Comprehensive Urology

Diseases and Conditions

Procedures

Imaging Services

The daVinci System

Delta Medix Patient General Information

Open Pyeloplasty

*This procedure is commonly performed in children, so this literature may be for you as parents rather than as a patient.

Definition

open = through an incision

pyelo = the pelvis of the kidney or the center part of the kidney where the ureter begins

plasty = to reconfigure or reshape

After urine is produced by the kidney, it drains into the center of the kidney called the collecting system. The individual passageways of the collecting system come together to form one large central area call the renal pelvis. The renal pelvis subsequently funnels urine into the ureter. The ureter is a thin tube that connects each kidney with the urinary bladder.

When there is a problem within the ureter or kidney, we can often approach it with a small telescope that is inserted through the urethra (tube through which you urinate), into your bladder, and then into the ureter. The scope can be advanced all the way into the renal pelvis or its branches. Another approach to the renal pelvis or ureter is through a small hole made in the back in the region of the kidney. This is referred to as percutaneous (through the skin)access to the kidney or ureter.

When there is an occlusion or blockage at the junction where the renal pelvis meets the actual ureters, we call this a ureteropelvic junction obstruction (UPJ obstruction). The exact cause of a UPJ obstruction is unknown but may be due to:

  • a blood vessel crossing this area and consequently compressing the region
  • a true area of scar tissue
  • an area of the ureter that is missing muscle components in its wall and therefore does not have proper peristalsis (contracting motion to move urine along)

*People are usually born with UPJ obstructions, but may also develop them later in life. Notall UPJ obstructions require correction. Sometimes they are discovered incidentally (while evaluating another problem) in older adults who have had no symptoms, and in whom the kidney has suffered minimal damage as a result. Alternatively, if a patient is found to have a very minimally or non-functioning kidney as a result of an undiscovered UPJ obstruction, then surgical correction may not be warranted. In other words, there may be no benefit to the procedure. Factors that dictate a need for treatment include:

  • pain or other symptoms due to the presence of obstruction
  • deterioration of a functioning kidney due to the obstruction
  • formation of stones or infections due to impaired urine flow
  • a younger patient in which there is greater uncertainty as to whether the kidney will ultimately lose function

When the UPJ obstruction is corrected through an endoscopic (through a scope) procedure, it is referred to as an endopyelotomy. It is not always practical or appropriate, however, to operate on the kidney or ureter through a scope. In these instances a pyeloplasty (open operation), may yield a better success rate or may be safer for the patient. Common reasons for an open operation include:

  • a failed prior endopyelotomy
  • a lengthy scar or UPJ obstruction that would not respond well to endopyelotomy
  • a UPJ obstruction in a child is more commonly treated with an open procedure
  • an anatomic abnormality where the ureter is attached to the renal pelvis in a high position (termed a high insertion)

After any of these procedures, it is usually necessary to leave a stent (plastic drainage tube) in the ureter for a few weeks to allow adequate drainage and resolution of inflammation of the tract. This tube is not visible on the outside of the body as one end is in the kidney, and the other in the bladder. The stent can be easily removed in the office without anesthesia. The amount of time that the stent remains in will depend on your particular situation.

Preparation

There is no particular preparation for this procedure. As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc..."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter).

Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The actual procedure will take a few hours and depends on the individual's anatomy and the type of repair chosen by the surgeon. This operation is performed under general anesthesia (complete sleep).

The approach to the kidney may be through an incision in the back, the flank (side of the body), or on the abdomen. Your position on the tale will therefore vary with the chosen approach. In certain instances, it may be necessary to remove a rib in order to properly operate on the kidney. Depending on your anatomy and the type of incision used, we will decide whether we will have better exposure if a rib is removed. Subsequently, the ureteropelvic junction (UPJ) obstruction will then be identified. The length of the abnormal segment, as well as the point at which the ureter and renal pelvis connect will dictate how the remainder of the procedure is performed. Regardless, all variations include removing or excising the blocked or non-functioning segment and reconnecting the remainder of the ureter to the renal pelvis in anon-obstructing fashion. Before all of the sutures are placed, a stent may be placed in the ureter spanning the distance from the renal pelvis to the bladder. It will remain in for a few weeks.

Again, the stent is a small plastic tube that allows urine to adequately flow from the kidney to the bladder while the repair is healing. Sometimes, a stent is brought out through the side (i.e. through a small hole in the skin) to make removal easier. In certain cases, a drain may be placed on the outside of the kidney and brought out through a small second skin incision near the first. The purpose of this drain is to allow urine that leaks out of the kidney suture lines to exit the body. The use of a drain will depend on your particular case and the surgeon's judgment. In small children and infants, the procedure is sometimes done without the use of either a stent or drain.

After the repair is complete, the deep tissue and skin incision are closed. A dressing will be applied over the wound.

Post Procedure

After the procedure, you will be in the recovery room until you are admitted to your room. The usual hospital stay can be as short as one night, but is more typically two. Occasionally, some patients may stay longer.

In the recovery room, you may have a catheter in your urethra that is attached to a bag. Its purpose is to keep the bladder empty. Because of this catheter, and the presence of the stent, you may have an urge to urinate even though your bladder is empty. You will have some discomfort over the area of the incision.

The following morning, the urethral catheter (one in the bladder) will probably be removed. The sense of urgency may remain, however, because of the stent. Although the stent is soft plastic, any degree of sensation from its presence is possible. You may have no sensation that the stent is there, or it can be somewhat bothersome at times. The symptoms can be any one or a combination of back or groin discomfort, urinary frequency, urgency or burning. If an external drain was placed, the time of its removal will depend on the amount of leaking from this drain.

Patients usually have minimal to no blood in the urine. When present, this usually disappears within a few days.

Expectations of Outcome

While our intent is to adequately open the UPJ obstruction, this is not always possible. Success of these procedures varies.

As previously mentioned, the stent will remain in the ureter for a few weeks. It is easily removed in the office.
Despite a properly performed procedure, an obstruction can persist or recur at any point in time. It is therefore imperative that you be followed up in our office at regular intervals.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

  • Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you or your child might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You or your child may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. We also see infections more commonly in patients who already have a stent in place prior to this procedure.
  • Wound Infection: As with any incision, an infection can occur. This would present with unusual redness, swelling and/or drainage (white to yellow thick fluid) from in between the sutures. Usually, these are managed with antibiotics. In some instances, as mall area of the superficial (upper layer) incision needs to be opened for adequate drainage. An abscess is an infection collection in the body. It can present with the same symptoms as sepsis and usually requires drainage.
  • *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
  • Urinoma: If there is leakage of urine across the repair, a urinoma (collection of urine) can form outside of the kidney or ureter. This urinoma is rarely of any consequence. If the leakage persists or becomes large, it can cause discomfort by placing pressure on adjacent structures. If a stent is in good position and providing good drainage down to the bladder, the leak will usually stop and the urinoma will disappear with time. If persistent or troublesome, a minimally invasive procedure to place a drain outside the ureter or kidney may be necessary. This is more common inpatients who have no external drain placed during surgery.
  • Blood Loss/Transfusion: Significant blood loss from this procedure is uncommon. Despite our understanding of the anatomy (specifically the location blood vessels), it is possible to cause an injury to a "crossing vessel" (one that courses across the area of the renal pelvis). Although its position is usually predictable, there are instances in which there are vessels in an unexpected position. Usually, bleeding can easily be controlled. A need for transfusion is rarely necessary.
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation(especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg(calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
  • Hernia: A hernia (weakening of supportive tissue under the skin) is possible with any type of incision. The majority are only a cosmetic problem. Sometimes, repair is necessary.
  • Ileus or Bowel Obstruction: Because we operate near the intestines, they can go into prolonged spasm (ileus), or they may become blocked. Treatment ranges from observation to surgery (less commonly).
  • Injury to an Adjacent Organ: This type of complication is rare. This is more common in patients who have had prior surgeries in this area. During dissection, any of the following are possible and may be noticed immediately during the operation, or shortly after:
    • pneumothorax (partial or complete lung collapse) requiring temporary placement of a special chest tube for a few days
    • spleen (left side procedure) or liver (right side procedure) injury--treatment could range from observation to
    • angiogram (if significant bleeding), or even open surgery (a general surgeon may be asked to assist with this problem)
    • colon (large intestine) or bowel (small intestine) injury--treatment is usually open surgery (by a general surgeon) if the hole is significant (a general surgeon may be asked to assist with this problem).
  • Chronic Pain: Any surgery can be associated with chronic pain in the area of the incision. Although it is extremely rare, it is slightly more common in operations that involve an incision in the flank (side of the body).
  • Nephrectomy: In the overwhelming majority of cases, we will know if nephrectomy(kidney removal) is warranted, and we will have suggested this as the solution to the UPJ obstruction instead of an attempted repair. Although very uncommon, the look and feel of the kidney during surgery may be worse than was apparent through prior testing. In that regard, sometimes a patient is better off with the kidney removed than repaired. Another uncommon reason for removing a kidney is in patients who had other prior repairs with such significant scarring that the current repair is not possible.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

Delta Medix, P.C.