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Laparoscopic Pyelopasty

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17/06/2006

The commonest congenital abnormality of the ureter is a narrowing where the ureter joins the renal pelvis of the kidney.  The result is a mechanical blockage to urine flow from the kidney.   As you might expect it can cause pain, urinary infections, the development of kidney stones and high blood pressure.  It is thus appropriate to offer surgical correction.  It affects both kidneys in 10% of patients.  In 2/3 patients the blockage is caused by a narrowing in the ureter and in the remaining 1/3 by kinking of the ureter over an extra blood vessel supplying the lower part of the kidney.

The kidneys sit high on the back wall of the abdomen, below the diaphragm .  Traditional surgery therefore requires a large incision and sometimes the removal of a rib.  These types of incisions have a reputation for been both painful and unsightly.  Postoperative pain increases the risk of the development of chest infections.  Patients usually spend 7-10 days in hospital.

The laparoscopic approach, first developed in 1993 is performed through 4 x 5-12 mm cuts near the rib cage.  In both operations it is necessary to insert an internal stent into the ureter and kidney up from the bladder to act as an internal support following the surgery.  It will be removed under local anaesthetic 3-4 weeks later.  Occasionally it will not be possible to complete the procedure laparoscopicaly an so we will need to perform a standard incision.  This occurs in 2% of cases.  Most patients will be allowed home after 48hrs with a supply of analgesia.  We will confirm that the operation was successful by repeating the renogram that you had preoperatively at 3 months.

Several procedures have been developed over the years to treat this condition but pyeloplasty gives the highest chance of cure. The evidence to date suggests that laparoscopic pyeloplasty has an even higher success rate (98%) than traditional surgery (87%).  Balloon dilatation (stretching the narrowed area until it splits using a balloon threaded up from the bladder) and endopylectomy (placing an instrument through the kidney into the renal pelvis to incise the narrowed area from within) are successful in about 75%.


Potential Risks and Complications

Although this procedure is very safe, as in any surgical procedure there are risks and potential complications. The safety and complication rates are similar when compared to the open surgery. Potential risks include:

  • Bleeding: Blood loss during this procedure is typically minor and a blood transfusion is rarely required.
  • Infection: All patients are treated with broad-spectrum intravenous antibiotics prior to starting the surgery to decrease the chance of infection from occurring after surgery. If you develop any signs or symptoms of infection after the surgery (fever, drainage from your incision, urinary frequency, discomfort, pain or anything that you may be concerned about) please contact us at once.
  • Hernia: Hernias at incision sites are uncommon since all keyhole incisions are closed carefully at the completion of surgery.
  • Tissue / organ injury: Although uncommon, possible injury to surrounding tissue and organs including bowel, vascular structures, spleen, liver, pancreas and gallbladder could require further surgery. Injury could also occur to nerves or muscles related to positioning.
  • Conversion to open surgery: this surgical procedure may require conversion to the standard open operation if extreme difficulty is encountered during the laparoscopic procedure. This could result in a larger standard open incision and possibly a longer recuperation period.
  • Failure to correct UPJ obstruction: Roughly 3 % of patients undergoing this operation will have persistent blockage due to recurrent scarring. If this occurs additional surgery may be necessary

What to expect after surgery?

You will be taken to the recovery room and transferred to your hospital room once you are fully awake and your vital signs are stable.

  • Hospital Stay: The length of hospital stay for most patients is approximately 1-2 days.
  • Diet: Most patients are able to tolerate liquids the day after surgery and regular food the next day.
  • Postoperative Pain:  Regular paracetamol (intravenous) and an anti-inflammatory are usually sufficient in controling pain.  Intravenous opiates (morphine) tend to make you feal sick and slow down the recovery of your bowel function. Be warned that you may experience some minor transient shoulder pain (1-2 days) related to the carbon dioxide gas used to inflate your abdomen during the surgery.

  • Nausea: You may experience some nausea related to the anesthesia or pain medication. Medication is available to treat persistent nausea.

  • Urinary Catheter: You can expect to have a urinary catheter draining your bladder for approximately 2 days after the surgery. It is not uncommon to have blood tinged urine for a few days after surgery.

  • Drain: You will have a drain coming out of a small incision in your side. This drain is placed around the operative site to prevent blood and fluid from building up around the kidney and pyeloplasty repair. The drainage typically appears blood-tinged. It is usually removed the day the urinary catheter is removed.  If persistent high volume drainage occurs, you may have to go home with the drain and have it removed later.

  • Fatigue is common and should subside within a few weeks.

  • Ambulation: On the day after your surgery it is very important to get out of bed and begin walking under the supervision of your nurse to help prevent blood clots from forming in your legs.


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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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