Laparoscopic pyeloplasty

What is laparoscopy?

This is a technique to reach parts of the body without the use of large incisions. Instead, a narrow telescope and instruments are inserted through small incisions allowing surgery to be performed. The intention is to achieve the same results as would be obtained by conventional surgery.

What are the advantages of a pyeloplasty performed laparoscopically?

The advantages are multiple and include the following:

  • smaller skin incision - four 1 cm incisions rather than a 30 cm incision
  • better view because of the magnification of the system
  • less pain because the incisions are smaller and the muscles are parted rather than cut
  • 2 to 4 days in hospital compared to a week or longer by open surgery
  • less blood loss and reduced need for a blood transfusion
  • the ability to return to work in 2 to 4 weeks compared to 6 or more weeks after traditional open surgery

What are the disadvantages of a pyeloplasty performed laparoscopically?

As the hands are not directly in the body, it is less easy to feel what is happening compared to open surgery. In some situations, the tactile feedback can be important and if that becomes true, it would be necessary to make an incision to carry on. This is extremely rare. Other disadvantages include the increased length of time necessary for the operation, the significantly increased cost of the equipment and the necessity for the surgeon to be experienced in laparoscopy before being able to perform the operation.

How is a laparoscopic pyeloplasty performed?

After a general anaesthetic has been given, a telescope is placed through the urethra into the bladder. A little tube (stent) is placed in the ureter, which is the tube that connects the kidney to the bladder.

Afterwards, incisions are made in the side of the abdomen. Typically, there are about 3 or 4 incisions between 0.5 cm and 2 cm just below the ribs on the side of the problem. The narrow part of the junction between the renal pelvis and the ureter is excised. A new ‘join’ between the kidney and ureter is constructed. The operation lasts for about 2 hours to 3 hours. If there is a crossing vessel, the join is made on the other side of the crossing vessel and this makes the operation take a longer time to complete. At the end of the procedure, there is usually a tube left inside the body near the site of the operation and this comes out through the skin (‘drain’). This is removed when fluid stops draining, which is usually after a day or so. There is another tube (‘catheter’) coming out from the bladder through the urethra and connected to a ‘catheter bag’. This is removed after a day or so also. The ‘stent’ placed internally between the kidney and the bladder remains at the end of the operation and is removed later under local anaesthetic about 6 weeks after surgery.

What are the side-effects of the laparoscopic pyeloplasty?

There are some risks associated with laparoscopy alone and some with the surgery. The common or serious risks of pyeloplasty include

  • The operation does not work. This occurs in 5 to 10% of patients and would need a second procedure to correct. The risk of this is similar to that when performed by traditional open surgery
  • A drain is required for a longer period than normal. In general, a drain is required for a day after the operation. If urine leaks for longer than expected, a drain may be necessary for a longer period
  • Infection: this occurs rarely because of antibiotics, but the urine or wound can still become infected requiring further or different antibiotics
  • Injury to other structures in the body. This is a risk of all surgery, but slightly higher when performed laparoscopically. Rarely, the kidney may have to be removed altogether
  • Conversion from keyhole (laparoscopic) to traditional open surgery: if there is substantial difficulty performing the operation, then a traditional or larger incision may be required to complete the operation
  • Bleeding may occur and a blood transfusion may have to be given. Rarely, the kidney may need to be removed or the bleeding controlled by special techniques
     

The risks of laparoscopy relate to the use of the small incisions and working with small instruments. These are rare include

  • Entry into the abdomen instead of staying in retroperitoneum
  • Gas entry into the skin around the incisions. This can result in the skin feeling crackly after surgery, but is short-lived
  • Damage to nearby structures, which may include bowel or other organs in the abdomen. If this occurs, a large incision is necessary into the abdomen to fix this

Are there any problems urinating after treatment?

Immediately after treatment, there is usually a catheter in place. This is a tube that drains the bladder. After a day or so, the catheter may be removed if all is well and passing urine may be uncomfortable for a short period.

What can I expect post-operatively?

The drain and catheter are usually removed on the first or second day after surgery. You can usually go home between the second and fourth day of the operation. After 2 to 4 weeks after the operation, it may be possible to return to work. People vary and it depends on the degree of physical activity necessary to be performed and how you feel.

You can drive when you are able to brake safely, and this usually takes several weeks.

The internal tube (‘stent’) between the kidney and bladder is usually removed between three to six weeks after the operation. The stent can cause discomfort include pain on passing urine that may be felt in the back on the side of the operation, lower abdomen or tip of the penis. There may also be some blood in the urine. These problems can be worse if you are more active, but not always. The stent can usually be removed easily under a local anaesthetic by a special telescope inserted down the urethra i.e. the tube through which urine passes out of the bladder. This means coming into hospital for a morning or afternoon only and is performed as an outpatient procedure. Antibiotics will need to be taken for 3 days after the stent has been removed.

Three months later, another diuretic renogram (MAG3 study) is performed. This is another test performed as an outpatient, and will probably be similar to a test performed to help substantiate the diagnosis of PUJ obstruction in the first place. This is to determine whether obstruction is still present or not. Another study may be performed one year later.