Pyeloplasty Neonatal

Pyeloplasty neonatal surgery

Neonatal pyeloplasty consists of surgery performed on newborns for the treatment of pelvi-ureteric junction obstruction, a condition wherein the passage of urine from the kidney to the ureter is obstructed. This condition may cause hydronephrosis or swelling of the kidney and may lead to damage if not corrected.

What is PUJ Obstruction in Newborns?

• Obstruction of PUJ results from the impairment of the connection between the renal pelvis and the ureter, leading to the accumulation of urine.

Common Causes:

• Congenital narrowing of the junction
• Extra blood vessel crossing the PUJ
• Kinking of the ureter
• High insertion of the ureter

Indications for Neonatal Pyeloplasty

Indications for surgery include:

• Severe hydronephrosis seen on ultrasound
• Decreased renal function on renogram
• Recurring urinary tract infections
• Increasing swelling of the kidneys over time

Types of Neonatal Pyeloplasty

Open Pyeloplasty (Most Common in Neonates)

• Small flank incision
• Gold standard with a >95% success rate

Laparoscopic or Robotic Pyeloplasty

• Rare in neonates because of their very small anatomy
• More commonly performed in older infants/children

Neonatal pyeloplasty procedure

Neonatal pyeloplasty is performed in order to correct pelvi-ureteric junction obstruction in the newborn to restore normal urine flow from the kidney to the ureter.

Pre-operative Preparation

• Baby undergoes ultrasound, diuretic renogram, urine tests, and blood tests.
• Newborns are kept fasting for a few hours before surgery.
• General anaesthesia is given by a pediatric anaesthesiologist.
• Positioning: The baby is placed in a flank or lateral position.

Incision and Exposure

• A small flank incision of 2–3 cm is made below the ribs. This is standard in neonates.
• The muscles are gently separated, without being cut, to expose the kidney.
• The renal pelvis and PUJ are carefully exposed.

Identifying the Obstruction

The surgeon examines:

• The narrowed PUJ segment
• Any additional crossing blood vessel
• Kinking or abnormal insertion of the ureter

Dismembered Pyeloplasty (Anderson–Hynes Technique)

• This is the gold standard and most common technique in newborns.
• Steps:
• The obstructed part of the PUJ is cut and removed.
• The end of the ureter is trimmed if necessary to provide smooth flow.
• The renal pelvis is reshaped and reduced if very large.
• The healthy end of the ureter is brought to the renal pelvis.
• A wide, tension-free anastomosis between ureter and pelvis is performed using fine pediatric sutures.

Stent Placement

Depending on the surgeon's preference:

Option A: Internal DJ Stent (Common)

• Inside, a tiny double-J stent is placed to permit the passage of urine.
• Removed after 4–6 weeks under light anaesthesia.

Option B: External Stent / Nephrostomy Tube

• Used in very small neonates or complex cases.
• Drains urine externally for 1–2 weeks.

Closure

• The incision is closed in layers.
• Skin is closed with absorbable sutures or surgical glue.
• A small bandage is applied.

Postoperative Care

• Baby is shifted to the recovery room and monitored.
• IV fluids, antibiotics, and pain control are administered.
• Feeding usually resumes in 4–6 hours.
• The hospital stay is usually 2-4 days.

Follow-Up

• Stent removal at 4–6 weeks (if DJ stent).

Ultrasound at:

• 6 weeks
• 3 months
• 6–12 months

Renogram if hydronephrosis persists.

Procedure Duration

• Usually 60–90 minutes, depending on anatomy.

Success Rate

• 95–98% success in neonates
• Most babies regain near-normal kidney function.

Laparoscopic neonatal pyeloplasty

Laparoscopic pyeloplasty is possible but not common in the newborn period (0–28 days) because of their very small body size and limited working space. Typically, it is performed by high-volume pediatric laparoscopic surgeons and more commonly done after 3–6 months of age.

However, when carried out in selected neonates, it offers excellent cosmetic and functional results.

Indications for Laparoscopic Pyeloplasty in Neonates

Same indications as open surgery but done laparoscopically when:

• The baby has significant hydronephrosis with obstruction.
• Kidney function is deteriorating.
• Minimal comorbidities
• Surgeon experienced in pediatric laparoscopy
• Parents prefer minimally invasive surgery.

Advantages of Laparoscopic Pyeloplasty 

• Smaller incisions 3–5 mm
• Less post-operative pain
• Faster recovery
• Minimal blood loss
• Better cosmetic outcome
• Shorter hospital stay
• Baby resumes breastfeeding quickly

Open neonatal pyeloplasty

Open pyeloplasty represents the gold standard treatment for PUJ obstruction in the newborn. It is considered the most frequently performed technique in neonates because it is safe, reliable, and offers an excellent surgical field even in very small babies.

Success rate: 95–98%

Why Open Pyeloplasty Is Preferred in Neonates?

• Large exposure of anatomy despite small body size
• Easier and faster than laparoscopic in newborns
• Lower risk of injury to the surrounding tissues
• Very high success rate
• Excellent improvement in long-term renal function

Neonatal pyeloplasty recovery

Recovery after pyeloplasty among newborns (0–28 days) is generally good and fast due to their great healing ability. Most newborns recover completely within weeks, and renal function keeps on improving in months.

Immediate Recovery after Surgery (first 24–48 hours)

Hospital Stay

• Typical length of stay: 2–4 days
• Baby is closely watched for:
• Breathing
• Urine output
• Hydration
• Pain level

Feeding

• Feeding is usually restarted 4–6 hours after surgery
• Breast-feeding is encouraged as soon as baby is comfortable

Pain Control

• Usually, only paracetamol is required.
• Neonates feel very minimal pain from small incisions, especially after open flank surgery.

Urine Drainage

Baby may have:

• Internal DJ stent (no external tube), or
• External stent/nephrostomy tube, if very small or complex case

Both are normal and temporary.

First Week After Discharge

General Condition

• Baby feeds normally
• Sleeps normally
• Crying is not excessive
• Mild irritability can be expected for 1–2 days

Incision Care

• Keep incision clean & dry
• Apply dressing as instructed 
• Only sponge baths until stitches are dry 
• Sutures are absorbable: no removal needed 

Medications 

• Mild pain medicine (paracetamol) if needed 
• Antibiotics for a short course (based on surgeon protocol) 

4–6 Weeks After Surgery 

Stent Removal 

• If a DJ stent was placed, it is removed after 4–6 weeks under brief anaesthesia 
• If an external stent was used, it may be removed earlier (1–2 weeks) 

Ultrasound Scan 

Done to see: 

• Decrease in hydronephrosis 
• Good urine stream 
• No obstruction 

Some swelling may still remain — this is normal. 

3–6 Months After Surgery 

• The kidney starts to improve significantly. 
• Ultrasound demonstrates gradual improvement in hydronephrosis 
• A renogram may be done if swelling persists 

Baby usually has: 

• Normal feeding 
• Normal growth 
• Normal activity for age 

Conclusion

Neonatal pyeloplasty is a highly effective and safe procedure for treating pelvi-ureteric junction (PUJ) obstruction in newborns. Whether performed through an open or laparoscopic approach, the surgery reliably restores normal urine flow, protects kidney function, and prevents long-term damage. Recovery in newborns is typically smooth, with minimal discomfort and rapid healing. With a success rate of 95–98%, early diagnosis, timely surgical correction, and proper follow-up give newborns an excellent chance at normal kidney development and a healthy future. 

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FAQ

1. Is pyeloplasty safe for newborns? 

• Yes. It is a standard, well-established procedure with a very high success rate of 95–98%. Neonatal kidneys heal extremely well. 

2. Will my baby be in pain? 

• Very little, pain is mild and usually controlled with paracetamol. Newborns recover quickly. 

3. What is the long-term outcome?

• Excellent, most babies regain normal kidney drainage and function with no long-term problems. 

4. Will there be a visible scar? 

• Only a small scar, 2–3 cm, which fades with time as the baby grows. 

5. Can the obstruction of PUJ recur? 

• Recurrence is rare (2–5%). Regular follow-up ensures early detection if it happens.