which may make the ureteral dissection and anastomosis more challenging

Application of the PEER retractor and the Endoholder opens the operative field and facilitates dissection

Microline scissors have a disposable tip which is always sharp for ureteral transection and spatulation

Lapra-Ty clips will securely anchor the running anterior and posterior suture lines and will facilitate a tight closure

Technical points: Caveats

Facility with intracorporeal suturing is essential and will make the running anastomosis relatively expeditious and easy

Early in the surgeon’s experience, application of three 12 mm trocars will facilitate the procedure

It is ideal to work with the laproscope between the two “working” trocars. However, the laparoscope may be moved to optimize the angle of vision

When using 5 mm working trocars, the needle and Lapra-Ty clip applier are inserted through the 12 mm (laparoscope) trocar and a 5 mm laparoscope is used

CreditsSurgeon: Jaime Landman

Director of Minimally Invasive Urology

Columbia University Department of Urology,

New York, NY

Assistant: Sean Collins

Director of Minimally Invasive Urology

Louisiana State University Department of Urology,

New Orlenes, LA