Meaning, Treatment, Types & Cost Of Pyeloplasty Surgery

Overview

Pyeloplasty is a surgical procedure used to remove narrowing or blockage in the ureteropelvic junction, or UPJ (the area between the ureter and the renal pelvis). Removing the blockage allows urine to flow freely from the kidney to the bladder.

A human kidney is made up of large numbers of nephrons that help filter blood and produce urine. The urine from all nephrons together drains into the renal pelvis (a funnel-shaped part of the kidney used to collect the urine), from which the ureters (tubes for passage of urine to the bladder from the kidney) carry the urine and transport it to the bladder.

The ureteropelvic junction obstruction (UPJO) prevents urine from reaching the bladder, resulting in hydronephrosis (swollen kidneys caused by urine accumulation inside the kidney).

This article discusses the meaning of pyeloplasty, its indications and contraindications, why it is done, the risks associated with the procedure, and what to expect before, during, and after the surgery.

What is the pyeloplasty, and why is it performed?

“Pyelo” refers to the kidney or renal pelvis, and “plasty” means a surgical procedure to repair, replace, or restore something.

Pyeloplasty is a surgical procedure used to repair an obstruction at the ureter-renal pelvis junction. The surgery’s purpose is to restore the urine flow and protect the kidneys from further damage. Pyeloplasty is one of the most frequently used treatments for UPJO. It has been widely regarded as both safe and effective.

What are the indications for pyeloplasty surgery?

• The pyeloplasty is indicated for treating obstruction of the ureteropelvic junction (UPJ) in the presence of one or more of the following: Clinical signs that include recurring infections and abdominal and flank pain
• Evidence of obstruction on scintigraphy
• Reduced renal function
• Infection of the upper urinary tract
• Urinary tract calculi

What are the benefits of the pyeloplasty surgery?

Pyeloplasty surgery has several advantages that make it the ideal treatment for UPJ. The following are some of the advantages of this procedure:

• It aids in the prevention of kidney function loss caused by UPJ.
• It alleviates painful symptoms while also improving the patient’s quality of life.
• It keeps infections at bay.
• Robotic and laparoscopic pyeloplasty techniques help treat UPJ without many complications and even ensure patients’ quick recovery.
• When compared to other UPJ treatments, pyeloplasty has a higher success rate.

What are the contraindications for pyeloplasty?

Pyeloplasty is not recommended for patients who have any of the following conditions:

• Coagulation disorders
• Non-functional kidney
• Comorbidities that hinder pyeloplasty surgery
• Acute UTIs in the case of robotic pyeloplasty

Who is a candidate for pyeloplasty surgery?

Both adults and children can require pyeloplasty. One in every 1500 babies is found to have a UPJ obstruction at birth. It affects twice as many men as women.

If the disorder does not get better in 18 months, infants will most likely require pyeloplasty.
Adults, teenagers, and older children can also develop a UPJ blockage and may require a pyeloplasty in the case of kidney obstruction.

What are the types of pyeloplasty repair procedures?

There are three main techniques of surgery that can be performed to treat UPJ.
In general, open surgery is performed on infants, while laparoscopic and robotic surgeries are performed on teenagers and adults.

Open pyeloplasty

• The surgeon makes a small cut (incision) in the patient’s belly or flank to obtain access to the kidney during an open pyeloplasty.
• The surgeon, after removing the narrowed or obstructed ureter part, reconnects it with the healthy part of the ureter with the help of sutures.
• If required, the surgeon may also insert a stent to maintain the ureter’s opening while it heals. The procedure usually takes between 2 and 4 hours.
  Laparoscopic pyeloplasty
• A surgeon makes several small incisions in order to insert a laparoscope (a small tube with a camera and surgical tools attached) through them and advance it to the patient’s flank or abdomen.
• The laparoscope is used to direct the surgical tools and repair the renal pelvis and ureter.
• After the surgery, a ureteral stent may be placed in the ureter for up to 4 weeks to allow the surgical site to heal.

When compared to open pyeloplasty, laparoscopic pyeloplasty surgery is associated with less post-operative pain and quicker recovery times.

Robotic pyeloplasty

• Robotic pyeloplasty is similar to open pyeloplasty surgery, except the surgeon makes 3–4 small incisions instead of one large abdominal or flank incision.
• Through these tiny incisions, trocars or portals are inserted to allow the robotic arms’ insertion, which enables the renal surgeon to remove the blockage and perform the repair.
• By sitting a few feet away from the patient at the operating desk or console, the surgeon operates the robotic equipment in real-time with precise motion.
• A high-definition, three-dimensional view of the renal anatomy is provided by a stereoscopic lens (placed using one of the robotic arms). Using the view, the blocked area is cleaved and removed using surgical robotic arms.

What to expect before the surgery?

• The patient must inform the surgeon about any known drug or anaesthesia allergies, a personal or family history of bleeding disorders, and current medications, including over-the-counter (OTC) medications, dietary supplements, vitamins, or herbs.
• The patient will be asked to inform the doctor whether they are taking blood thinners, anticoagulants, or other (prescribed) medications that could potentially interfere with the patient’s blood coagulation process. These medicines may be discontinued prior to surgery on the advice of the surgeon or concerned physician.
  • • Presurgical urine culture to evaluate the need for specific antibiotics used to treat it if the test is positiveThe renal surgeon will order the following tests after reviewing the patient’s medication and medical history:
      • • Urinalysis

       

  • • Blood tests: A complete blood count; a basic metabolic panel (a comprehensive test done to evaluate the levels of glucose, sodium, calcium, potassium, chloride, carbon dioxide, blood urea creatinine, and nitrogen).
• • • Imaging studies (such as ultrasound and MRI) to evaluate the extent of hydronephrosis due to the UPJO obstruction.

   

  • • A nuclear medicine renal scan with furosemide washout may also be performed to determine the extent of obstruction. It also helps in assessing post-operative results.
• The patient will be notified when they should be admitted to the hospital.
• According to the urologist’s advice, the patient should refrain from eating and drinking for a specific period prior to surgery.
• The surgical procedure, along with any risks associated with it, will be extensively explained to the patient. The patient will be provided with a consent form to be signed, which would permit the surgeon to perform the surgery. Prior to actually signing, the patient must read the form carefully and inquire about any concerns they may have.

What to expect during the surgery?

The steps for performing pyeloplasty vary depending on the surgical technique used by the surgeon and the age of the patient. In general, a pyeloplasty operation consists of the following steps:

• The patient will be given a surgical robe to change into, and the patient will be transferred to the operation room.
• Prior to beginning the surgery, the anaesthesiologist will administer general anaesthesia to the patient, allowing them to be asleep for pain-free and safe treatment.
• Incisions will be made on the patient, depending on the technique used for the surgery. The patient will be positioned on the table in a lateral decubitus position, and the procedure will begin with an incision.
• Regardless of the surgical method used, once the surgeon has obtained access to the kidney, they begin mobilising the organ to pinpoint the location or potential cause of the blockage. The most common cause is obstruction of the UPJ.
• Sometimes an additional blood vessel may traverse the region and impinge on the ureter, causing the obstruction. If a new vessel is discovered, it will be mobilised and further dissection will be performed to gain access to the blocked portion of the ureter and renal pelvis.
• When the surgeon locates the blockage at the UPJ, they will cut and split the region below and above the obstruction, allowing the blocked urine to pass.
• A stent will be placed to help with urine flow, and it will be removed via cystoscopy a few days after surgery.
• To drain any excess fluid at the location of pyeloplasty repair, the surgeon might as well attach a drain to the patient’s abdomen near the incision.

What to expect after the surgery?

• Depending on the technique used, the patient’s hospital stay may be extended for a few days following pyeloplasty surgery.
• After the pyeloplasty, patients will be shifted to the recovery room to monitor their vitals (heart rate, blood pressure, and respiration rate). Once the patient’s vitals have stabilised, they will be taken to a hospital room.
• Patients may be on liquids for the first few days after surgery before gradually resuming a solid diet. The surgeon may prescribe pain relievers and antibiotics to help prevent post-operative infections.
• Sometimes, the patient may have a drain attached to the abdomen near the incision to let any extra fluid drain out. This drain will be removed before the patient’s discharge from the hospital.

After discharge:

Patients will be advised to take care of themselves following the surgery. It is preferable to have a carer present, at least for some time.

While recovering from surgery, the patient should:

• Consume a lot of water.
• Maintain the wound dressing (bandages) on the stomach as per the doctor’s instructions.
• Take a shower. Baths should be avoided as they may cause an infection.
• If the stitches are not dissolvable, return to the healthcare provider to have them removed as instructed by them.
• The stent would be removed a few weeks following surgery during a quick procedure under topical anaesthesia, and the surgeon may do an ultrasound to evaluate for swollen kidneys.

What is the recovery time following pyeloplasty surgery?

The length of recovery after pyeloplasty depends on the surgical technique used. Internal healing after  laparoscopic or robotic pyeloplasty typically takes between three and four weeks, whereas open pyeloplasty may take about eight weeks. During this time, the patient must avoid strenuous activity, heavy lifting, and training.

What are the risks associated with the pyeloplasty procedure?

Even though the pyeloplasty repair is safe, as with any surgical operation, there can be risks and potential complications.

Some of the risks, though rare, include:

• Persistent bleeding
• Infection
• Damage or injury to the adjacent organs and tissues
• Allergic reactions to the anaesthesia
• Scarring
• Blood clots
• Hernia
• Chances of developing obstruction again, requiring re-operation

Conversion from laparoscopic to open pyeloplasty In rare cases, patients may sustain an injury to:

• Stomach
• Important blood vessels.
• Small intestine
• Large intestine
• Liver
• Pancreas
• Spleen
• Ovary
• Fallopian tube
• Bladder

When to contact the surgeon?

Attend all scheduled follow-up appointments. If patients experience any of the following symptoms, contact the surgeon as soon as possible:

• Infection symptoms include fever, redness, warm skin all around the incision, and pus.
• Vomiting or nausea
• Severe pain that is not relieved by pain medications
• Elevated swelling at the site of the incision
• Severe bleeding in the urine, which is thick
• shortness of breath, chest pain, or passing out

What is the cost of pyeloplasty repair surgery in India?

The pyeloplasty surgery cost in India can depend on a number of factors, including:

• The city in which the treatment is done
• Costs of diagnostic tests and consultation fees
• The hospital chosen, its location, and its reputation
• The surgeon’s experience and expertise,
• The type of pyeloplasty being performed (open or laparoscopic)
• Patient’s condition

These are just a few factors, and there can be others involved depending on the individual. To obtain an accurate estimate for a specific procedure, it is always best to consult with a surgeon or hospital directly.

Takeaway

Overall, pyeloplasty is a safe and efficient method of treating urinary tract obstructions. The procedure does have a high rate of success and can help individuals suffering from this condition improve their quality of life; however, as with any surgical operation, there are risks and complications with pyeloplasty surgery, including infection, bleeding, and scarring. To ensure a quick recovery, patients should discuss the benefits and risks of the pyeloplasty surgical procedure with their health professional and follow postoperative instructions.