Redo Pyeloplasty

Redo pyeloplasty surgery

Redo pyeloplasty represents a repeat surgery that is applied to address ureteropelvic junction obstruction (UPJO) that was not remedied at the time of the initial procedure. It helps to normalize the kidney urine output to the ureter and avoid additional kidney destruction.

What Is Redo Pyeloplasty?

Redo pyeloplasty is required when:

• The initial pyeloplasty failed to heal.
• Scar tissue forms again
• There is an overtaken cross-ship.
• Again the ureter constricts (re-stenosis).
• Infection or chronic stagnation proceeds.

Compared to the first surgery, it is more difficult because of scar tissue and distorted anatomy.

Redo Pyeloplasty Indications

Redo surgery is undertaken when the patient has:

• Constant flank/abdominal pain.
• Recurrent infections
• Failure to improve hydronephrosis.
• Worsening renal function
• Diuretic renogram (MAG3) obstruction--functional.
• Imaging (USG, CT urogram) Narrowing/stricture present.

Redo pyeloplasty procedure

Redo pyeloplasty is a re-operative procedure undertaken due to failure of the initial pyeloplasty operation to correct the ureteropelvic junction obstruction (UPJO). The operation is also more complicated than primary pyeloplasty due to the presence of scar tissue and altered anatomy.

Depending on the preferred method, the surgery may be laparoscopic or robotic or open.

Anaesthesia & Positioning

• General anaesthesia is administered to patient.
• Lying in the lateral decubitus (side-lying) position.
• Draped and sterile prepared.

Kidney (Trocar Placement) Access

If laparoscopic/robotic:

• 3–4 small ports (5–12 mm) are placed.
• A camera port is inserted in the area of the umbilicus.
• CO 2 insufflation forms working space.

If open:

• Flank or subcostal incision is done.

Dissection of Scar Tissues (Most Critical Step)

Redo surgery requires:

• Thick fibrosis must be carefully dissected.
• Definition of the renal pelvis, ureter and UPJ.
• Maintaining cross vessels.
• The surgeon should not destroy the kidney or ureter, as a result of abnormal anatomy.

Determination of the Obstructed Segment

Common findings:

• A short or long stricture
• Kinked UPJ
• Missed crossing vessel
• Excessive scarring
• Lost or insufficiently done prior repair.
• The affected portion is properly identified.

Excision of the Scarred/Narrow Segment

• The blocked UPJ section is excised totally.
• Limitations of the ureter and renal pelvis are excised to healthy tissue.
• Sufficient blood flow is provided to heal.

Reconstruction (Dismembered Anderson-Hynes Pyeloplasty)

• This is the most widely used method of repair.

Steps:

• Renal pelvis is opened
• Spatulation of healthy ureter is done to enlarge it.
• Ureter is again fused to the renal pelvis in a tension free and water tight manner.
• Absorbable fine sutures are used to suture.
• In case of the presence of crossing vessels they are transposed previous to the anastomosis.

Installation of a Double-J (DJ) Stent

• An internal soft stent is introduced across the repair.
• Use: to assist the anastomosis, avoid leakage, enhance the drainage.
• Stent removal occurs typically at 4–6 weeks.

Drain Placement

• To identify: A small drain can be placed close to the kidney.
• Urine leak
• Excess bleeding

Closure

• Laparoscopy is a procedure that involves removal of ports and small skin incisions.
• Muscles and skin in open operations are sewered in layers.

Redo Pyeloplasty Duration.

• Laparoscopic/Robotic: 2–3 hours
• Open: 1.5-2.5 hours (depends on the complexity of cases)

Post-Procedure

• IV fluids, antibiotic and analgesic.
• Drain removal in 24–48 hours
• Discharge in 2–4 days
• Post stent-removal imaging.

Revision pyeloplasty surgery

The procedure of revision pyeloplasty is a repeat operation of the ureteropelvic junction (UPJ) undertaken after a failed pyeloplasty procedure. It normalizes urine flow of the kidney to the ureter and does not lead to kidney degeneration.

It is also more difficult technically due to scar tissue, adhesions and distorted anatomy as a result of the initial operation.

What is the Reason for Revision Pyeloplasty?

Surgery is necessitated in case of:

• Perennial UPJ obstruction following BG.
• Recurrent flank pain
• Incompleting hydronephrosis.
• Scar tissue (stricture) development.
• Vehicles that lost their way during the initial operation.
• Poor or poor quality prior repair.
• Spoiled healing or leakage of anastomosis.
• Frequent urinary infections.
• MAG3 diuretic renogram or CT urogram usually establishes obstruction prior to revision surgery.

Revision Pyeloplasty Approaches

The surgeon may choose:

Laparoscopic Revision Pyeloplasty

• Minimal cuts, easy recovery, popular.

The robotic Revision Pyeloplasty

• Maximum accuracy; particularly best used in complex redo cases.

Open Revision Pyeloplasty

• Applied in case of scarring or distorted anatomy.

Redo laparoscopic pyeloplasty

Redo laparoscopic pyeloplasty is a minimally invasive repeat operation that is done when the original pyeloplasty is ineffective in the correction of ureteropelvic junction obstruction (UPJO). It is an alternative to open surgery since it presents fewer pain, shorter recovery time and enhanced visualization, with or without scar tissue.

Why Redo Laparoscopic Pyeloplasty Be Performed?

Redo surgery is recommended in the event that a patient has:

• Intrinsic or recurrent UPJ obstruction.
• Ongoing hydronephrosis
• Recurrent flank pain
• Poor drainage of MAG3 renogram.
• A missed crossing vessel
• Stricture at the repair site.
• Past surgery failed because of infection or failure to heal.

Procedure Laparoscopic Pyeloplasty Redo (Step-by-Step)

Anaesthesia & Positioning

• General anaesthetic performance.
• Lateral decubitus (side-lying) patient.

Port Placement

The laparoscopy ports (5 -12mm) are usually 3-4 laparoscopic ports inserted to perform:

• Camera
• Working instruments
• Retraction
• The working space is made by CO2 insufflation.

Scar Tissue Dissection

• The most difficult step is this because of fibrosis.

Surgeon carefully:

• Removes adhesions of the former surgery.
• Recognizes the renal pelvis, ureter and UPJ.
• Preserves crossing vessels
• Does not cause kidney or ureter damage.

Identifying the Problem

Common findings:

• Recurrent stricture
• Anastomotic scarring
• Kinked UPJ
• Missed crossing vessel
• Non-dependent anastomosis
• Redundant renal pelvis

Removal of Pathologic Area

• The scarred or tightened UPJ is totally eliminated.

Reconstruction (Anderson-Hynes Dismembered Pyeloplasty)

• The most widely employed method.

Steps:

• Renal pelvis opened
• Ureter enlarged (spatulated).
• Ureter is re-inserted into the renal pelvis in a tension free position.
• In case of necessity, crossing vessel is repositioned ahead of repair.
• The fine absorbable sutures are used to create a watertight anastomosis.

Internal DJ Stent Placement

• A ureteral stent of Double-J is inserted.
• Supports healing
• Ensures free urine drainage
• Removed after 4–6 weeks

Drain Placement & Closure

• A drain is left temporarily
• Ports are removed
• Small wounds are stitched up or patched up using skin glue.

Duration of Surgery

• 2–3 hours
• The prostate was located just above the penis.

Recovery Following Redoing Laparoscopic Pyeloplasty

Hospital Stay:

• 2–3 days

Return to Work:

• 2–3 weeks

Stent Removal:

• 4–6 weeks

Complete Healing:

• 6–8 weeks

Benefits of Redo Laparoscopic Pyeloplasty

• Smaller incisions
• Less blood loss
• Enhanced imaging of scarred region.
• Faster recovery
• Less postoperative pain
• Shorter hospital stay

Success rate of redo pyeloplasty

Redo pyeloplasty is largely successful and in spite of being more complicated than the original (first-time) pyeloplasty, it is a successful procedure.

Success rate of Redo Pyeloplasty

• Overall success rate: 80–90%
• Research findings have always indicated that redo pyeloplasty, regardless of the type, be it open, laparoscopic, and robotic, is highly successful in the long term particularly when done by a skilled surgeon.

Success Rate according to Surgical Technique

Redo Pyeloplasty Laparoscopy.

• 85–90% success
• Enhanced image and accuracy over open surgery.

Robotic Redo Pyeloplasty

• 90–95% success
• Thought to be the most effective strategy of redo cases of complexity.
• Indicated when the fibrosis is dense or when there is a missed crossing vessel.

Open Redo Pyeloplasty

• 80–85% success

• Rarely used except in extremely complicated and reoperative cases.

Conclusion

Redo pyeloplasty is one of the best solutions to patients whereby the ureteropelvic junction obstruction persists or recurs after the first repair is performed. Despite being technically more difficult as a result of scar tissue and distorted anatomy, the current laparoscopic and robotic procedures offer great visibility and accuracy, which has led to a high success rate of 80-90. When symptoms are evaluated appropriately, surgeons have the opportunity to make an excellent contribution and provide a patient with long-term relief, enhance renal drainage, and save their renal functions. Redo pyeloplasty is the standard of treatment in failed primary UPJ obstruction repair.

Redo pyeloplasty surgery India GetWellGo

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FAQ

1. What is the reason why the first pyeloplasty does not work?

• Its failure can be caused by scar tissue, inadequate healing, missed crossing vessel, infection or improper alignment of the repair.

2. Is re- laparoscopic pyeloplasty safe?

• Yes. Although redo laparoscopic pyeloplasty is indeed more difficult than primary surgery, it is still safe and commonly practiced by skilled urologists.

3. Will a stent be placed following redo pyeloplasty?

• Yes. A Double-J (DJ) stent is fitted between 4- 6 weeks to maintain free flow of urine and healing.

4. Does robotic redo pyeloplasty perform better?

• Robotic surgery is more accurate and could be more successful, particularly with redo cases.

5. What will happen in case a redo pyeloplasty fails too?

• When the redo operation fails, one may consider endopyelotomy, ureterocalicostomy, buccal mucosa graft ureteroplasty or in some exceptional instances, the renal autotransplantation.

6. Is redo pyeloplasty effective in enhancing kidney functioning?

• Early done, it can tend to stabilize or enhance the kidney drainage or functioning. Intensive intervention can only avert additional harm.