Blockage of the kidney where it joins the ureter is the commonest congenital abnormality of the ureter. It can lead to pain, urinary infections, kidney stones, loss of function and high blood pressure. Pelvi-ureteric junction (PUJ) obstruction is usually confirmed by two scans 1/ a renogram (radio-isotope study) which assesses kidney outflow obstruction and function and 2/ a CT (computed tomography) scan to show anatomical details. 10% of patients presenting with a PUJ obstruction will have both sides affected. The blockage may be caused by either a narrowing in the ureter or compression of the ureter externally by an extra blood vessel supplying the lower part of the kidney.
Several procedures have been developed over the years to treat this condition but pyeloplasty gives the highest chance of cure.
Balloon dilatation stretches the narrowed area until it splits using a balloon threaded up from the bladder and is inserted through a cystoscope. This may be successful in up to 75% of cases. Not all patients are suitable for this procedure however.
Endopyelotomy involves cutting the narrowed area from the inside using a telescope inserted either through the side or from below through the bladder. The success rate is approximately 80% but again not all patients are suitable for this form of treatment.
Laparoscopy is commonly known as "keyhole surgery”, however although the incisions are small the view is not. Modern equipment produces a wide, bright, clear and magnified view of the operation, often superior to the traditional open approach. In addition, the gas used to distend the abdomen during laparoscopy also greatly reduces bleeding during surgery. Since laparoscopic pyeloplasty was first performed in 1993 the results published from many hundreds of patients' operations have shown an average success rate of over 90%.
Traditionally the surgical approach to the kidneys requires a 20-25cm incision because the kidneys lie high in the abdomen, beneath the ribs. The success rate for this approach is also high (approximately 90%). The laparoscopic operation is performed through 4 x 5-10 mm cuts below the ribs on the side of the abdomen. An internal plastic tube (stent) is inserted into the ureter using a cystoscope (optical scope placed into the bladder) at the start of the operation. The kidney is identified and the PUJ is exposed. The ureter is opened and the PUJ is then divided. If the cause of obstruction is a compressing blood vessel the ureter is moved to the other side of it. The PUJ is then reconstructed by suturing the ends of the ureter together again.
Rarely technical difficulties may make the operation unable to be completed laparoscopically, if this eventuates conversion to the open procedure may be achieved without difficulty. The likelihood of this happening is less than 5%.
After the operation
Laparoscopy does not eliminate post-operative pain however any discomfort experienced should be easily controlled using the pain-killers you will be prescribed. The expected hospital time is between 2-4 days (compared with 5-8 days following open surgery). The stitches used to close the wounds are buried and will dissolve.
Although the incisions are small, a significant operation has taken place internally and as such you should not undertake strenuous physical exercise, even if you feel like it, until at least 3 weeks (A return to full activities may take 6-12 weeks with an open approach). You may drive as soon as you think you could brake hard and swerve quickly to avoid an accident (typically 2 weeks).
The internal stent is removed under a local anaesthetic 4 weeks after surgery. The renogram (radio-isotope test) is repeated at 3 months, 1 year, 2 years and 3 years. Occasionally pooling of the radio-isotope in the kidney from changes due to previous longstanding blockage may make the renogram difficult to interpret. If this happens a short dye test under anaesthetic at 4-6 months is preformed using a cystoscope to ensure that the new join remains open and is draining freely.