Laparoscopic pyeloplasty

Department : Laparoscopic Urology

What is PELVIC URETERIC JUNCTION (PUJ) OBSTRUCTION

The urine formed in the kidney collects in the kidney pelvis. This pelvis is connected to the bladder by a tube called the ureter. Sometimes there is obstruction at the junction of the kidney’s pelvis and ureter. If the obstruction is complete, the function of the kidney will be seriously affected. The obstruction can be present at the time of birth or later, at any age. The commonest age of presentation is early in adult life.

The cause of obstruction is usually a developmental defect of the muscle in this region. It can be due to other causes also, such as an abnormal kidney artery in this region producing mechanical obstruction.

PELVIC URETERIC JUNCTION (PUJ) OBSTRUCTION 1

Kidney drains urine in to the bladder via renal pelvis and ureter. There can be a narrow segment at the junction of this renal pelvis and ureter in some people by birth. This narrow segment blocks the free flow of urine from kidney into the bladder. This is termed Pelvic Ureteric Junction Obstruction. This block may cause reduction in renal function it left untreated. In order to a prevent renal failure later in life PUJO has to be treated at appropriate time without delay.

PELVIC URETERIC JUNCTION (PUJ) OBSTRUCTION 2

Symptoms of Pelvic Ureteric Junction Obstruction ( PUJO )

Most often it dosent produce any symptoms. Now a days due to common usage of prenatal USG, PUJ Obstructions are more commonly detected during the anomaly scan done, during 5th week of pregnancy. Very rarely it prenatal USG is not done. Children present later in life with following symptoms.

  1. Palpable mass.

  2. Episodic flank pain associated with nausea an vomiting

  3. Urinary Tract Infection (UTI)

  4. Hematuria – Blood in urine

 

PELVIC URETERIC JUNCTION (PUJ) OBSTRUCTION 3

How do you identify and confirm the problem

By means various investigations like

  1. USG Abdomen – PUJ Obstuction presents with hydronephrosis without dilatation of ureter.
  2. DTPA Renogram – It is s functional nuclear study to identify functional block at the level of PUJ.

Treatment :

Only treatment opinion available is Pyeloplasty. Where we cut the blocking portion of PUJ Obstruction and anastomose the normal pelvis and ureter. This procedure can be done by a key Hole Surgery. Laparoscopic surgery gives equal results as open surgery with less post op pain, early discharge from hospital, early recovery and early resumption of daily activities.

How is it treated ?

The treatment is by surgery. This can be done either by open surgery, with its accompanying morbidity of a 15 cm wound or in some cases, by endoscopic techniques ( endopyelotomy).

By far, the best results are obtained by open surgical techniques. Now laparoscopy can do the same repair with the same results but avoiding all the morbidity of the open surgical wound and is considered by many Urologists as the gold standard.

Steps of repair

  • Removal of the defective pelvis ureteric junction.
  • Trimming down the renal pelvis.
  • Reconstruction of the pelvis and pelvi ureteric junction over a stent. A stent is a tube made from special polyurethane or silicone. It helps in proper healing of the repair. It has to be removed after a few weeks.

Pre Operative Preparation

  • Medical fitness check up as outpatient about a week before admission.
  • Admit the day before surgery.
  • Laxative on the day of admission

Surgery

  • Surgery usually takes 2 to 4 hours. You will be in the post operative ICU on the day of surgery and will return to your room only the next day afternoon.
  • There will be a urethral catheter and a drain from the side of the abdomen.
  • There will also be an internal stent (a 1.5mm tube) inside the ureter, the tube connecting the kidney to the bladder.

Post Operatively

  • Liquid diet (after doctor examines you) and later solid diet may be taken from the 2nd post operative day onwards.
  • You will be easily able to get up without assistance and pain from the 2nd post operative day onwards.
  • This includes walking without help to the toilet.
  • The Urethral Catheter and drain will be removed usually by the 5th post operative day.
  • You would be discharged usually within 1 week.

At Home

  • No rest is needed at home.
  • The internal stent will be removed as an outpatient in 6 to 8 weeks.

For review

  • Routine review will be after about 1 week. Further reviews and follow up dates will be advised by your doctor at the time of the initial review.