Laparoscopic Pyeloplasty

1
Laparoscopic Pyeloplasty

• Jaime Landman, MD
• Assistant Professor of Urology
• Columbia University
• Department of Urology

2
Patient Selection

• Indications
• Symptomatic UPJ obstruction
• Asymptomatic UPJ obstruction with documented
  deterioration of renal function
• Contraindications
• Intra-renal pelvis
• Multiple prior abdominal surgeries (relative)

3
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

4
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

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Patient Positioning
Areas that are carefully padded
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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

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Port Placement
12mm trocar
5 mm trocar
5 mm trocar (optional)
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Port Placement (post-operative)
Feet
Head
7mm Jackson Pratt drain in retractor site
5mm left hand working site
5mm right hand working site
12mm laparoscope site
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Steps of the procedure

• Deployment of trocars
• Mobilization of Colon and Kocherizing the
  duodenum (right side)
• 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
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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
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Step 1. Deployment of Trocars
12
Step 2. Mobilization of Colon and Kocherizing the
duodenum (right side)
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Step 3. Identification and limited mobilization
of the ureter
14
Step 4. Transection of the UPJ and spatulation of
the ureter
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Step 5. Anastomosis
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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

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Technical points Caveats

• Facility with intracorporeal suturing is
  essential and will make the running anastomosis
  relatively expeditious and easy
• Early in the surgeons 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

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Credits

• Surgeon 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