NARUS 2018: When Pyeloplasty Fails
When consenting patients for an operation in the setting of a failed pyeloplasty, it is important to consider all of the potential approaches one may attempt/employ. For instance, according to Dr. Stifelman, it is important to have a ureteroscope available for a possible endopyelotomy or balloon dilation. One should also be ready to do a spiral flap, buccal mucosa graft, ureterocalycostomy and/or nephropexy. Given how challenging these procedures can be, Dr. Stifelman mentions that it is important to bring courage, imagination, patience, and a plan to the operating room. Furthermore, adjunct tools that may be the use of fluoroscopy, an ureteroscope, indocyanine green (ICG), Potts scissors, buccal mucosa harvest, and an omental wrap. When positioning the patient prior to operating, it is important to have full access to the urethra, the target operative area, and the percutaneous nephrostomy tube. Given the case may take longer than primary pyeloplasties, Dr. Stifelman also notes that it is important to have lots of padding and to make sure the patient is secure and security has been tested prior to draping.
Dr. Stifelman presented a case of a 28-year-old female school teacher that had a left ureteropelvic junction obstruction and had undergone a prior left open retroperitoneal pyeloplasty several years prior. Abdominal imaging noted an anterior, missed, crossing vessel leading to poor renal function (renal T1/2 40 minutes). Dr. Stifelman then presented a video demonstrating robotic redo pyeloplasty repair, taking note of the fibrotic tissue around the renal pelvis that is much more difficult to remove compared to a primary repair. The key according to Dr. Stifelman is to make sure to take your time to clear all of the fibrotic tissue from the renal pelvis prior to the reconstruction.
A second case presented included a 58-year-old paraplegic man who underwent a failed pyeloplasty and endopyelotomy. This was also in the setting of a solitary kidney (previously blown out left kidney secondary to a UPJ. Dr. Stifelman then presented a video of a redo pyeloplasty in this setting, again noting the time required to dissect out the renal pelvis. For this case, Dr. Stifelman utilizes ICG to identify the avascular area of the stricture to ensure the entirety of the stricture is removed. After the ureter was spatulated below the stricture it was clear that a regular pyeloplasty was not feasible, and thus he ultimately performed a spiral graft to allow mobilization of the cut ureteral end to the renal pelvis.
A final case presented by Dr. Stifelman included a 22-year-old male who suffered a motor vehicle accident and ureteral avulsion with a subsequent urinoma. He then developed a ureteral stricture, had a nephrostomy tube placed and underwent several failed endoscopic procedures, in addition to a failed pyeloplasty. Subsequent imaging confirmed an abrupt stop of contrast at the level of the renal pelvis. Dr. Stifelman then showed a video of his repair, noting the ureterotomy at the level of the scar tissue, removal of the fibrotic segment, proximal ureter spatulation, bringing the poster walls of the ureter and renal pelvis together with a 4-O vicryl suture in a running fashion, creation of a posterior plate, and securement of a buccal mucosa graft to the affected area with a final omental wrap.
Dr. Stifelman concluded with several points, noting that when attempting a robotic redo pyeloplasty it is important to go in with a comprehensive plan and be prepared for everything. He notes that a robotic approach maintains all of the principles of reconstruction, with the added benefit of precision, magnification and water tight closure.
Speaker: Michael Stifelman, Hackensack Medical Center, Hackensack, NJ
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV