ENDOPYELOTOMY

Endopyelotomy is one of the method of treatment for adults and older children with primary or secondary pelviureteric junction obstruction.

Indication:
PUJ obstruction – Primary or Secondary associated with small pelvis

Imaging Investigation:
Ultrasound
Intravenous pyelogram
Diuretic renogram
CT scan is essential to look for a crossing vessel.


Procedure
Anaesthesia
General anesthesia

Position
Lithotomy position for cystosopy and prone position for Endopyelotomy
Antibiotics
IV antibiotics based on urine culture report
Things

Surgical procedure
Initially Cystoscopy is performed and 6fr ureteric catheter is placed to allow opacification and distention of the renal pelvis and to assist in passage of a guide wire.
The patient is then placed in prone position and the shoulder and hips are padded to assist in ventilation and prevent pressure complication.
Under fluoroscopic control a posterior middle calyx is accessed, thus providing adequate visualization of the pelviureteric junction while minimizing the incidence of pneumothorax.
The procedure is initiated with transparenchymal route and a guide wire is then passed into the renal pelvis after dilatation of the tract to accomodate a 30fr sheath. A safety guide wire is passed down the ureter into the bladder.
Then the nephroscope is introduced through the amplatz sheath and the pelvicalyceal system is inspected.
A cold knife, laser or electrocautery may be used to incise the tissue.
The incision is oriented posterolaterally . This incision should extend in depth until periureteral fat is visualized and the PUJ is funnel shaped.
An endopyelotomy stent is placed to bridge the incised ureter.
The stent exits the flank as a nephrostomy tube.
The nephrostomy may be clamped and removed after 2-3 days. The stent is generally removed at 6 weeks.

Contraindications for the procedure:
Coagulopathy
Large redundant pelvis
Crossing vessels
Strictures greater than 2cms etc.
Complication:
Failure to relieve obstruction if stenosis is greater than 1.5cm in length.
Intraoperative haemorrhage.

Post operative care:
Antegrade nephrostogram should be performed if the patient has fever,flank pain,irritative voiding symptoms postoperatively.

Advantages :
Reduces operative time
Minimizes blood loss
Less scars and sutures
Short periods of hospitalization.