Pyeloplasty

Blockage of the kidney where it joins the ureter is the commonest congenital abnormality of the ureter. It can lead to pain, urinary infections, kidney stones, loss of function and high blood pressure. Pelvi-ureteric junction (PUJ) obstruction is usually confirmed by two scans 1/ a renogram (radio-isotope study) which assesses kidney outflow obstruction and function and 2/ a CT (computed tomography) scan to show anatomical details. 10% of patients presenting with a PUJ obstruction will have both sides affected. The blockage may be caused by either a narrowing in the ureter or compression of the ureter externally by an extra blood vessel supplying the lower part of the kidney.

Several procedures have been developed over the years to treat this condition but pyeloplasty gives the highest chance of cure.

Balloon dilatation stretches the narrowed area until it splits using a balloon threaded up from the bladder and is inserted through a cystoscope. This may be successful in up to 75% of cases. Not all patients are suitable for this procedure, however.

Endopyelotomy involves cutting the narrowed area from the inside using a telescope inserted either through the side or from below through the bladder. The success rate is approximately 80% but again not all patients are suitable for this form of treatment.

Robotic pyeloplasty

Robotic is commonly known as "keyhole surgery”, however, although the incisions are small the view is not. Modern equipment produces a wide, bright, clear and magnified view of the operation, often superior to the traditional open approach. In addition, the gas used to distend the abdomen during laparoscopy also greatly reduces bleeding during surgery. Since laparoscopic pyeloplasty was first performed in 1993 the results published from many hundreds of patients' operations have shown an average success rate of over 90%.

Traditionally the surgical approach to the kidneys requires a 20-25cm incision because the kidneys lie high in the abdomen, beneath the ribs. The success rate for this approach is also high (approximately 90%). The robotic operation is performed through ports placed in the abdomen. An internal plastic tube (stent) is inserted into the ureter using a cystoscope (optical scope placed into the bladder) at the start of the operation. The kidney is identified and the obstructed junction of the renal pelvis to the ureter (PUJ) is exposed. The ureter is opened and the PUJ is then divided. If the cause of obstruction is a compressing blood vessel the ureter is moved to the other side of it. The PUJ is then reconstructed by suturing the ends of the ureter together again. The sophisticated robotic “endowrist” allows a wide range of movement and precise control of the suturing to reconstruct the urinary drainage system.

A temporary drain is routinely placed to remove any fluid from the area after the surgery and a urinary catheter is inserted to measure urine production during and after the operation. The entire operation is performed without the surgeon’s hands entering the body.

After the operation

Minimally invasive procedures are less traumatic than open procedures however this does not mean that they are pain-free. Medication will be given to keep pain at a manageable level to allow you to mobilise. It is important to get out of bed early in the recovery period. The benefits of this include avoiding blood clots and chest infections as well as promoting the return of normal bowel function. The nursing staff are very helpful with this process. Blood tests will be done after surgery and medical staff will review your progress on a regular basis as well. The drain will be removed as your recovery progresses. The sutures are dissolvable and do not need to be removed.

Although the incisions are small, a significant operation has taken place internally and as such you should not undertake strenuous physical exercise, even if you feel like it, until at least 3 weeks (A return to full activities may take 6-12 weeks with an open approach). You may drive as soon as you think you could brake hard and swerve quickly to avoid an accident (typically 2 weeks).

Follow-up

The internal stent is removed under a local anaesthetic 4 weeks after surgery. Imaging (either CTIVU or renogram) is repeated at 3 months and 1 year. Occasionally pooling of the radio-isotope in the kidney from changes due to previous longstanding blockage may make the renogram difficult to interpret. If this happens a short dye test under anaesthetic at 4-6 months is performed using a cystoscope to ensure that the new join remains open and is draining freely.