Laparoscopic Anterior Y-V Pyeloplasty: A Valuable Treatment Option in Patients with Small or Intrarenal Pelvis *

Introduction

Most urologists consent that dismembered pyeloplasty yields the best therapeutic results in the treatment of ureteropelvic junction obstruction (UPJO).^1–3 Nevertheless, the technique is time-consuming as much suturing is needed. Procedures such as Fenger plasty or Foley Y-V, which involve less suturing and are technically easier, have been found equally efficacious.^4–6 These procedures seem to be preferable in patients with small or intrarenal pelvis.

It takes a considerable amount of time and is very inconvenient to suture the rear part of the anastomosis in laparoscopic classical Foley Y-V plasty. Therefore, we propose a modified version of the procedure—anterior Y-V plasty, in which a V-shaped flap is created from the anterior wall of the renal pelvis. Thus, two lines of sutures are located on the anterior, easily accessible wall of the renal pelvis.

Materials and Methods

Operative technique (Video)

Patient preparation and preoperative procedures

No bowel preparation was performed. Antibiotics were given to patients with positive urine culture at the time of surgery. After induction of general anesthesia, the procedure starts with cystoscopy, retrograde pyelography, and stent (Double-J, 6F or 7F, 26–28 cm) placement.

Patient positioning and trocar placement

The patient was placed in a 45° flank position. The first 10-mm trocar was introduced below the umbilicus using a Hasson technique. After achieving the pneumoperitoneum, three additional trocars (2 × 5, 1 × 10 mm) were inserted under direct vision—a 5-mm trocar halfway between the umbilicus and the xiphoid at the edge of the rectus muscle, a 10-mm trocar below the level of the umbilicus laterally to the rectus muscle, and the fourth, 5-mm trocar in the midclavicular line below the costal margin.

Colon mobilization and access to the UPJ

The mesentery was incised lateral to the edge of the colon and the bloodless plane between the mesentery and Gerota's fascia was exposed. The colon was gently mobilized medially and Gerota's fascia was incised and entered. The proximal ureter and the renal pelvis were localized.

Crossing vessel

In cases involving anterior crossing vessels, the vein was divided and the artery (if present) was displaced cephalad. To fix the translocated vessel in the superior position, the perivascular tissue was approximated with three to four interrupted 3-0 monofilament sutures to the edge of Gerota's fascia, which had previously been divided over the renal pelvis. The procedure was not performed in patients with posterior crossing vessels. In such cases an A-H plasty with anterior transposition of the vessel was carried out.

Incision of the renal pelvis and proximal ureter

The renal pelvis and the proximal ureter were fully mobilized. Two incisions were made on the anterior aspect of the renal pelvis. The apex of the V was situated close to the UPJ and the wings of the V were formed by two incisions: one toward the upper calix and the other in the direction of the lower calix. Then the vertical incision was carried down the anterior proximal ureter as low as 1 cm below the area of stenosis (Fig. 1).

OPEN IN VIEWER

FIG. 1.

Incision of the renal pelvis and the ureter.

Anastomosis

The apex of the pelvic flap was approximated to the apex of the ureterotomy incision by the first suture. The anastomoses of the medial and lateral walls were then performed with interrupted sutures over a Double-J stent, using a freehand suturing technique. The suturing material preferred by the authors was 4-0 monofilament suture with a curved needle.

Drainage and catheterization

At the end of the procedure, a 5-mm closed suction drain was positioned close to the anastomosis and a 16F urethral catheter was left indwelling. The abdominal drain was removed when the output was below 50 mL over 24 hours. The urethral catheter was removed the next day.

Results

As 1 patient did not turn up for the follow-up, the success rate was evaluated in 35 cases. Complete success was defined as absence of any clinical symptoms combined with the improvement of hydronephrosis on imaging studies (ultrasound [US], duretic IVU), and no sign of obstruction on diuretic IVU (patent UPJ). Diuretic renography was routinely used only for patients who had undergone it preoperatively. If IVU findings were equivocal (reduction of hydronephrosis but not visible UPJ), diuretic renography was carried out (3 cases—all complaining of the flank pain before the operation and asymptomatic after the procedure). In all 3 patients, the T1/2 was below 12 minutes.

Complete success was observed in 34 of 35 patients (97.1%). The mean follow-up time was 24 (4–43) months. The follow-up examinations were carried out every 3 months (US, the assessment of symptoms according to an analog pain scale). Three months after the procedure, diuretic IVU and/or diuretic renography were performed in all patients. A successive diuretic IVU was performed at 18 months after the procedure. Subsequently, a yearly visit to a urologist was recommended.

The mean operative time was 160 minutes. We did not observe any serious complications in the postoperative period. A drain was removed after 4 days on average.

Our only failure was observed during the first year after surgery. Pain was observed immediately after stent removal and so a new stent was inserted again for 4 weeks. This maneuver was ineffective and IVU performed after removing the stent showed hydronephrosis with no patent UPJ. Then the patient underwent retrograde laser endopyelotomy, which was also unsuccessful. Finally, the patient underwent open pyeloplasty.

Discussion

The creation of anastomosis, which is the most difficult stage in laparoscopic pyeloplasty, requires advanced surgical skills. Urologists often choose nondismembered procedures to shorten the operative time and report satisfactory therapeutic results.^4–6 For patients with small or intrarenal pelvis and no dorsally crossing vessels, Y-V plasty seems to be an attractive alternative to A-H plasty. ⁷ One of the difficulties in laparoscopic Foley Y-V plasty is the posterior part of the anastomosis. The posterior edge of the pelvic flap is covered by the anterior part of the anstomosis previously created. It has to be exposed then. To achieve this, an assistant catches the threads of the first suture and moves the pelvis laterally. However, this may cause excessive tension to the anastomosis, which may end in its damage. It seems to us that intracorporeal laparoscopic suturing is easier in anterior Y-V plasty than in classical Foley Y-V plasty because two lines of sutures are located on the anterior, easily accessible wall of the renal pelvis.

Most of the procedures described above were performed at the beginning of our lap program. This explains why the operative time was relatively long. For many authors the operative time does not include stent placement and repositioning. As all the operations we performed started with cystoscopy and stent placement, we included stent placement and repositioning in the operative time.

The opponents of the Y-V procedure maintain that, using it, one cannot perform the reduction of the enlarged renal pelvis.^1,8 However, there are authors who claim that pelvic reduction will not improve the results of pyeloplasty. ⁹ Our analysis indicates that the reduction of the renal pelvis is not needed, but our trial has not been prospective or randomized. As it has not been conclusively determined yet what influence the reduction of the renal pelvis may have on the effects of pyeloplasty (no randomized trials in the literature), we suggest performing Y-V pyeloplasty in patients with small renal pelvis. In such cases the reduction of the renal pelvis is not performed during A-H plasty, either.

Our experience in open pyeloplasties corroborates the observation of Janetschek et al. ¹⁰ that the dorsal transposition of the ventrally crossing vessel may not always give good therapeutic results. Therefore, in our material, the most commonly followed procedure in cases of anterior crossing vessels was cephalad translocation whatever type of plasty was performed. This technique is similar to the technique described by Meng and Stoller. ¹¹ A Y-V plasty, which caudally transposes the UPJ, increases the distance between the translocated vessel and the newly created UPJ.

We used the transperitoneal approach in all cases. Hence, in the case of a dorsally crossing vessel, its cephalad translocation could be very difficult. It seems to us, then, that in such cases A-H plasty and the anterior transposition of the vessel should be performed. However, the transposition of the dorsal vessel anteriorly is rarely needed because the direct relationship between a crossing vessel and the dorsal surface of the UPJ is observed in few cases. ¹²

In our analysis, ultrasound and diuretic urography were the basic procedures we used to diagnose UPJO and to evaluate the success rate of the surgery. We agree with Yurkanin and Fuchs ¹³ that diuretic IVU is a valuable test for preoperative and postoperative evaluation of patients with UPJO. The combination of contrast and furosemide creates a maximal diuresis and such “supranormal” conditions would certainly unmask and document UPJO. It is very important that all our patients were symptomatic. In such cases, routine diuretic renography is not, in our opinion, of any additional benefit. We are aware that diuretic urography does not provide a quantitative measure of treatment outcome. Yet, it seems to us that this information is not indispensable in the evaluation of the operative procedures. Although, in a number of urological centers, diuretic renography is a commonly used study for diagnosing UPJO, in others diuretic urography is used as it is considered an equally reliable test. ¹³ It seems to us then that both tests are complementary and that is how we treated them in our diagnostic and follow-up protocol.

It is well known that the length of the follow-up may considerably affect the evaluation of the therapeutic effects. However, most recurrences occur within 2 years after the surgery, whether it is endopyelotomy or pyeloplasty. ¹⁴ In our material, the mean follow-up time was 24 months. It is very likely that with time the success rate in that group will gradually decrease. But it is also very likely that the success rate will decrease in patients who underwent other kinds of pyeloplasty (e.g., A-H procedure). Late recurrences observed by Madi et al. ¹⁵ at 2, 2.5, and 6 years postoperatively were not related to the type of repair. Further follow-up is necessary as it will, hopefully, make it possible to compare the therapeutic results of anterior Y-V technique with the gold-standard A-H plasty.

The analyzed group of patients is not big. However, our results seem to indicate that the modified procedure may constitute a reasonable treatment option for patients with small or intrarenal pelvis and no dorsally crossing vessels.