When the blockage in the urinary tract is found at the level where the part of the kidney that collects the urine (Renal pelvis) joins the ureter (the tube that carries the urine from the kidney to the bladder). This junction is referred to as Pelviureteric Junction and the obstruction at this level is called Pelviureteric Obstruction. The PUJ obstruction may be present right from birth (congenital) or may develop later in life (acquired) due to some disease process or as a result of a certain procedure done in the past.
Pelviureteral Junction obstruction is the most common congenital cause of upper urinary tract obstruction and leads to progressive dilatation of the renal urine collecting system.
Pyeloplasty is the surgical procedure that is recommended for PUJ (Pelviureteric Junction) Obstruction. "Pyelo" refers to the Renal pelvis and "Plasty" refers to the surgery or procedure that encompasses repair, restoration, or replacement.
Open Pyeloplasty is the standard treatment. However, there are various techniques for performing Pyeloplasty and among these Laparoscopic Pyeloplasty is by far the most common surgical technique for PUJ Obstruction.
Laparoscopic Pyeloplasty is also referred to as Keyhole surgery. The objective of Pyeloplasty surgery for PUJ obstruction is to remove the narrowed portion of PUJ and connect the remaining part to the ureter to ensure easy drainage of urine through the urinary passage. There are several ways to access the kidney to be able to perform the surgery. However, most commonly, this surgery is done using Laparoscopy.
Laparoscopic Pyeloplasty is a minimally invasive reconstructive surgery done to repair the obstruction in the upper urinary tract passage at the level where the ureter leaves the kidney.
In children with recurrent PUJ Obstruction, Laparoscopic Pyeloplasty is a viable alternative to Open Pyeloplasty surgery. It requires a shorter hospital stay and less pain after the procedure. However, it is technically challenging so one has to make sure while choosing the Laparoscopic Urologic surgeon who has considerable experience in performing the procedure in a high volume of cases.
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Q1 Who needs Pyeloplasty surgery?
A1 Both adults and children may require a Pyeloplasty procedure to repair the obstruction present at UPJ (Ureteropelvic Junction). UPJ obstruction may be present at the time of birth (1 in 1500 babies). Twice as many males have this condition in contrast to females.
Infants, if do not improve even after 18 months, may require Pyeloplasty.
Older children or adults may develop PUJ obstruction later in life and may require Pyeloplasty to rectify the condition.
Q2 What are the causes of PUJ obstruction?
A2 The abnormality in the anatomy (structure) of the Pelviureteral junction may be present since birth (congenital) or may be acquired later in life, as a result of other medical conditions such as stone or rarely, cancer.
PUJ may pass over a blood vessel in some patients, the blood vessel in such case is referred to as a crossing vessel. This may also be the cause of LUJ obstruction.
Though present at birth in some patients, PUJ obstruction, may not show up until later in life.
Q3 What are the symptoms of Pelviureteric Junction Obstruction?
A3 The PUJ Obstruction may present with the following symptoms:
Poor flow of urine
Pain in the flank or abdomen
Impaired and worsening kidney function
Infect of the urinary tract passage
Stones in the urinary tract
High Blood Pressure
Q4 Is Pyeloplasty an invasive Procedure?
A4 There are several techniques adopted to perform the Pyeloplasty surgery, in order to access the kidney, more specifically the obstructed Pelviureteric Junction where the ureter leaves the kidney.
In babies and infants, Open surgery is safer than the Laparoscopic approach and it is an invasive surgery. Here, the urosurgeon directly visualizes the surgical site, without the help of a camera, after making a large incision, cutting skin and tissues to access the area to be operated upon.
However, in Laparoscopic Pyeloplasty a camera is used, and a robot may also be used as in Robotic Computer-assisted Pyeloplasty.
Open Pyeloplasty is a safer surgery than Laparoscopic Pyeloplasty in babies and infants. However, in adults, Laparoscopic Pyeloplasty or Keyhole surgery may be a better alternative to correct PUJ Obstruction.
Q5 Is Laparoscopic Pyeloplasty an outpatient or inpatient procedure?
A5 Laparoscopic Pyeloplasty is an inpatient procedure that implies that the patient (baby, child, or adult) has to be admitted to the hospital. A hospital stay may be for one to two days. However, the hospital stay for Laparoscopic pyeloplasty may vary from patient to patient.
Q6 How much time does the Laparoscopic Pyeloplasty procedure take?
A6 It takes around 3 hours to perform Laparoscopic Pyeloplasty for PUJ obstruction.
Q7 What type of anesthesia is given to perform Laparoscopic Pyeloplasty surgery?
A7 Laparoscopic Pyeloplasty Surgery is done under General Anesthesia in which patient is put to sleep.
Q8 What happens in Laparoscopic Pyeloplasty Surgery?
A8 Pyeloplasty surgery encompasses removal of the narrowed or obstructed part of the urinary tract i.e., Pelviureteric Junction, and joining the remaining loose ends of the urinary tract together.
It can be done by several techniques such as Open Pyeloplasty which requires a large incision in order to perform the surgery or, Laparoscopic Pyeloplasty surgery.
Laparoscopic Pyeloplasty is also known as a keyhole surgery as it needs a few very small incisions, each less than half of an inch, and hence the name.
Three keyhole size incisions or cuts are made in the skin of the abdomen at the side of the affected kidney. A fibre optic instrument fitted with a camera and light at the end and tiny surgical instruments are passed through these holes in order to access the obstructed PUJ site and finally, remove it and join the remaining loose ends of the urinary tract. The urologist does not have to actually put his hands inside the abdomen.
At the end of this procedure, a catheter (flexible tube) is left in place. It comes out of the bladder through the urethra and, connected to the catheter bag which collects the urine.
Additionally, a drainage tube is left in place near the surgical site, coming out of one of the incisions, which drain the fluid coming out from around the kidney or the repair site. Both of these tubes are removed after a day or so.
A small plastic tube, referred to as ureteral stent is placed in the ureter after the procedure is complete, which is eventually removed after a span of 4 to 6 weeks.
Q9 What are the benefits of Laparoscopic Pyeloplasty?
A9 Laparoscopic Pyeloplasty has a lot to offer in contrast to Open Pyeloplasty, in terms of:
Minimally invasive surgical technique
Quick recovery
Minimal pain which can rather be referred to as discomfort
Aesthetically pleasing due to small incisions
Early resumption of daily activities
Shorter hospital stay
Less potential for complications
No or reduced need for blood transfusion
Comparable results to that of Open Pyeloplasty surgery
Open Pyeloplasty is a cheaper surgical option in contrast to Laparoscopic Pyeloplasty surgery for Ureteropelvic Junction Obstruction, with comparable efficacy and needs less operating time, but it is still associated with more complications, increased morbidity, more post operative pain, more blood loss, longer hospital stay and delayed resumption of daily activities for the patient.
Q10 What are the complications associated with Laparoscopic Pyeloplasty?
A10 Laparoscopic Pyeloplasty is a safe and effective procedure for PUJ Obstruction with a reported 97% success rate and the results are comparable to that of Open Pyeloplasty surgery.
Complications whether during the procedure (Intraoperative) or after the procedure (Post Operative) are rare and the major complications that necessitate any active intervention is seen in a very low number of cases, which may be:
Stone formation
Urine Leakage
Hematoma formation
Recurrence of PUJ narrowing, requiring treatment again
Colonic lesion
Urinary tract infection
Q11 What is the difference between Robotic Computer-Assisted Pyeloplasty and conventional Laparoscopic Pyeloplasty?
A11 Laparoscopic Pyeloplasty is way better than Open Pyeloplasty surgery as it provides comparable results but with lesser morbidity. However, technically it is challenging as it requires advanced Laparoscopic skills, on part of the urology surgeon and more operating time.
Robotic computer-assisted Pyeloplasty has somewhat reduced the technical challenge, especially in the reconstruction of the remaining urinary tract passage, after the removal of the narrowed or obstructed part and along with other benefits offered by Laparoscopic Pyeloplasty, Robotic Pyeloplasty reduces surgeon's fatigue as well.
Robotic Pyeloplasty, like Open Pyeloplasty requires less operating time whereas Laparoscopic Pyeloplasty requires considerably increased operating time. Laparoscopic as well as Robotic pyeloplasty have comparable efficacy, success rate, minimal blood loss, shorter hospital stay and fewer complications.
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Dr. Anant Kumar
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Chairman, Urology, Renal Transplant, Robotics, and Uro-Oncology
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Dr. Sujit Chowdhary
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