Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalMay 2004

947

Surgical Atlas
PyeloplastyT.W. HENSLE and A. SHABSIGH

Surgery Illustrated
Pyeloplasty (Anderson-Hynes)
T.W. HENSLE and A. SHABSIGH
Children’s Hospital of New York, NY-Presbyterian Medical Center, Department of Paediatric
Urology, 3959 Broadway, New York, NY 10032, USA

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

INTRODUCTION hydronephrosis include: (i) the amount of

dilation present on ultrasonography; (ii) the
PUJ obstruction has been described as the relative function of the individual renal unit,
most common congenital anomaly of the as measured by radionuclide scan; and (iii) the
urinary tract and in the past as the most rate of radionuclide washout with diuretic
common cause of abdominal mass in infancy. augmentation (T1/2).
However, currently PUJ obstruction almost
never presents as an abdominal mass but
almost always as antenatally or neonatally
detected hydronephrosis on screening PATIENT SELECTION
ultrasonography. Neonatal hydronephrosis is
a relatively common problem which is In those neonates and infants who have
detected in ª 1.5% of all pregnancies. significant and persistent renal pelvic dilation
Spontaneous resolution of antenatally on ultrasonography, some decrease in relative
detected hydronephrosis is also relatively renal function, as determined by a scan, and a
common and occurs in about half of the prolonged washout curve on radionuclide
infants in whom hydronephrosis has been scan, the diagnosis of true PUJ obstruction
diagnosed antenatally. In those neonates can safely be entertained and correction of
where the hydronephrosis persists, ª 40% is that obstruction is usually indicated.
secondary to VUR and the other 60% is
caused by abnormalities in the transport of Specific equipment and materials for infant
urine from the renal pelvis to the bladder, but pyeloplasty include:
not all persistent neonatal hydronephrosis is
secondary to obstruction. In about half of the • Inflatable fluid bag attached to a hand
children followed for persistent neonatal pump (blood pressure).
hydronephrosis renal function will be • Baby Richardson retractors.
preserved and the hydronephrosis will • Peanuts or Kitners.
improve over time. However, the other half • A Dennis-Brown ring retractor.
need to be evaluated carefully to identify and • Sutures for traction.
correct real anatomical obstruction when it is • Marking pen.
present. • Fine vascular forceps (Bishop-Harmon
forceps).
The determination of which neonates and • Fine vascular needle holders.
infants with hydronephrosis have significant • 6–0/7–0 monofilament absorbable suture.
obstruction at the PUJ is not always easy. The • 3.5/5.0 F feeding tube.
criteria for determining the significance of • Optical magnification (loupes).

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PREPARATION AND POSITIONING A Foley catheter is placed in the bladder and SURGICAL STEPS
the patient positioned with the affected side
A decision about the need for preoperative up and tipped up slightly, so the incision can Adherence to rigid principles of surgical
retrograde pyelography has to be made be made anteriorly just beneath the 12th rib. technique offers the best chance for
individually. A retrograde pyelogram is not An empty intravenous fluid bag is placed obtaining favourable results in PUJ repair no
routinely taken, or necessary, in neonates and under the patient and inflated to extend the matter what technique is selected. The
infants having the PUJ repaired. However, subcostal space. Anderson-Hynes dismembered pyeloplasty,
there are individuals who have simultaneous because it is simple, is the preferred technique
obstruction at the PUJ and vesico-ureteric at most paediatric centres around the world.
junction.

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 P Y E L O P L A S T Y T. W. H E N S L E A N D A . S H A B S I G H

Figure 1

An incision is made from the tip of the 12th

rib and carried medially to a point about 5 cm
lateral to the rectus abdominus muscle. This
incision allows the surgeon direct access to
the renal hilum and the PUJ.

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T. W. H E N S L E a n d A . S H A B S I G H

Figure 2

The internal and external oblique muscles are

incised in the direction of the skin incision
using a knife or needle tip Bovie coagulator,
and the muscle incision is carried laterally to
the latissimus dorsi.

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 P Y E L O P L A S T Y T. W. H E N S L E A N D A . S H A B S I G H

Figure 3

The transversus abdominus is split bluntly in

the direction of the fibres and the
lumbodorsal fascia opened sharply.

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T. W. H E N S L E a n d A . S H A B S I G H

Figure 4

The peritoneum is bluntly displaced medially

and lumbodorsal fascia incised. At this point,
the Dennis-Brown ring retractor or some
other self-retaining retractor can be placed in
the wound for maximum exposure.

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Figure 5

Great care must be taken to minimize trauma

and preserve blood supply in the region of the
upper ureter.

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T. W. H E N S L E a n d A . S H A B S I G H

Figure 6

Once the PUJ has been exposed, fine stay

sutures are placed in the anterior portion of
the upper ureter and the anterior portion of
the renal pelvis, and both structures gently
mobilized. Methylene blue or a marking pen
can be used to outline the area of incision or
the renal pelvis and the upper ureter including
the obstructed area.

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 P Y E L O P L A S T Y T. W. H E N S L E A N D A . S H A B S I G H

Figure 7

The upper ureter is then transected above the

traction suture obliquely and anterior to
posterior, leaving the medial blood supply
undisturbed. The renal pelvis and obstructed
PUJ are transected similarly, leaving the
traction suture in place at the most
dependent portion of the inferior renal pelvis.
The ureter is then incised for 2–3 cm on its
inferior (posterior) border, to provide an open
tube for triangulated anastomoses to be made
eventually. At the same time the renal pelvis is
trimmed to exclude redundant tissue.

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Figure 8

At times a 3.5 or 5.0 F feeding tube is used as

a temporary ureteric stent to protect the back
wall of the ureter from the sutures used for
anastomoses. The ureter is anastomosed to
the transected renal pelvis using 6–0 or 7–0
monofilament absorbable sutures. The suture
line is made with a combination of
interrupted sutures at the most dependent
portion of the ureter and renal pelvis, and a
running suture up either side of the
anastomoses.

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 P Y E L O P L A S T Y T. W. H E N S L E A N D A . S H A B S I G H

Figure 9

Before the anastomoses is completed the

temporary stent is removed. Once an
anastomosis has been completed a Penrose
drain is placed near the area of anastomoses
and the wound closed in layers using running
absorbable suture to the internal oblique,
external oblique, subcutaneous tissue, and
skin.

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TROUBLE SHOOTING and Foley catheter are usually removed on the anastomoses is when the lower pole of the
first day after surgery and the patient kidney is elevated into the wound and then
If there is a question about the adequacy of discharged 2 days after. replaced into the retroperitoneum. The
the anastomoses a needle can be placed in the anastomoses are best done in situ rather than
anterior portion of the renal pelvis and the elevating the kidney into the wound.
pelvis infused with fluid to test the potency of ‘SURGEON TO SURGEON’
the anastomoses. Stents and nephrostomy The worst thing that can happen during the
tubes are not routinely used. There are several key issues that make this procedure is when placing the temporary
operation proceed smoothly. The first is to stent down the ureter, as it is possible that the
make sure enough redundant renal pelvis is vesico-ureteric junction cannot be traversed
POSTOPERATIVE CARE removed to provide good drainage and avoid with a fine feeding tube or wire and access
stasis. The second issue is to make a wide gained to the bladder. This usually indicates
The patient has a Telfa and Tegaderm dressing enough incision into the recipient ureter to some problem at this junction and at that
applied with absorbing gauze over the area of provide an open anastomosis. The third is to point the surgeon should consider leaving a
the Penrose drain, which has been brought ensure that the anastomoses are not twisted. nephrostomy tube for postoperative
out through the end of the incision. The drain The most common cause for torsion of the management.

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