BERKELEY, CA (UroToday.com) - Open surgery is the gold standard treatment for adult ureteropelvic junction obstruction (UPJO), with published success rates consistently over 90%. However, because of technological development, the management of UPJO has been revolutionized by the introduction of endoscopic, laparoscopic, and robotic techniques.[1, 2]
Percutaneous endopyeloplasty is a horizontal suturing of the longitudinal endopyelotomy incision through a percutaneous tract. The initial concept of percutaneous UPJ suture was reported by Oshinsky, et al.[3] However, percutaneous endopyeloplasty was developed and refined in an animal model by Desai, et al.[4, 5] They used a laparoscopic suturing device (SewRight SR5, LSI Solutions, Victor, NY) that was modified to be used through a nephroscope working channel. They showed that the advantages of this technique, over conventional antegrade endopyelotomy, consist of minimal urinary extravasation, full thickness ureteral wall healing with primary intent, wider caliber reconstruction of the UPJ, and a shorter stenting period.[2, 4, 5] Yet, a financial disadvantage of this technique is the requirement for a disposable laparoscopic suturing device to perform the sutures,[1] In fact, in the beginning, our technique of endopyeloplasty was used because this laparoscopic device was difficult to provide. Accordingly, we use a conventional absorbable 13 mm-needle suture with a 3.5 mm laparoscopic needle holder, via the nephroscope.
Technique
Under general anesthesia, or rarely spinal anesthesia, the patients are placed in the split-leg modified lateral position [6] (Video 1), the standard position of renal percutaneous surgery in our department, which has been used since 2003. After retrograde catheter placement, a percutaneous access through an upper or central calyx is achieved. If the kidney is located high, a caudal renal displacement is performed using the 18-gauge puncture needle.[7] Initially, a lower or middle calyx is punctured with an 18-gauge diamond-tipped needle. The needle's proximal end is progressively pushed in the cephalic direction. Consequently, the kidney is displaced caudally by the lever maneuver (Video 2). After “one shot” dilation,[8] a 24 F Amplatz sheath is placed in the renal pelvis. A through-and-through safety hydrophilic guide wire is inserted by introducing the safety guide wire through the ureteral catheter (Figure 1).
Irrigation is performed using normal saline -- save during endopyelotomy -- when a glycerin solution is used. When pelvic retraction is inconvenient, especially in large hydronephrosis, irrigation flow can be increased using manual pressure, by twisting the irrigant bag. In addition, an extra irrigation may be installed via the nephroscope drainage port (Figure 2). Consequently, the inflow of the irrigating fluid is almost doubled. Otherwise, the irrigant outflow can be blocked; the junction between the Amplatz sheath and nephroscope can be closed by a watertight grasp with the left hand (Figure 3). Alternatively, the rubber seal of the nephroscope can be adapted to the Amplatz sheath (Figure 4). Otherwise, a 24 Fr metallic sheath (Richard Wolf), with a faucet for drainage and with a rubber cap at the entry, is used with a 24 Fr Amplatz sheath. This method gives a good dilation of the renal pelvis for better exploration and suture. A supplementary irrigation can be placed through the metallic sheath faucet to add up more irrigant flow.
The UPJ is invaginated using traction on a 20 or 24 Fr balloon catheter that is inflated below the uretero-pelvic junction.[9] A longitudinal endopyelotomy incision is created using a 5 F electrode with pure cutting current (Figures 5 A-B) (Video 3). Alternatively, the incision can be performed using the metal mandrin of a ureteral catheter. Then, an initial suture is placed approximating the endopyelotomy incision distal and proximal ends (Figure 5 C). If possible, an additional 2 sutures are placed, one on either side of the initial suture (Figure 5 D). The sutures are performed using a conventional absorbable 13 mm needle suture with a lengthened 3.5 mm pediatric laparoscopic needle holder, via the nephroscope. Recently, because of mini-laparoscopy development,[10] 3-mm laparoscopic needle-driver and shears are easily available.
We have tried many brands of sutures and different sizes of needles with different structures. The best for this technique is an absorbable monofilament, 5/0 or 6/0, so it may glide easily in the narrow space between the nephroscope and the Amplatz sheath. The needle has to be short, about 13-mm (or maybe less 9 or 10-mm); thus it will fit “neatly” within the nephroscope tip when it is grasped in the middle by the needle holder, in the “conventional manner.” Therefore, it will pass in the Amplatz sheath and it will be shielded to avoid urothelium laceration. The whole needle will be visible in the nephroscope vision field; both ends will be monitored during the different movements. Moreover, a strong and thick needle is recommended to avoid being bent or twisted while passing in the tissues.
There are 3 ways in which the needle is handled. First, it is grasped in the middle, by the needle holder, in the “conventional” manner, oriented 45° forward (Figure 6). The needle is fashioned in a 3/4 semicircle to pass easily in the working sheath. This is used for the passage in the ureteral distal end of the incision (Figure 7). Second, the needle is grasped with its tip and curvature oriented backward (Figure 8). The needle is passed in retrograde fashion, mostly used in the pelvic proximal end of the incision (Figure 9). Both first and second manners are needed to complete the first stitch. Third, the needle is grasped with its body oriented in the same axe as the needle holder, with its tip oriented forward (Figure 10). The needle is passed using a forward push of the needle holder (Figure 11).
In these 3 ways, the needle is placed outside with the laparoscopic needle holder through the nephroscope working port. Then, the needle holder is attracted backward until the needle is blocked against the nephroscope tip, which will shield the needle to prevent urothelium injury. The suture is dragged alongside the nephroscope when it is introduced in the renal pelvis. That is why it is best to use a tiny monofilament suture (5/0 or 6/0), so it may glide easily in the narrow space between the nephroscope and the Amplatz sheath. So the friction is minimal during the movements of the nephroscope, when attracting the needle, and especially when pushing the knot from the outside to the endopyeloplasty site, there should be 2 strands of the suture passing between the nephroscope and the Amplatz sheath.
When the suture is passed in the 2 tissue edges, the needle is carefully attracted outside (Figure 12 A). Care should be taken to ensure that the afferent strand of the suture glides smoothly and that it is not blocked between the nephroscope and Amplatz sheath. Otherwise, there is risk to cut the suture or the ureteral wall. The nephroscope is once again reintroduced, following the suture, to ensure that the 2 strands are not mixed or intermingled with the safety guide wire and that a little traction on the suture provides a good approximation of the endopyelotomy incision. The knot is tied outside the Amplatz sheath and pushed progressively by an alligator forceps, while the second surgeon maintains a steady traction on the 2 strands, until reaching the endopyelotomy incision (Figure 12 B).
The first suture is the crucial part of endopyeloplasty, and it is the more difficult to perform. In concurrence with Oshinsky, et al.,[3] we think that in most cases, one suture is enough to have the Fenger-plasty result (Figure 5 C) (Video 3). The endopyelotomy incision has become horizontal and the tissue edges are close enough for a full-thickness healing with primary intent. The nephrostomy and endopyelotomy stent provide good kidney drainage. Therefore, the renal pelvis is retracted helping better approximate these tissue edges. Moreover, in our experience, and as it is well known mostly in classic endopyelotomy, postoperative nephrostogram at 48 hours reveals no extravasations. Therefore, a watertight endopyeloplasty repair is not necessary, and the other stitches are optional.
Before the standard endopyelotomy incision, dilation of the UPJ is performed.[3, 11 (Editorial comment)] In endopyeloplasty, this dilation may lead to thin fragile tissue that can result in sutures pulling-through during knot tying.[11 (Editorial comment)] In our experience, after endopyelotomy incision in UPJ with no previous double-J stenting, there is a retraction of the ureter, and the ureteral wall is thin. However, in case of preoperative double-J stenting, the UPJ and proximal ureter are larger, so the passage of the needle is easier. The ureteral wall is thicker, so there is less risk of tearing the ureteral wall. We think that endopyeloplasty seems technically easier in patients who had preoperative double-J stent insertion. Therefore, a double-J stent was placed at least 10 days before endopyeloplasty was scheduled.
In high-inserted UPJ, a long endopyelotomy can be performed, until reaching the more dependent renal pelvic part. In this case, the 2 tissue edges are nearer and the proximal incision angle and the distal end are adjacent, so endopyeloplasty is easier. Thus, the first suture might be performed in a single pass. On the contrary, when the UPJ is in a dependent position after endopyelotomy, the proximal incision angle and the distal end are wide apart, and the first suture may be more difficult.
This technique of endopyeloplasty can be simplified further. After the suture is passed in the 2 tissue edges, the two ends of the suture can be brought percutaneously through a 10-cm 8-F drain tube in a “tourniquet” fashion, and only one end is inserted through a 0.5-cm drain tube to block the knot, which is “left” outside. The suture is tied with tension. Then, it is fixed to the cutaneous entry with a gentle traction on the suture to provide a good approximation of the endopyelotomy incisions. After 5 or 7 days, the suture can be removed by cutting one suture end and performing a mild traction on the other strand. Thus, no foreign-material will be left in the renal pelvis. We use a similar technique to temporarily close the bladder neck after open adenomectomy, by performing a bladder neck removable partition purse-string suture for maximal hemostasis.[11] Alternatively, endopyeloplasty may be performed with only the first suture, and then a detachable inflatable stent [12] will be placed and inflated in the endopyeloplasty site, so the circumferential dilation may make the horizontal endopyeloplasty incision tightly shut, without the need of more sutures. The detachable inflatable stent may be removed about 5 to 7 days later.
We think that with endopyeloplasty, the new UPJ is reconstructed from a new segment of the proximal ureter, sutured with a new tissue of the renal pelvis wall. Thus, endopyeloplasty provides a transposition of the UPJ further down the proximal ureter in a “healthy” tissue. The UPJ “unhealthy” tissue is moved and “dissolved” into the renal pelvis wall (Figure 5 C), while in conventional endopyelotomy, the same walls of the initial UPJ remain. Moreover, in the Anderson-Hynes dismembered pyeloplasty, there is a resection of the UPJ tissue, so the ureteral vascular and neurologic continuity are severed. However, in endopyeloplasty, this continuity is preserved.
Transposition of crossing vessels is not always necessary, especially in high-inserted UPJ. After endopyeloplasty, the new UPJ is in a lower location. While, the crossing vessel might stay “higher” in the same position, so it may become crossed in the renal pelvic wall. Conversely, in conventional endopyelotomy, the UPJ remains in its initial position, so it may be hindered by the crossing vessel. In addition, we think that renal pelvic-tissue reduction, as performed in open or laparoscopic Anderson-Hynes dismembered pyeloplasty, is not always necessary. Since, in our experience, even in large hydronephrosis, there is a natural reduction or retraction after longer follow-up, when good kidney drainage is restored.
Actually, percutaneous endopyeloplasty is technically more difficult than endopyelotomy, and does have a steep learning curve, with significant technical expertise required.[13, and Editorial comment in 13] Moreover, Desai, et al.[2] think that our technique needs good technical expertise in endourology and laproscopy. In fact, we think that any endourologist with technical expertise of percutaneous surgery and endopyelotomy can perform this endopyeloplasty technique, even with no skill in laparoscopic surgery. Because learning this endopyeloplasty technique comprises only the maneuvers involving manipulation of the needle, these maneuvers are similar to alligator forceps uses, stone grasping, and adjusting the double-J stent loop in a calyx.[2, and author reply]
For the future, we feel that endopyeloplasty will probably benefit from the development of endoscopic suturing techniques, and the development of natural orifice transluminal endoscopic surgery (NOTES) procedures.[14, 15, 16, 17, 18] Moreover, with the development of endoscopic suturing techniques and a miniaturized endoscopic suturing device, perhaps endopyeloplasty can be performed in retrograde fashion using rigid or flexible ureteroscope, without the trans-renal-parenchyma passage (Video 4). Thus, perhaps, it will be quicker, with a need of only ureteroscopic skill…
This endoscopic suturing technique, of percutaneous endopyeloplasty, can be used for other applications in percutaneous renal surgery with Heineke-Mikulicz plasty of caliceal diverticulum neck, infundibulum stenosis, or Fraley’s syndrome. Moreover, we have used the same suturing technique to perform an endoscopic bladder suturing during “pluck” transurethral detachment of the intramural ureter, in the first part of nephroureterectomy (Video 5). In a female patient with transitional cell carcinoma of the left renal pelvis, the ureteral orifice was sealed with a figure-of-eight suture, before the intramural ureter was detached. Then, the bladder was sutured after ureteral detachment. The endoscopic suture of the bladder was possible, and allowed a short bladder catheterization, which suggests the feasibility of the endoscopic bladder suture using a needle holder through the nephroscope, and a conventional suture. The endoscopic suture might be used for transvesical NOTES, in case of bladder perforation or traumatic rupture. In addition, it might have further hypothetical applications: removal and neck closure of bladder diverticulum, endoscopic treatment of retrovesical hydatid cyst,[19] Heineke-Mikulicz plasty of short urethral strictures, bladder neck contracture, and vesico-urethral or pouch-urethral anastomosis stenosis, realignment and suture of urethral rupture, or endoscopic ureteral reimplantation and vesico-ureteral reflux treatment.
All these hypothetical suggestions and observations need to be verified. Consequently, further studies and further technical experience with longer follow-up, in a larger group of patients, are necessary to improve the technique of endopyeloplasty.
References:
- Symons SJ, Palit V, Biyani CS, et al. Minimally invasive surgical options for ureteropelvic junction obstruction: A significant step in the right direction. Indian J Urol 25: 27-33, 2009.
- Desai M, Ganpule AP. Editorial comment. Urology. 2012 Jan;79(1):230-1; author reply 231-2.
- Oshinsky G S, Jarrett T W, Smith A D. New technique of managing ureteropelvic junction obstruction: percutaneous endoscopic pyeloplasty. J Endourol 1996; 10: 147-151.
- Desai MM, Gill IS, Carvalhal EF, et al. Percutaneous endopyeloplasty: A novel technique. J Endourol 2002;16:431-443.
- Gill IS, Desai MM, Kaouk JH, et al. Percutaneous endopyeloplasty: Description of a new technique. J Urol 2002;168:2097-2102.
- Lezrek M, Ammani A, Bazine K, Assebane M, Kasmaoui el H, Qarro A, Beddouch A, Alami M. The split-leg modified lateral position for percutaneous renal surgery and optimal retrograde access to the upper urinary tract. Urology. 2011 Jul;78(1):217-20.
- Lezrek M, Bazine K, Ammani A, Asseban M, Kassmaoui el H, Qarro A, Alami M, Beddouch A. Needle renal displacement technique for the percutaneous approach to the superior calix. J Endourol. 2011 Nov;25(11):1723-6.
- Frattini A, Barbieri A, Salsi P, Sebastio N, Ferretti S, Bergamaschi E, Cortellini P. One shot: a novel method to dilate the nephrostomy access for percutaneous lithotripsy. J Endourol. 2001 Nov;15(9):919-23.
- Combe M, Gelet A, Abdelrahim AF, Lopez JG, Dawahra M, Martin X, Marechal JM, Dubernard JM. Ureteropelvic invagination procedure for endopyelotomy (Gelet technique): review of 51 consecutive cases. J Endourol. 1996 Apr;10(2):153-7.
- Porpiglia F, Morra I, Bertolo R, Manfredi M, Mele F, Fiori C. Pure mini-laparoscopic transperitoneal pyeloplasty in an adult population: feasibility, safety, and functional results after one year of follow-up. Urology 2012;79(3):728-32.
- Lezrek M, Ameur A, Renteria JM, El Alj HA, Beddouch A. Modified Denis technique: a simple solution for maximal hemostasis in suprapubic prostatectomy. Urology 61(5):951-5, 2003.
- Overtoom TT, Vijverberg PL, van Es HW, van Selm S, van Heesewijk HP. Treatment of ureteropelvic junction obstruction using a detachable inflatable stent: initial experience. AJR Am J Roentgenol. 2009;192(4):1103-6.
- Desai MM, Desai MR, Gill IS. Endopyeloplasty versus endopyelotomy versus laparoscopic pyeloplasty for primary ureteropelvic junction obstruction. Urology 2004;64:16-21. Editorial comment 21.
- Swain P, Park PO. Endoscopic suturing. Best Pract Res Clin Gastroenterol 2004;18:37–47.
- Swain P. Endoscopic suturing: now and incoming. Gastrointest Endosc Clin N Am 2007;17:505–20.
- Jeong CW, Oh JJ, Abdullajanov M, et al. Pure transvesical NOTES uterine horn resection in swine as an appendectomy model. Surg Endosc 2012; 26(2):558-64.
- Lima E, Rolanda C, Oso´rio L, et al. Endoscopic closure of transmural bladder wall perforations. Eur Urol 2009; 56:151–157.
- Bell RC, Cadière GB. Transoral rotational esophagogastric fundoplication: technical, anatomical, and safety considerations. Surg Endosc. 2011 Jul;25(7):2387-99.
- Lezrek M, Bazine K, Ammani A, Asseban M, Alami M, Moufid K, Kasmaoui el H, Beddouch A.Transurethral transvesical endoscopic management of a retrovesical hydatid cyst. J Endourol. 2012;26(11):1409-12.
Figures:
Figure 1: It is best to have a safety guide wire outside the Amplatz sheath; in UPJO, primarily, it is difficult to pass the guide wire down the ureter. Therefore, to avoid or to decrease maneuvers with radiation exposure, the working and safety guide wires are coiled in the renal pelvis. After the first introduction of the nephroscope in the renal cavities, the working guide wire is removed. The tips of the safety guide wire and the ureteral catheter are exteriorized through the Amplatz sheath. Then, the safety guide wire is introduced in the ureteral catheter and attracted downward through the ureter and the urethra, providing a through-and-through guide wire.
Figure 2: Two irrigations are installed, one through the irrigation channel and the other through the drainage channel of the nephroscope. Thus, the inflow of the irrigating fluid is almost doubled.
Figure 3: To block the irrigant outflow, the manual technique can be used. A: The index finger is placed around the nephroscope at the junction between the sheath entry and the nephroscope, and then the thumb is used for counter pressure, completing a tighter grip on the nephroscope. B: The other three fingers grasp tightly the Amplatz sheath for a watertight grip. The complex sheath-nephroscope is controlled and moved by the left hand (secondary hand), while the right hand (dominant hand) controls the needle holder or the forceps. This is used for short periods, so high-pressure episodes are short.
Figure 4: The rubber cap of the nephroscope working port can be directly adapted to the entry of the Amplatz sheath. This method will considerably reduce the irrigant outflow, and gives a good dilation of the renal pelvis for a better exploration. This technique is helpful in very large hydronephrosis when pelvic retraction hinders exploration. However, this method must be used with caution and for a very short time.
Figure 5: A: After invagination of the UPJ, a longitudinal endopyelotomy incision is created using a bugbee electrode. B: UPJ with no previous double-J stenting, after endopyelotomy, there is a retraction of the ureter, and the ureteral wall is thin. C: after the first suture, the endopyelotomy incision is now horizontal, and divided into two equal parts, anterior and posterior. (1): the initial UPJ. (2): the new UPJ. D: endopyeloplasty with 3 sutures placed; respectively 1: the first suture; 2: the second suture; 3: the third suture.
Figure 6: A conventional 13 mm-needle is grasped in the middle by the needle holder, which is passed through the nephroscope working channel.
Figure 7: A: The needle holder is advanced in the proximal ureteral lumen. The needle is passed in the distal end of the endopyelotomy from inside to outside. B: the nephroscope is in the retroperitoneal space, the needle is found protruding from the ureteral wall a few millimeters beyond the distal apex of the endopyelotomy incision. Minimal, blunt dissection of the peri-ureteral tissue is performed by the needle-holder tip, just enough to grasp the needle tip.
Figure 8: The needle-holder grasps the needle with its tip and curvature oriented backward.
Figure 9: A: For the second passage of the first suture in the pelvic edge, the needle is grasped with its tip oriented backward. B: the tip of the needle-holder is inserted beyond the tissue edge, and then it is retracted rearward. Thus, the needle is passed, in retrograde fashion, from outside to inside, in the pelvic proximal end of the endopyelotomy incision.
Figure 10: The needle-holder grasps the needle with its body oriented in the same axe as the needle-holder, and its tip oriented forward.
Figure 11: A: For the second suture, the needle is grasped with its body oriented in the same axe as the needle holder and its tip oriented forward. B: The needle is passed simultaneously in the two tissue edges of the posterior half of the endopyelotomy incision. For this purpose, a strong, solid needle is needed to avoid the needle twisting. 1: the first suture; 2: the needle tip protruding in the proximal ureteral lumen.
Figure 12: A: During extraction of the needle, care should be taken to ensure that the afferent strand of the suture glides smoothly and that it is not blocked between the nephroscope and Amplatz sheath. B: The knot is tied outside and pushed progressively by an alligator forceps, while the second surgeon maintains a steady traction on the 2 strands, until reaching the endopyelotomy incision.
Videos:
Video 1: The split-leg modified lateral position
Video 2: The needle renal displacement technique
Video 3: Percutaneous endopyeloplasty
Video 4: Retrograde endopyeloplasty is it possible
Video 5: Endoscopic bladder sutures in “pluck” nephroureterectomy
Written by:
Mohammed Lezrek, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Urology, Military Hospital Moulay Ismail, Méknes, Morocco
A more "conventional" way to perform percutaneous endopyeloplasty: A feasibility study - Abstract
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