Obstruction of the ureter can cause pain, kidney damage, and serious infections. Surgical correction is often necessary when these problems occur. One type of blockage, ureteropelvic junction (UPJ) obstruction is usually caused by a congenital (at birth) narrowing where the ureter joins the kidney.
Correction of ureteropelvic junction obstruction is most successful with surgical removal of the upper portion (less than one inch) of the ureter where it joins the kidney. The remaining portion of the ureter must then be meticulously sewn back to the kidney. Up until recently, this procedure (pyeloplasty) required a large flank incision along a lower rib resulting in a long recovery. Now, with laparoscopic (telescopic) surgery, the same successful technique can be performed through small “button-hole” incisions (laparoscopic pyeloplasty). The high magnification with this method provides improved visualization and precision, all while minimizing risks and recovery. Having some of the country’s most extensive private practice experience with laparoscopic kidney surgeries, Scott D. Miller, MD applies his minimally invasive expertise to this complex procedure.
Dr. Scott Miller uses a relatively uncommon modification to perform a laparoscopic pyeloplasty. The kidney does not exist within the abdominal cavity, but rather behind the intestines in a location called the retroperitoneal space. Most kidney surgeries involve going through the abdominal cavity in order to enter this space. Avoiding the abdominal cavity can minimize recovery and risk of intestinal injury. Although this technique (retroperitoneal laparoscopy) is more difficult to learn, once mastered, it is actually easier for the surgeon (and the patient).
Similar to other laparoscopic procedures, the surgeon makes a button-size incision below the side of the ribcage for the insertion of a telescope (near where one’s elbow would hang while standing). After expanding the retroperitoneal space with carbon dioxide gas, two or three additional small incisions are made to place narrow tubes used for interchangeable instruments. The surgeon can then visualize the kidney and the interchangeable instruments on a television monitor. After fully exposing the ureter, the upper portion (usually less than one inch) of the ureter is removed. Using a technique developed by Dr. Scott Miller, a thin plastic tube (ureteral stent) is inserted into the ureter. The ureter is then meticulously sewn back to the kidney with dissolvable suture, taking care to avoid touching any of these delicate structures with anything but the needle and suture. A small drainage tube is temporarily (usually less than 2 days) left in place. The ureteral stent, which now travels from the kidney down to the bladder, is left in place for 3-6 weeks, at which time it can be removed in the doctor’s office. The skin openings are closed with shower-resistant glue as a substitute for both stitches and bandages.
Results & More
Laparoscopic pyeloplasty facilitates quicker recovery, less pain, and a lower complication rate as compared to the typical open-incision repair of ureteral obstruction. Obviously, the primary goal is permanent correction of this obstruction. Our success rates exceed 96% for newly-diagnosed patients. The success rate is somewhat less in patients with a poorly-functioning kidney or in those who have undergone prior ureteral repair. A vast experience and a world-class surgical team help ensure this high level of success.
Most patients are discharged from the hospital the day following surgery. Risk of transfusion, damage to surrounding organs, blood clots, pneumonia, and wound infection are each under 1%.
Q: Does Dr. Scott Miller perform laparoscopic pyeloplasties with robotic assistance?
A: Currently, Dr. Scott Miller more commonly performs robotic pyeloplasty. Having a large experience with laparoscopic suturing, however, robotic assistance provides him with minimal advantages. With laparoscopic pyeloplasty he can avoid entering the abdominal cavity (retroperitoneal laparoscopy) thereby potentially lessening the recovery and surgical risks. He therefore chooses between the two methods on a case-by-case basis.
Q: How much pain can I expect after the procedure?
A: Pain is typically less with laparoscopic procedures when compared to open-incision surgery. Some abdominal cramps and shoulder discomfort can occur from the carbon dioxide gas used during surgery. This type of pain is best treated with anti-inflammatories rather than narcotics. Although everyone is different, post-operative discomfort is usually easily managed and short-lived.
Q: Is bruising normal after a laparoscopic procedure?
A: When a narrow tube is placed through a button-size skin incision, a small blood vessel just below the skin can break. However, since the snug fit of this tube will compress the blood vessel during surgery, bleeding will often not occur. If this blood vessel were to re-open at a later time, a small amount of blood could track over a large surrounding area (including the genitalia). This is not a true bruise but will have the same appearance. Most important, this finding is not an indication of internal problems.
Q: When can I return to work or other normal activities following my surgical procedure?
A: Dr. Scott Miller recommends at least two weeks away from work. Very few jobs would require more than four weeks of leave. In many cases, a small amount of light work-related duties are acceptable during the first two weeks. All patients should move around frequently from the time of surgery and resume light exercise at one week (gradually increasing to a normal routine by four weeks). Driving a car is often reasonable in approximately one week if reaction time is good. Of course, Dr. Miller will provide guidance for each individual situation.
Q: How long does the surgery take Dr. Scott Miller to perform?
A: Although many variables can affect the time necessary for Dr. Scott Miller to meticulously perform the surgery, he usually completes the procedure in two hours. However, the time away from family members also includes preparation (30-40 minutes), anesthetic reversal (15-20 minutes), and recovery room stay (2 or more hours). Dr. Scott Miller asks patients to arrive two hours prior to this process, during which time family members can remain present. Occasional updates are given to the family by the operating room nurse. Dr. Scott Miller will come to the waiting area when the patient is ready for transfer to the recovery room.
Q: How long do I stay in the hospital following surgery?
A: Most patients are ready for discharge on the day following surgery.
Q: How does the success rate of laparoscopic pyeloplasty compare to open-incision pyeloplasty?
A: Dr. Scott Miller’s results with laparoscopic pyeloplasty meet or exceed any other method of repair reported in the literature.
Q: Should I donate blood prior to my procedure?
A: Since the risk of needing a blood transfusion is less than 1%, blood donation is not necessary.
Q: When can I shower or bathe following my surgery?
A: Since shower-resistant glue was used as a substitute for both stitches and bandages, showering is acceptable once discharged from the hospital. Although water will not harm the surgical areas, mechanical cleansing of the incisions should be avoided for the first week to prevent premature removal of the glue. Complete immersion such as bathing or swimming is allowed at two weeks.
Q: What long-term follow-up care will I need?
A: Dr. Scott Miller will recommend periodic x-ray evaluation of the kidney for two years.
Q: What if the procedure does not work?
A: Often, a very minor procedure can correct persistent obstruction. In rare cases, the procedure would need to be repeated.