*This procedure is commonly performed in children, so this literature may be for you as parents rather than as a patient.
open = through an incision
pyelo = the pelvis of the kidney or the center part of the kidney where the ureter begins
plasty = to reconfigure or reshape
After urine is produced by the kidney, it drains into the center of the kidney called the collecting system. The individual passageways of the collecting system come together to form one large central area call the renal pelvis. The renal pelvis subsequently funnels urine into the ureter. The ureter is a thin tube that connects each kidney with the urinary bladder.
When there is a problem within the ureter or kidney, we can often approach it with a small telescope that is inserted through the urethra (tube through which you urinate), into your bladder, and then into the ureter. The scope can be advanced all the way into the renal pelvis or its branches. Another approach to the renal pelvis or ureter is through a small hole made in the back in the region of the kidney. This is referred to as percutaneous (through the skin)access to the kidney or ureter.
When there is an occlusion or blockage at the junction where the renal pelvis meets the actual ureters, we call this a ureteropelvic junction obstruction (UPJ obstruction). The exact cause of a UPJ obstruction is unknown but may be due to:
*People are usually born with UPJ obstructions, but may also develop them later in life. Notall UPJ obstructions require correction. Sometimes they are discovered incidentally (while evaluating another problem) in older adults who have had no symptoms, and in whom the kidney has suffered minimal damage as a result. Alternatively, if a patient is found to have a very minimally or non-functioning kidney as a result of an undiscovered UPJ obstruction, then surgical correction may not be warranted. In other words, there may be no benefit to the procedure. Factors that dictate a need for treatment include:
When the UPJ obstruction is corrected through an endoscopic (through a scope) procedure, it is referred to as an endopyelotomy. It is not always practical or appropriate, however, to operate on the kidney or ureter through a scope. In these instances a pyeloplasty (open operation), may yield a better success rate or may be safer for the patient. Common reasons for an open operation include:
After any of these procedures, it is usually necessary to leave a stent (plastic drainage tube) in the ureter for a few weeks to allow adequate drainage and resolution of inflammation of the tract. This tube is not visible on the outside of the body as one end is in the kidney, and the other in the bladder. The stent can be easily removed in the office without anesthesia. The amount of time that the stent remains in will depend on your particular situation.
There is no particular preparation for this procedure. As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc…”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter).
Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
To review the basics of what we discussed in the office: The actual procedure will take a few hours and depends on the individual’s anatomy and the type of repair chosen by the surgeon. This operation is performed under general anesthesia (complete sleep).
The approach to the kidney may be through an incision in the back, the flank (side of the body), or on the abdomen. Your position on the tale will therefore vary with the chosen approach. In certain instances, it may be necessary to remove a rib in order to properly operate on the kidney. Depending on your anatomy and the type of incision used, we will decide whether we will have better exposure if a rib is removed. Subsequently, the ureteropelvic junction (UPJ) obstruction will then be identified. The length of the abnormal segment, as well as the point at which the ureter and renal pelvis connect will dictate how the remainder of the procedure is performed. Regardless, all variations include removing or excising the blocked or non-functioning segment and reconnecting the remainder of the ureter to the renal pelvis in anon-obstructing fashion. Before all of the sutures are placed, a stent may be placed in the ureter spanning the distance from the renal pelvis to the bladder. It will remain in for a few weeks.
Again, the stent is a small plastic tube that allows urine to adequately flow from the kidney to the bladder while the repair is healing. Sometimes, a stent is brought out through the side (i.e. through a small hole in the skin) to make removal easier. In certain cases, a drain may be placed on the outside of the kidney and brought out through a small second skin incision near the first. The purpose of this drain is to allow urine that leaks out of the kidney suture lines to exit the body. The use of a drain will depend on your particular case and the surgeon’s judgment. In small children and infants, the procedure is sometimes done without the use of either a stent or drain.
After the repair is complete, the deep tissue and skin incision are closed. A dressing will be applied over the wound.
After the procedure, you will be in the recovery room until you are admitted to your room. The usual hospital stay can be as short as one night, but is more typically two. Occasionally, some patients may stay longer.
In the recovery room, you may have a catheter in your urethra that is attached to a bag. Its purpose is to keep the bladder empty. Because of this catheter, and the presence of the stent, you may have an urge to urinate even though your bladder is empty. You will have some discomfort over the area of the incision.
The following morning, the urethral catheter (one in the bladder) will probably be removed. The sense of urgency may remain, however, because of the stent. Although the stent is soft plastic, any degree of sensation from its presence is possible. You may have no sensation that the stent is there, or it can be somewhat bothersome at times. The symptoms can be any one or a combination of back or groin discomfort, urinary frequency, urgency or burning. If an external drain was placed, the time of its removal will depend on the amount of leaking from this drain.
Patients usually have minimal to no blood in the urine. When present, this usually disappears within a few days.
While our intent is to adequately open the UPJ obstruction, this is not always possible. Success of these procedures varies.
As previously mentioned, the stent will remain in the ureter for a few weeks. It is easily removed in the office.
Despite a properly performed procedure, an obstruction can persist or recur at any point in time. It is therefore imperative that you be followed up in our office at regular intervals.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.