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36 Retroperitoneoscopic Nephrectomy/Heminephrectomy
Left kidney
Ureter
275
Lower moiety
ureter
Renal
vein
Fig. 36.11 The arterial branches as shown in Fig. 36.10 should ideally
be divided first before similarly sealing and dividing the renal vein(s),
which should then become less engorged as shown above once there is
no blood flow through the kidney. The kidney is then freed by dividing
the perinephric attachments to the adrenal gland and peritoneum using
a combination of blunt dissection and hook diathermy. Care must be
taken not to breach the peritoneum on the anterior aspect
Ureter
Upper moiety
ureter
Psoas
Fig. 36.13 For heminephrectomy, it is essential to identify the ureter
of the moiety to be resected by tracing them up to the duplex kidney;
this is usually the more dilated, dysplastic ureter as shown. A portion of
the ureter is then skeletalized to preserve the blood supply to the
retained ureter before it is transected using hook diathermy and/or
scissors
Upper renal
moiety
Renal
pedicle
Psoas
Right lower
renal moiety
Upper moiety
ureter
Psoas
Fig. 36.12 The necessary amount of ureter can then be resected by
dissection down to the pelvis aided by traction on the ureter cranially. It
can then be ligated with an endoloop at the distal end if necessary
before resection. The ureter will normally deliver through one of the
working 5-mm ports and the kidney should be delivered through the
primary port site. The site may need to be stretched or extended,
depending on the size of the specimen
Fig. 36.14 The proximal ureter is then mobilized cranially. Often for
an upper heminephrectomy (as shown), it may traverse between the
main renal vessels and therefore needs to be carefully mobilized
through these while preserving the vessels
Psoas
Upper
moiety
ureter
Upper
moiety
vessels
Main
renal
pedicle
Right lower
renal moiety
Fig. 36.15 Once the ureter is mobilized up to the upper moiety, it can
be used for traction laterally to aid in identification of vessels to this
moiety
276
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J. Lam
Upper
moiety
Adrenal
gland
ureter
Upper
moiety
venous
branch
Right lower
renal moiety
Main
renal
pedicle
Fig. 36.16 The vessels are then individually isolated using the
Maryland or right-angled forceps before being sealed and divided using
hook monopolar diathermy if small or a bipolar or ultrasonic forceps if
large. The arterial branches as shown in Fig.
36.15 should ideally be
divided first before similarly sealing and dividing the vein(s), which
should then become less engorged as shown above once there is no
blood flow through the upper moiety
Upper
renal
moiety
Adrenal
gland
Right lower
renal moiety
Resected
upper
moiety
Preserved
right lower
renal
Main
renal
pedicle
Fig. 36.19 The resected moiety should be checked to ensure that all
dilated calyces are excised and hemostasis is achieved on the cut surface of the lower moiety. The distal ureter can be mobilized and resected
if required if it is a refluxing unit, but care must be taken to preserve
vascularity to the residual ureter
Preserved
right lower
renal moiety
Suction drain
Lower moiety
ureter
Upper
moiety
ureter
Preserved
renal
pedicle
Fig. 36.17 There should be clear demarcation following successful
devascularization of the upper renal moiety, which also appears dysplastic here as shown
Upper moiety
Right lower
Upper moiety
ureter
Adrenal
gland
renal moiety
Fig. 36.18 The upper renal moiety is then freed from the adrenal
gland and perinephric attachments with blunt dissection and hook diathermy. It is then resected from the lower renal moiety using either
ultrasonic or bipolar forceps, aided with traction on the upper moiety
ureter
Main
renal
pedicle
Fig. 36.20 A suction drain (10 Fr) can be inserted via the inferior port
site down to the renal bed to minimize the risk of hematoma or urinoma
formation. The resected specimen can then be retrieved via the primary
port site, which seldom needs to be extended given the naturally small,
dysplastic moiety
36 Retroperitoneoscopic Nephrectomy/Heminephrectomy
277
36.6 Alternatives
The posterior prone approach can be used for retroperitoneoscopic renal surgery and has the advantage of gravity to aid
the exposure of the renal pedicle, which may then only
require two ports but is more limited for access to the lower
ureter. Traditional laparoscopy can also be used for renal surgery and provides a more familiar anterior approach to the
kidney but has the disadvantage and potential risks of transgression of the peritoneal cavity.
36.7 Highlights and Pitfalls
• Appropriate instruction to the camera assistant is essential
to maintain correct orientation in the retroperitoneal space.
• Steps must be taken to avoid breaching the peritoneum in
the initial dissection to create space for the primary port,
ensuring adequate mobilization of the peritoneum before
inserting working ports as well as care with instrument
insertion and manipulation so as to avoid trauma to the
peritoneum within the confined space.
• Careful dissection and identification of the vessels to both
renal moieties is required in heminephrectomy to avoid
vascular injury to the remaining moiety because the vascular anatomy is variable and branching may occur at a
very short distance from the renal parenchyma.
• For a grossly dilated ureter in heminephrectomy, it may
be useful to insert a ureteric stent into the normal ureter
cystoscopically at the start of the procedure to aid
identification.
Suggested Reading
Borzi PA. A comparison of the lateral and posterior retroperitoneo-
scopic approach for complete and partial nephroureterectomy in
children. BJU Int. 2001;87:517–20.
Leclair MD, Vidal I, Suply E, Podevin G, Héloury Y.
laparoscopic heminephrectomy in duplex kidney in infants and children: a 15-year experience. Eur Urol. 2009;56:385–91.
Valla JS. Retroperitoneoscopic surgery in children. Semin Pediatr Surg.
2007;16:270–7.
Retroperitoneal
Pyeloplasty
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Harish Chandran
Abstract
Pyeloplasty treats the anatomical and functional obstruction at the pelvi-ureteric junction
(PUJ). This chapter discusses the endoscopic performance of this operation. Embryology,
antenatal findings, postnatal investigations, and treatment options (including follow up and
indications for surgical intervention) are not discussed, as these can be found in other textbooks addressing these issues.
Keywords
Antenatal hydronephrosis • Ultrasound • Anderson-Hynes • Pyeloplasty • Retroperitoneal •
Transperitoneal • Laparoscopic
37
37.1 General Information
Pyeloplasty treats the anatomical and functional obstruction
at the pelvi-ureteric junction (PUJ). This chapter discusses
the endoscopic performance of this operation. Embryology,
antenatal findings, postnatal investigations, and treatment
options (including follow up and indications for surgical
intervention) are not discussed, as these can be found in
other textbooks addressing these issues.
Pyeloplasty can be performed in a variety of ways and by
a number of different approaches. The technique described
in detail here is endoscopic retroperitoneal pyeloplasty. A
pyeloplasty aims to produce better drainage from the affected
kidney. This goal is achieved by creating dependent drainage
from the pelvis, by fashioning the pelvis and ureter to resemble a funnel. The original description of this procedure by
H. Chandran
Department of Paediatric Surgery and Urology, Birmingham
Children’s Hospital, Birmingham, UK
Anderson and Hynes incorporates the excision of the narrowed segment of the PUJ, and the anastomosis of the spatulated ureter to the trimmed pelvis (Fig. 37.1).
In recent years, laparoscopic pyeloplasties have been performed with increasing frequency and in ever-younger
patients. As surgeons’ experience increases and instrumentation improves, this method of pyeloplasty has become the
method of choice in paediatric hospitals. Access to the kidney can be via either the retroperitoneal route or via a transperitoneal approach.
I prefer retroperitoneoscopic pyeloplasty, which is
described in further detail here. This approach avoids the
need to mobilise other organs (colon) or unnecessarily open
anatomical planes. It also lessens the risk of injury to other
structures and avoids the sequelae of an intraperitoneal leak
of urine, which irritates the peritoneum.
© Springer-Verlag Berlin Heidelberg 2017
M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_37
279
280
H. Chandran
Fig. 37.1 The pyeloplasty: the excision of the narrowed segment of the PUJ and the ureter, and the anastomosis of the spatulated ureter to the
trimmed pelvis
37 Pyeloplasty
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281
37.2 Working Instruments
• Three 5mm ports.
• 5mm, 0 degree telescope.
• Dissectors (Kellys) x 2
• Scissors.
• Laparoscopic needle holders x 2. These can be 3mm (with
reducer) or 5mm.
37.3 Positioning, Port Siting,
Ergonomic Considerations
and
The patient is placed close to the edge of the operating table
and in the kidney position (Fig. 37.2).
The surgeon and assistant stand behind the patient, with
the monitor screen facing them. The nurse is positioned
opposite the surgeons, and can observe the operation on
another monitor (Fig. 37.3).
A small (5-mm) incision is made close to the angle
between the lowest rib and the vertical paraspinal muscles.
A pair of Metzenbaum scissors is used to dissect and
spread the muscle fibres to reach the retroperitoneum
(Fig. 37.4).
An inflation device is used to create a space posterior to
the kidney, lifting it medially off the psoas muscle. A 5-mm
port is inserted into this space and secured (Fig. 37.5).
The central port is used for the telescope and the other
two ports are used for the operating instruments
(Fig. 37.6).
Fig. 37.2 The patient is placed close to the edge of the operating table
and in the kidney position
282
H. Chandran
Fig. 37.4 A small (5-mm) incision is made close to the angle between
the lowest rib and the vertical paraspinal muscles. A pair of Metzenbaum
scissors is used to dissect and spread the muscle fibres to reach the
retroperitoneum
Fig. 37.3 The surgeon and assistant stand behind the patient, with the
monitor screen facing them. The nurse is positioned opposite the surgeons, and can observe the operation on another monitor
Kidney Peritoneum
Space created by
37 Pyeloplasty
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Fig. 37.5 An inflation device is
used to create a space posterior to
the kidney, lifting it medially off
the psoas muscle. A 5-mm port
with blunt trocar is inserted into
this space and secured
283
balloon
Trocar
Fig. 37.6 The central port is used for the telescope and the other two
ports are used for the operating instruments
284
Fibrous capsule
in renal medulla
H. Chandran
37.4 Relevant Anatomy
Cross sectional anatomy of a normal kidney (Fig. 37.7).
Hydronephrosis is graded by ultrasound. There are many
different ways in which the severity may be expressed.
Figure 37.8 shows the grading that is most commonly used
by radiographers; this system is related to the grading used
Fig. 37.7 The anatomy of a normal kidney
Renal cortex
Renal medulla
Renal papilla
Fat in renal
sinus
by the Society for Fetal Urology (SFU). The SFU grading
system (Table 37.1) is widely used to describe ultrasound
findings in North America and in many countries in Europe.
This system allows clinicians to communicate the severity of
the hydronephrosis in a standardised manner and also
informs the management of the child.
Renal column
Minor calyx
Major calyx
Renal artery
Renal pelvis
Renal vein
Renal pyramid
Ureter
Moderate Severe
37 Pyeloplasty
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Fig. 37.8 Hydronephrosis is
graded by ultrasound. The grading most commonly used by
radiographers
285
Normal
Table 37.1
hydronephrosis
Grade Ultrasound appearance
0 No dilatation
1 Pelvis only dilated
2 Pelvis dilated and a few calyces visible
3 Pelvis and many calyces dilated
4 Pelvis and calyces dilated and parenchyma thinned
The Society for Fetal Urology (SFU) grading of
Mild
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