What Is Pyeloplasty

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Introduction

Pyeloplasty is a surgical procedure designed to correct a condition known as ureteropelvic junction obstruction. This condition occurs when there is a blockage or narrowing at the point where the renal pelvis (the part of the kidney that collects urine) connects to the ureter (the tube that carries urine from the kidney to the bladder).

Pyeloplasty aims to alleviate this obstruction, restoring normal urine flow and preserving kidney function. This short overview will delve into the reasons for pyeloplasty, the surgical techniques involved, the recovery process, and the outcomes associated with this procedure.

Understanding ureteropelvic junction obstruction

Ureteropelvic junction obstruction is a congenital or acquired condition that impedes the flow of urine from the renal pelvis to the ureter.1 This is essentially an obstruction in the tube that collects urine produced in the kidneys and transports it to your bladder. Congenital cases often involve a structural abnormality present from birth, such as an abnormal blood vessel compressing the ureter.

Acquired cases may result from several differing conditions – kidney stones, infections, scarring, or disruption from previous surgeries. Regardless of the cause, ureteropelvic junction obstruction can lead to complications such as urinary tract infections or the development of kidney stones, and, if left untreated, kidney damage is likely.2

Indications for pyeloplasty

Pyeloplasty is recommended when conservative approaches, such as medications or the insertion of a stent to temporarily widen the ureter, prove ineffective in relieving the obstruction.3 The decision to undergo pyeloplasty is based on various factors, including the severity of symptoms, the presence of complications, and the overall health of the patient.

Common symptoms of ureteropelvic junction obstruction include:4

  • Pain in the lower back, where the kidneys are situated
  • Recurring urinary tract infections
  • Hematuria (presence of blood in the urine)
  • Abnormal lumps near the abdomen
  • Vomiting
  • Hydronephrosis (enlargement of the kidney due to buildup of urine)
  • In infants - poor growth and failure to thrive

Scans may be done during pregnancy to identify any congenital abnormalities in the kidneys. After birth, or for adults with acquired ureteropelvic junction obstruction, a blood urea and nitrogen test or a creatinine clearance test may be conducted. Both of these identify if a kidney is improperly functioning and unable to exude the collected urine and fluids from the body.5

Another option is using an intravenous pyelogram (IVP), which is a method that uses a dye that is injected into the bloodstream that needs to pass through the kidneys. An X-ray can be used to take pictures of the kidneys this way and identify any issues. In some instances, a voiding cystourethrogram may be needed, where a catheter will be inserted into the urinary tract, a liquid injected into the bladder and the backflow into the kidneys, and the passing of the liquid out of the body are both observed via x-ray in real-time. This may help identify where the blockage is situated.6

Alternative methods to help with ureteropelvic junction obstruction or scarring are:

  • Observation – this is an option when symptoms are not too painful and do not interfere quality of life enough to justify surgery
  • Internal ureter stretching - stretching the area that is narrow or obstructed using a balloon that is passed up either from the bladder or through the skin over the kidney, while under real-time X-ray screening to undo the blockage7
  • Telescopic incision or endopyelotomy – using an electric wire passed up from the bladder or through the skin over the kidney to cut open and widen the narrowed area. This is effective if there is unusual musculature or polyps obstructing the ureter8
  • Temporary stenting – placing a small plastic stent through the narrowed area to keep it open

Surgical techniques

There are different surgical techniques employed in pyeloplasty, each tailored to the specific needs of the patient. The two approaches are open pyeloplasty and minimally invasive pyeloplasty, with the latter further divided into laparoscopic and robotic-assisted procedures.

Open pyeloplasty

Open pyeloplasty involves making a large incision in the abdomen to access the affected kidney. The surgeon then identifies and removes the obstructed segment of the ureter, followed by the reconstruction of the ureteropelvic junction where the ureter meets the kidney.

This method allows for direct visualisation and manipulation of the structures, making it suitable for complex cases or when the patient has had previous abdominal surgeries. Usually, a stent is put in the newly repaired ureter to help with recovery after the surgery is finished.9 The stent is typically removed six to eight weeks after surgery is complete.

Before surgery, the general fitness of the patient is checked to ensure they will not suffer further complications post-surgery, and a test to check for strains of bacteria that are resistant to antibiotics. This will help prevent the spread of the resistant bacteria in case of an infection and lower the risk of further complications occurring because of bacterial resistance whilst the patient is in recovery. Patients will also be asked not to eat or drink for six hours before the surgery.

Anti-thrombosis stockings are also used while the surgery is ongoing to prevent the formation of blood clots in the legs. The procedure comes with risks for those who have heart stents or stents or grafts in the blood vessels, as well as those who have a surgical implant or artificial joints. Although the surgery may still be done with further precautions and care.10

Laparoscopic pyeloplasty

Laparoscopic pyeloplasty is a minimally invasive technique that utilises small incisions and specialized instruments. The surgeon inserts a thin, flexible tube with a camera (laparoscope) through one incision and additional instruments through other small incisions. The obstructed portion of the ureter is then removed, and the remaining segments are reconnected.

Similarly to open pyeloplasty, a stent is inserted that is removed four to six weeks post-surgery. Sometimes an additional drain is also left, which exits through your back to drain away any fluids around the kidney that form as a result of the pyeloplasty repair. Laparoscopic pyeloplasty offers advantages such as reduced post-operative pain, shorter hospital stays, and faster recovery compared to open surgery.12

Robotic-assisted pyeloplasty

Similar to laparoscopic pyeloplasty, robotic-assisted pyeloplasty employs the use of a robotic surgical system to enhance precision and dexterity. The surgeon controls the robotic arms from a console, allowing for more intricate movements. This technique combines the benefits of laparoscopy with improved manoeuvrability, making it particularly advantageous for complex cases.

Recovery and postoperative care

Recovery from pyeloplasty varies depending on the surgical approach and individual patient factors. In open pyeloplasty, patients may experience more significant pain initially and may require a longer hospital stay. In contrast, minimally invasive techniques often result in shorter recovery times and less discomfort.

Following surgery, patients are closely monitored for complications, such as bleeding, infection, or urinary leakage. Pain management, removal of drainage tubes, and the gradual return to normal activities are key components of the postoperative care plan. Regular follow-up appointments with the urologist help assess the success of the procedure and monitor the patient's overall kidney function.

Outcomes and complications

Pyeloplasty is generally considered a highly successful procedure, with a success rate of around 90%.11 Most patients will experience significant improvement in symptoms, and most importantly, kidney function is often preserved or restored, and the need for kidney removal, or dialysis is prevented. However, like any surgical intervention, pyeloplasty carries some risks and potential complications.

Possible complications may include infection, bleeding, injury to adjacent structures, and the development of scar tissue, which may require additional procedures. The overall risk of complications is relatively low, and the benefits of correcting ureteropelvic junction obstruction typically outweigh the potential drawbacks, and surgeries are not conducted unless they are safe to do so.

Summary

Pyeloplasty is a surgical intervention for ureteropelvic junction obstruction, offering a solution to restore normal urine flow and prevent further complications. The choice of surgical technique depends on various factors, including the patient's overall health, the complexity of the case, and the surgeon's expertise.

Advancements in surgical technology, such as laparoscopy and robotic-assisted techniques, have enhanced the precision and minimally invasive nature of pyeloplasty, leading to improved patient outcomes and shorter recovery times. As with any medical procedure, close collaboration between the patient and the healthcare team is essential to ensure the best possible results and a smooth recovery process. Pyeloplasty stands as a testament to the continual progress in urological surgery, offering an improved quality of life for those affected by ureteropelvic junction obstruction.

References

  1. Al Aaraj, Mahmoud S., and Almostafa M. Badreldin. ‘Ureteropelvic Junction Obstruction’. StatPearls, StatPearls Publishing, 2023. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK560740/.
  2. Borin JF. Ureteropelvic Junction Obstruction in Adults. Rev Urol [Internet]. 2017 [cited 2024 Mar 25]; 19(4):261–4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5811884/.
  3. Hyams, Elias S., and Michael D. Stifelman. ‘Chapter 31 - COMPLICATIONS OF MINIMALLY INVASIVE RECONSTRUCTION OF THE UPPER URINARY TRACT’. Complications of Urologic Surgery (Fourth Edition), edited by Samir S. Taneja, W.B. Saunders, 2010, pp. 365–73. ScienceDirect, https://www.sciencedirect.com/science/article/pii/B9781416045724000315.
  4. Grasso, Michael, et al. ‘UPJ Obstruction in the Adult Population: Are Crossing Vessels Significant?’ Reviews in Urology, vol. 3, no. 1, 2001, pp. 42–51. PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476031/.
  5. Yap, Ernie, et al. ‘Atypical Causes of Urinary Tract Obstruction’. Case Reports in Nephrology, vol. 2019, Feb. 2019, p. e4903693. www.hindawi.com, https://doi.org/10.1155/2019/4903693.
  6. ElSheemy, Mohammed S., et al. ‘The Role of Voiding Cystourethrography in Asymptomatic Unilateral Isolated Ureteropelvic Junction Obstruction: A Retrospective Study’. Journal of Pediatric Urology, vol. 13, no. 2, Apr. 2017, p. 206.e1-206.e7. PubMed, https://doi.org/10.1016/j.jpurol.2016.10.018.
  7. Klein, Julie, et al. ‘Congenital Ureteropelvic Junction Obstruction: Human Disease and Animal Models’. International Journal of Experimental Pathology, vol. 92, no. 3, June 2011, pp. 168–92. PubMed Central, https://doi.org/10.1111/j.1365-2613.2010.00727.x.
  8. Gerber GS, Kim JC. Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic junction obstruction. Urology. 2000; 55(2):198–202; discussion 202-203. Available from: https://pubmed.ncbi.nlm.nih.gov/10688078/
  9. Braga, Luis H. P., et al. ‘Risk Factors for Recurrent Ureteropelvic Junction Obstruction after Open Pyeloplasty in a Large Pediatric Cohort’. The Journal of Urology, vol. 180, no. 4 Suppl, Oct. 2008, pp. 1684–87; discussion 1687-1688. PubMed, https://doi.org/10.1016/j.juro.2008.03.086.
  10. Sachdeva, Ashwin, et al. ‘Graduated Compression Stockings for Prevention of Deep Vein Thrombosis’. The Cochrane Database of Systematic Reviews, vol. 2018, no. 11, Nov. 2018, p. CD001484. PubMed Central, https://doi.org/10.1002/14651858.CD001484.pub4.
  11. Seo, Ill Young, et al. ‘Long-Term Follow-up Results of Laparoscopic Pyeloplasty’. Korean Journal of Urology, vol. 55, no. 10, Oct. 2014, pp. 656–59. PubMed Central, https://doi.org/10.4111/kju.2014.55.10.656.
  12. Bansal, Punit, et al. ‘Laparoscopic versus Open Pyeloplasty: Comparison of Two Surgical Approaches- a Single Centre Experience of Three Years’. Journal of Minimal Access Surgery, vol. 4, no. 3, 2008, pp. 76–79. PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699080/.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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