| back together. Other forms of pyeloplasty are designed to reshape the junction so that its caliber is wider without actually removing the scarred or diseased segment. These methods are a bit trickier and the success rates are not quite as good as the dismembered approach. The main deterrent to the open approach has been the large incision, with the attendant postoperative pain, disfigurement, and opportunity for infection.
Endopyelotomy
In endopyelotomy, the junction is incised and then allowed to scar over a stent with the hope that the new scar will be sufficiently wide to allow flow of urine from the kidney through the ureter. Various forms of endopyelotomy were designed to counter the drawbacks of the large open incisions. The retrograde methods are done through the urethra and bladder without making any incisions on the abdomen at all. The antegrade method uses a small poke hole in the back to gain access to the junction from above. While considered minimally invasive and less painful, endopyelotomy has a long-term success rate of about 83% -- considerably less than a dismembered pyeloplasty. An endopyelotomy is a particularly poor choice for patients with certain types of anatomy, such as in the setting of an aberrantly crossing vessel, or if the ureter inserts very high at a non-dependent portion of the renal pelvis. On the other hand, it may be a very good choice for some elderly patients who are too frail to risk a major reconstruction if they have the right anatomic features.
Laparoscopic Pyeloplasty
Laparoscopic forms of pyeloplasty represent an excellent balance between adequate reconstruction and minimally invasive features to avoid large open incisions. The junction may be spliced (dismembered) just as in open surgery, and these operations carry the same long-term success rates (~92% for adults). They also carry the usual benefits of laparoscopic surgery over open surgery:
- Less blood loss
- Less pain
- Shorter hospital stay
- Smaller scars
- Fewer wound infections and other complications
- Earlier return to activities of daily living, including driving
Dr. Kaynan is uniquely skilled, not only in the manual laparoscopic suturing skills requisite for this type of reconstruction, but also in both trans-abdominal laparoscopic techniques, as well as retroperitoneoscopic techniques. In the retroperitoneoscopic method, the ureteropelvic junction is approached directly through the flank, skipping past intra-abdominal organs such as the colon. In the unlikely event of a postoperative bleed or urinary leak, the problem is better contained to the flank and patients are not as likely to get sick from these events. |
