Kalabhavi Srinivas K.pdf

A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL COMPARING
OPEN PYELOPLASTY AND LAPAROSCOPIC PYELOPLASTY IN THE
TREATMENT OF PRIMARY URETEROPELVIC JUNCTION (UPJ)
OBSTRUCTION AT KLES HOSPITAL & MRC, BELGAUM FOR A PERIOD
OF 1 YEAR FROM APRIL 2004 TO MARCH 2005
Submitted by :
DR. SRINIVAS. K. KALABHAVI
DISSERTATION
Submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
In partial fulfillment
of the requirements for the award of the degree of
M.S IN GENERAL SURGERY
Under the Guidance of :
DR. I. V. UPPIN MS
Associate Professor
DEPARTMENT OF GENERAL SURGERY
J. N. MEDICAL COLLEGE,
BELGAUM-590010. KARNATAKA.
APRIL 2006
I

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
Declaration By The Candidate
I hereby declare that this thesis entitled “A
PROSPECTIVE RANDOMIZED CONTROLLED TRIAL COMPARING OPEN
PYELOPLASTY AND LAPAROSCOPIC PYELOPLASTY IN THE TREATMENT OF
PRIMARY URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION AT KLES
HOSPITAL & MRC, BELGAUM FOR A PERIOD OF 1 YEAR FROM APRIL 2004
TO MARCH 2005” is a bonafide and genuine research work carried
out by me under the guidance of DR. I. V. UPPIN MS. Associate
Professor, Department of General Surgery. J. N. Medical College,
Belgaum.
Date : DR. SRINIVAS. K. KALABHAVI
Place : Belgaum Department of General Surgery,
J. N. Medical College,
Belgaum - 590 010.
II

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
Certificate By The Guide
This is to certify that the thesis entitled “A PROSPECTIVE
RANDOMIZED CONTROLLED TRIAL COMPARING OPEN PYELOPLASTY AND
LAPAROSCOPIC PYELOPLASTY IN THE TREATMENT OF PRIMARY
URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION AT KLES HOSPITAL & MRC,
BELGAUM FOR A PERIOD OF 1 YEAR FROM APRIL 2004 TO MARCH 2005”
is a bonafide research work done by DR. SRINIVAS. K.
KALABHAVI in partial fulfillment of the requirement for the
Degree of Masters of Surgery in General Surgery.
Co-Guide Guide
Dr. R. B. Nerli MS MCh (Urology) Dr. I. V. Uppin MS
Professor & Head, Associate Professor
Department of Urology, Department of General Surgery,
J. N. Medical College, J. N. Medical College,
Belgaum – 590 010. Belgaum – 590 010.
Karnataka. Karnataka.
Date :
Place : Belgaum
III

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
Endorsement By Head Of The Department,
Principal/Head Of The Institution
This is to certify that the thesis entitled “A PROSPECTIVE
RANDOMIZED CONTROLLED TRIAL COMPARING OPEN PYELOPLASTY
AND LAPAROSCOPIC PYELOPLASTY IN THE TREATMENT OF PRIMARY
URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION AT KLES HOSPITAL &
MRC, BELGAUM FOR A PERIOD OF 1 YEAR FROM APRIL 2004 TO
MARCH 2005” is a bonafide research work done by DR.
SRINIVAS. K. KALABHAVI under the guidance of
DR. I. V. Uppin MS Associate Professor Department of
General Surgery, J. N. Medical College, Belgaum.
DR. A. S. GODHI. M.S.,F.I.C.S DR. V. D. PATIL. MD. (Paed)
Professor & Head, Principal,
Department of General Surgery, J. N. Medical College,
J. N. Medical College, Belgaum – 590 010.
Belgaum. Karnataka. Karnataka.
IV

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
COPYRIGHT
Declaration By The Candidate
I hereby declare that Rajiv Gandhi University of
Health Sciences, Karnataka, Bangalore, shall have the
rights to preserve, use and disseminate this thesis in print
or electronic format for academic / research purpose.
Date : DR. SRINIVAS. K. KALABHAVI
Place : Belgaum. Department of General Surgery,
J. N. Medical College,
Belgaum - 590 010.
© Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
V

Acknowledgement
I express my deep sense of gratitude to Professor of Surgery
and my guide Dr. I. V. Uppin MS and Co-Guide Dr. R. B. Nerli MS MCh
(Urology) whose guidance and encouragement all throughout their
periodic assessment and specific corrections, coupled with their
rich knowledge and keen interest in the topic, was my constant
source of inspiration leading to the success of this study.
I would like to take this opportunity to express my most
sincere and humble gratitude to Dr. A. S. Godhi M.S.,F.I.C.S, Professor
and Head of Department of Surgery, J. N. Medical College,
Belgaum for his guidance, continuous supervision and critical
review of this work at regular “thesis meetings.”
I express my deep sense of gratitude to Dr. S. M. Uppin M.S., F.I.C.S
Professor of Surgery, Dr. S. S. Shimikore M.S. Professor of Surgery,
Dr. M. S. Sangolli M.S. Professor of Surgery, Dr. V. M. Uppin M.S.,
Professor of Surgery, Dr. A. C. Pangi M.S., Associate Professor of
surgery, Dr. A. S. Gogate M.S., Assistant Professor of Surgery, Dr.
Sanjay Karpoor M.S., Lecturer of Surgery for their encouragement,
valuable guidance and moral support throughout the course of this
study.
I humbly recognize the courtesy of Dr. V. B. Dhaded M.S.,F.I.C.S,
Professor of Surgery, Dr. P. S. Pattanshetti M.S., Associate Professor
of Surgery, Dr. R. R. RaoM.S., Assistant Professor of Surgery,
Dr. S.T.Vedbhushan M.S., Lecturer of Surgery on whom I have made
demands of one kind or another and their response has energized
the realization of this dissertation.
VI

I shall also remain grateful to Dr. B. V. Gogeri M.S.,F.R.C.S.,
Associate Professor of Surgery, Dr. S. C. Metgud M.S., Assistant
Professor of Surgery, Dr. A. P. Bellad M.S., Assistant Professor of
Surgery for their valuable suggestions during the preparation of
this dissertation.
I am also thankful to Dr. Mallikarjuna Reddy M.S.,M.Ch (Urol)
Associate Professor, Dr. S. I. Neeli M.S. M.Ch (Urol) Associate
Professor, Dr. Abhinandan S. M.S M.Ch (Urol) Associate Professor, Dr.
Vinay Patil M.S M.Ch (Urol) Associate Professor, Dr. Shailesh A. M.S (M.Ch)
registrar in urology and Dr. I. R. Ravish, M.S (M.Ch) registrar in urology.
I am also thankful to Dr. S. Patil, M.S. Lecturer and Dr.
Srinivasrao M.S. Lecturer, Dr. Basavaraj K. M.S Lecturer for their
guidance.
I am grateful to Dr. V. D. Patil M.D.,D.C.H., Principal of J. N.
Medical College, Belgaum for allowing me to undertake this study.
I express my sincere thanks to Medical Director of K.L.E.S.
Hospital and MRC and the District Surgeon, Civil Hospital,
Belgaum for allowing me to utilize the facilities to undertake this
study.
I offer my sincere thanks to my colleagues and friends
Dr. Kantesh, Dr. Rohan Thakkar, Dr. Ramesh, Dr. Ramya, Dr.
Gagan & Dr. Prashant for their valuable help in completing this
study.
I am grateful to my mother & other family members for their
constant inspiration, encouragement and moral support.
I am grateful to Mr. Dhareshwar for his valuable suggestions
in statistical analysis of my dissertation.
Most importantly I thank the backbone of my study, my
patients for their cooperation and willing participation in the study.
VII

I am also thankful to Mr. Satish, Ms. Rajeshwari, Mr. Kaleem &
Mr. Shripad of Sheegra Designing & Printing Solutions for their excellent
typographic work.
VIII
Dr. Srinivas K. Kalabhavi

LIST OF CONTENTS
S. No Topic Page No
1 Introduction 1
2 Aims and objectives 3
3 Review of literature 4
4 Materials & Methods 57
5 Observations & Results 80
6 Discussion 93
7 Summary & Conclusion 101
8 Bibliography 105
9 Annexures
Master Chart 112
Proforma 114
IX

Figure
No.
LIST OF FIGURES
Topic Page No
1 Arterial blood supply to the ureter 11
2 A lower pole-crossing vessel causing UPJO 11
3 Dismembered pyeloplasty 32
4 Dismembered pyeloplasty in a large or redundant
renal pelvis
5 Dismembered pyeloplasty in aberrant or accessory
lower pole vessels
6 Foley Y-V plasty 37
7 Culp-Deweerd spiral flap 38
8 Scardino-prince vertical flap 39
9 Intubated ureterotomy 41
10 Prenatal diagnosis of HN 56
11 Pictoral analog pain scale 79
X
32
33

LIST OF TABLES
Table No. Topic Page No
1 Sex Incidence 80
2 Laterality 81
3 Age distribution 81
4 Symptoms 83
5 Associated anomalies 83
6 Postoperative complications 85
7 Renal function on renal scientigraphy
(GFR/min) in open pyeloplasty group
(n=15)
8 Renal function on renal scientigraphy
(GFR/min) in laparoscopic pyeloplasty
group (n=15)
9 Preoperative and postoperative
pyeloplasty analog pain and activity
scores
10 Assessment of objective outcome 92
XI
87
89
91

XII

LIST OF GRAPHS
Graph No. Topic Page No
1 Sex Incidence 82
2 Laterality 82
3 Symptoms 84
4 Postoperative complications 86
5 Renal function on renal scientigraphy
(GFR ml/min) in open pyeloplasty
group (n=15)
6 Renal function on renal scientigraphy
(GFR ml/min) in laparoscopic
pyeloplasty group (n=15)
XIII
88
90

LIST OF PHOTOGRAPHS
S. NO Topic Page No
1 IVP 20
2 Renal USG 22
3 CT scan of KUB 22
4 M.R. Urogram 23
5 Renal scientigraphy with Tc-99m DTPA scan 25
6 Position of the patient 60
7 Open pyeloplasty procedure : Dissection of
8
9
obstructed upj in left kidney
Traction on proximal ureter before
dismembering the dilated pelvis
Dismembered ANDERSON-HYNES
pyeloplasty
being performed
10 Anastomosis of proximal ureter to the redundan
pelvis in a watertight fashion
11 Completed anterior anastomosis 66
12 Completed posterior anastomosis 66
13
Incision wound after the procedure with drain
seen
14 Excised narrowed proximal ureter 67
15 Laparoscopic instruments 70
XIV
64
64
65
65
67

16 Insertion of trocar and laparoscopes 71
17 Showing enlarged pelvis due to PUJO 71
XV

LIST OF PHOTOGRAPHS
XVI
Contd…
S. NO Topic Page No
18 Pelvis being opened with guidewire being
seen
19 Reconstruction of UPJ 72
20 Reconstruction of UPJ being completed 73
21 Completed laparoscopic pyeloplasty with a
drain through one of the port site
22 Preoperative renal scientigraphy showing
reduced renal function in the left kidney
23 Postoperative renal scientigraphy showing
24
improved renal function in the left kidney
Showing postoperative scar after 3 months in
open and laparoscopic pyeloplasty done in a
same patient who had bilateral PUJO
72
73
75
75
76

INTRODUCTION
Proforma
Many treatment options exist for the management of UPJ obstruction. Open
pyeloplasty has high success rate & has been considered the gold standard. But there
is a significant postoperative pain & long recovery time in open pyeloplasty
surgeries. In an attempt to minimize the post-operative morbidity of open surgical
UPJ correction many minimally invasive options have been developed. These include
balloon dilation, antegrade endopyelotomy, retrograde endopyelotomy, Acucise
endopyelotomy and Laparoscopic pyeloplasty 1 .
During last decade, advances in endourological techniques have resulted in
significant progress in the development of minimally invasive surgical procedures to
treat UPJ obstruction. UPJ is the most common site of upper urinary tract obstruction
occurring in 1 in 1500 births. The historical aspects of UPJ repair were reviewed by
Kay in 1989 & Schaeffer & Grayhack in 1986. The first reconstructive procedure
was performed by Trendelenberg in 1886, although patient died of postoperative
complications. Kuster is credited with the first successful open pyeloplasty (1891). In
1892 Frenzer, applied the Heineke-Mikulitz principle for reconstruction of the UPJ 2 .
Flap techniques were introduced by Schwyer in 1916. His Y-V pyeloplasty
was then modified successfully by Foley in 1937. Spiral flap of Culp DeWeerd
(1951), the vertical flap of Scardino & Prince (1953), Thompson & colleagues (1969)
renal capsular flaps developed later in 1949. Anderson & Hynes, two English
surgeons described their modification of Kusters dismembered procedure that
involved anastomosis of the spatulated ureter to a projection of the lower aspect of
the pelvis after a redundant portion was excised 2 .

Proforma
The techniques of intubated ureterotomy were popularized by Davis in 1943,
but they had been previously described by Fiori in 1905, Albarran in 1909 and Keyes
in 1915 2 . Laparoscopic pyeloplasty was first reported in 1993 both by Schuessler and
co-workers and by Kavoussi and Peters, who utilized dismembered pyeloplasty
technique. During last decade, advances in endourological techniques have resulted
in significant progress in the development of minimally invasive surgical procedures
to treat UPJ obstruction. The combination of less postoperative morbidity, improved
cosmesis, shorter convalescence and comparable operative success rates has lured
many patients away from gold standard of open pyeloplasty. Only few retrospective
studies have been conducted regarding laparoscopic versus open pyeloplasty. Success
rates are comparable for laparoscopic pyeloplasty and open pyeloplasty 3 .

AIMS AND OBJECTIVES
Proforma
To compare the efficacy of laparoscopic pyeloplasty versus open pyeloplasty
in the treatment of primary UPJ obstruction with respect to the SUBJECTIVE
OUTCOME (Postoperative pain, activity level, time when oral feeds are started) and
OBJECTIVE OUTCOME (success rate, complications, improvement in renal
function, operative time, recovery time/hospital stay, cost of the treatment and
cosmesis).

Historical notes 26, 27 :
REVIEW OF LITERATURE
Proforma
The term hydronephrosis was introduced by Rayer in 1841. He described a
patient with hydronephrosis caused by reduplication of the ureter with folds and
contractions at the level of the ureteropelvic junction. Bonetus in 1679, described a
child with a hydronephrotic kidney in whom the ureter was merely a fibrous cord..
Gustave Simon in 1869 performed the first deliberate (and successful) nephrectomy
and showed conclusively that a kidney could be removed without permanent
impairment to the health of the individual. This event is notable because it paved the
way for renal surgery.
In the late 1800s, surgeons began conserving renal tissue rather than
proceeding directly to nephrectomy. The first reported attempt at surgical repair of
hydronephrosis is credited to Trendelenburg in 1886. He used an abdominal
approach, which resulted in a colonic injury, and the patient died shortly after
surgery. The case was not reported until 4 years later. Kuster is credited with the first
successful procedure for the relief of hydronephrosis performed on June 14, 1891.
The patient was a 13-year-old boy with a solitary kidney who had previously
undergone a nephrostomy, which would not close. Kuster found the upper ureter to
be entirely obliterated, resected the obliterated tissue, and anastomosed the ureter into
the most dependent portion of the renal pelvis. The operation was successful and
stimulated great interest in the repair of hydronephrosis. Kuster reported his case to
the 21st German Surgical Congress on June 8, 1892. At that time, Trendelenburg
described his case and endorsed the concept of conservative surgery for
hydronephrosis. Christian Fenger of Chicago, unaware of Kuster's work, simultane-

Proforma
ously and independently surgically corrected UPJ obstruction using the Heineke-
Mikulicz principle. Fenger has been given credit for introducing conservative renal
surgery in the United States. By 1899, he had reported seven cases; four patients
were clinically relieved and free of symptoms and three cases failed, requiring
nephrectomy.
Conservative renal surgery for the relief of hydronephrosis was considered so
important that it was the main topic of discussion at the 13th International Congress
of Medicine in Paris in 1900. Five papers were delivered by pioneers in the field:
Kuster, Fenger, Bazy, Albarran, and Legueu. As operations to correct hydronephrosis
became more widely performed, comparisons of primary nephrectomy versus
pyeloplasty were published. In 1903, primary nephrectomy had an 80% cure rate but
a 20% mortality rate. Pyeloplasty had a 37% cure rate and a 10% mortality rate.
Some surgeons, led by Pasteau, were convinced that hydronephrosis was the
result of a movable kidney resulting in obstruction of the ureter by anomalous blood
vessels, adhesive bands, or torsion of the ureter. Their preferred surgical approach
involved nephropexy and lysis of these bands. Others believed that hydronephrosis
was caused by constriction of the upper ureter and was best corrected by pyeloplasty.
In 1921, von Lichtenberg described a technique for pyeloureteroplasty in which an
inverted U-shaped incision was made in the adjacent walls of the renal pelvis and
ureter through the obstructed UPJ. The anterior and posterior edges of the pelvis and
ureter were then sutured together. In 1923, Schwyzer described a technique for
correcting UPJ obstruction, based on principles of pyloroplasty in which the ureter
was first freed of adhesive bands. A. Y-shaped incision was then made, extending
from the renal pelvis to the ureter. The flap was pulled down into the split ureter and
sutured in place, forming a "V." Resection of the redundant renal pelvis and

Proforma
nephrostomy drainage was introduced in the late 1920s by Papin and Walters. In
1937, Foley modified Schwyzer's Y procedure by extending the upper limbs of the Y
onto the posterior and anterior walls of the renal pelvis. The lower limb of the Y was
extended down the lateral aspect of the ureter. In 1943, Davis described intubated
ureterotomy in which a longitudinal incision is made in the narrowed portion of the
ureter; a tube is left in place for 6 weeks until the ureter regenerates around the tube.
In 1949, Anderson and Hynes described dismembered pyeloplasty (although it was
the method used by Kuster almost 60 years earlier). Their objectives were to excise
the obstructing lesion, resect the redundant pelvis if necessary, and place a dependent
flap of renal-pelvic tissue into the split ureter. Maintenance of ureteral continuity was
considered important by many, and in 1951 and 1953 flap pyeloplasties were
described by Culp and Scardino, respectively. However, as favorable results with the
dismembered pyeloplasties accumulated, it became clear that maintenance of ureteral
continuity was not essential to success and the flap and intubated procedures were
relegated to secondary roles for the treatment of long ureteral strictures.
Laparoscopic pyeloplasty was first performed by Schuessler 60 and coworkers
in 1993 on 5 patients with a mean follow up of 12 months. Recker and associates in
1995 reported an early European experience in 5 patients. Janetschek and colleagues
in 1996 reported their results in Austria with both retroperitoneoscopic and
laparoscopic approaches to both dismembered and non-dismembered pyeloplasty.
Chen and coworkers in 1998 reported laparoscopic pyeloplasty in 44 patients. Baeur
and his associates in 1999 performed a comparative study of the objective and
subjective outcomes of the laparoscopic versus open pyeloplasty in a multicentre
review.

Proforma
Although a variety of procedures have been described for management of the
obstructed UPJ, several basic principles must always be applied to ensure successful
repair. For any technique, the resultant anastomosis should be widely patent and
performed in a watertight fashion without tension. Finally, the reconstructed UPJ
should allow a funnel-shaped transition between the pelvis and the ureter that is in a
position of dependent drainage.

Proforma
URETEROROPELVIC JUNCTION OBSTRUCTION (UPJ OBSTRUCTION)
UPJ obstruction may be defined as a functional or anatomic obstruction to
urine flow from the renal pelvis to proximal ureter that results in symptoms or renal
damage 4 .
Hydronephrosis caused by clinically significant obstruction at the UPJ is a
well-known and commonly encountered condition in infants and children.
Historically, it is known that 50% of all abdominal masses in infants are of renal
origin, and of these renal masses, 40% are from UPJ obstruction with resultant
hydronephrosis (HN). The UPJ is the most common site of urinary tract obstruction,
occurring in l in 1500 births 2 . With early recognition and institution of properly timed
surgical correction, the majority of these kidneys can be predicted to remain
asymptomatic and contribute significantly to the total renal function of the patient.
However, failure of timely recognition and treatment often results in destruction of
the involved renal unit, and nephrectomy is ultimately required 5 .
UPJ obstruction occurs in all age groups, from intra-uterine life to old age, but
there tends to be a clustering in the neonatal period because of the detection of
antenatal HN and again later in life because of symptomatic occurance. UPJ
obstruction occurs more commonly in boys than girls in the newborn period, when
the ratio exceeds 2:1 6 , left sided lesions predominate (approx. 67%) and bilateral UPJ
obstruction is present in 10-40% of cases 7 .
Embryology:

Proforma
The UPJ is formed during the 5 th week of embryogenesis. The collecting
system of the kidney develops from the ureteric bud, which contacts and penetrates a
cap of metanephric blastema 8 . The ureteric bud dilates, forming a primitive renal
pelvis. The primitive renal pelvis splits into a cranial and caudal portion, forming the
future major calices. Each major calyx continues to divide and further penetrate the
metanephric blastema. There will be 12 or more such divisions, continuing until the
end of the 5 th month of gestation, when the 2 nd generation tubules enlarge and absorb
the tubules of the 3 rd and 4 th divisions, resulting in the formation of the minor calices.
The 5 th and successive generations converge on the minor calices and form the renal
pyramids. The ureteric bud thus gives rise to the ureter, renal pelvis, major and
minor calices, and 1-3 million collecting ducts 5 . By the 10 th week of embryogenesis,
urine is formed and can pass from the glomeruli to the bladder 9 .
Histology:
The renal pelvis is composed of 3 layers: mucosa, muscularis and adventitia.
The inner layer is mucosa and is lined by transitional epithelium supported by a
lamina propria. The epithelium is 2-3 cells thick in the renal pelvis and 4-5 cells thick
in the ureter. The epithelium sits on a thin basal lamina, which rests on the lamina
propria composed of dense fibroconnective tissue with prominent elastic fibres. In
transverse section, the ureteral lumen appears stellate as a result of the folds of
mucosa resulting from the looseness of the lamina propria, the elastic fibres and the
muscularis. The muscularis is composed of interdigitating fibres of smooth muscles
separated by strands of connective tissue. These muscle fibers are arranged into an
inner longitudinal layer and an outer circular layer. The adventitia is external to the

Proforma
muscular layer and is composed of fibroelastic tissue, which is continuous with the
capsule of the kidney 10 .
Blood supply 3 :
In an adult, the ureter is generally 22 to 30 cms in total length, varying with
body size and habitus. Its origin at UPJ is often vaguely defined in the normal state.
The ureter receives its blood supply from multiple feeding arterial branches along its
course. In the retroperitoneum, the ureter may receive branches from renal artery,
gonadal artery, abdominal aorta & common iliac artery. After entering the pelvis,
additional small branches to the distal ureter may arise from the internal iliac artery
or its branches, especially vesical and uterine arteries, but also from the middle rectal
and vaginal arteries. Arterial branches to the upper ureter approach from the medial
direction, whereas arterial branches within pelvis approach the ureter from a lateral
direction. After reaching the ureter, the arterial vessels course along longitudinally
within the periarterial adventitia in an extensive anatomising plexus. The venous and
lymphatic drainage of the ureter generally parallels the arterial supply.
The normal ureter is not of uniform caliber with 3 distinct narrowing along its
course. The first is at UPJ, second region of narrowing occurs as the ureter crosses
the iliac vessels and the third site is at uretero vesical junction.
1

Renal
Gonadal
Aortic
Common, iliac
Internal iliac
Uterine
Middle rectal
Vaginal
FIG No. 1 : ARTERIAL BLOOD SUPPLY TO THE URETER
Lower pole crossing vessel
Superior vesical
Inferior vesical
Proforma
FIG No. 2 : A LOWER POLE-CROSSING VESSEL CAUSING UPJO

Nerve supply 3 :
Proforma
The ureters receive preganglionic sympathetic input from T10-L2 spinal
segments. Postganglionic fibres arise from several ganglia in the aorticorenal,
superior and inferior hypogasrtic autonomic plexuses. Parasympathetic input is from
S2-S4 spinal segments. Exact role of ureteral neural input is unclear. Normal ureteral
peristalsis does not require autonomic input but, rather, originates and is propagated
from intrinsic smooth muscle pacemaker sites located in the minor calyces of the
renal collecting system. The autonomic nervous system may exert some modulating
effect on this process.
Pain Perception and Somatic Referral 3 :
The pain fibres leave the kidney, renal pelvis, and ureter, travelling with the
sympathetic nerves. They are primarily stimulated by nociceptors sensitive to
increased tension (distention) in the renal capsule, renal collecting system, or ureter.
The resulting visceral pain is felt directly and is referred to somatic distributions that
correspond to the spinal segments providing the sympathetic distribution to the
kidney and ureter (eighth thoracic through second lumbar). Pain and reflex muscle
spasm are typically produced over the distributions of the subcostal, iliohypogastric,
ilioinguinal, and /or genitofemoral nerves, resulting in flank, groin, or scrotal (or
labial) pain and hyperasthesia, depending on the location of the noxious visceral
stimulus.

Physiology:
Proforma
The origin of electrical activity for ureteral peristalsis begins at pace maker
sites located in the proximal portion of the collecting system. Muscular contractions
occur within the calices and renal pelvis more frequently than in the upper ureter.
Hence, the renal pelvis fills, producing a rise in the renal pelvic pressure. A bolus of
urine is then delivered from the pelvis into the upper ureter, after which ureteral
contractions move the bolus down the ureter. The UPJ remains closed during these
ureteral contractions to prevent flow of urine back into the renal pelvis. Two to six
ureteral peristaltic contractions occur per minute and are propelled at a rate of 2-6
cms/second. Efficient transport of urine is dependent on coaptation of the pelvis and
ureteral walls. Resting baseline intraureteral and intrapelvic pressures range from 0-5
cm H2O. Ureteral pressures during a contraction range from 20-60 cm H2O. As the
volume of urine increases, there is a 1:1 correlation between conduction of caliceal
contractions and ureteral contractions 11 .
Etiology:
The precise cause of UPJ obstruction remains elusive. A narrowing of the
UPJ is often found, but whether this is a result of developmental arrest or of
incomplete recanalization of the ureter is not yet known 12 .
The causes of UPJ obstruction can be divided into 2 types.
1. Primary or congenital UPJ obstruction.
Intrinsic causes.
Extrinsic causes.
2. Secondary or acquired UPJ obstruction.

I. Primary or congenital UPJ obstruction:
1. Intrinsic causes:
Congenital obstruction most often results from intrinsic disease.
Proforma
a. A frequently found defect is the presence of an aperistaltic segment of the ureter.
In these cases, histopathologic studies reveal that the spiral musculature normally
present has been replaced by abnormal longitudinal muscle bundles or fibrous
tissue 13 . Further work has shown that the expression of transforming growth
factor β (TGF-β) is increased in the pelvis of partially obstructed kidneys 14 .
This results in failure to develop a normal peristaltic wave for propagation of
urine from the renal pelvis to the ureter. Such ureter may appear grossly normal
at the time of surgery, and in fact, may often be calibrated to No.14 Fr or greater.
b. A less frequent intrinsic cause of congenital UPJ obstruction is true ureteral
stricture. These are most frequently found at the UPJ, although they may be
located at sites anywhere along the ureter. Electron microscopy has demonstrated
excessive collagen deposition at the site of the stricture.
c. Other causes of intrinsic UPJ obstructions include,
Valvular mucosal folds (kinks or valves).
Persistent fetal convolutions.
Upper ureteral polyps.
High insertion of ureter.

Proforma
The presence of these kinks, valves, bands or adhesions may also produce
angulations of the ureter at the lower margin of the renal pelvis in such a manner that,
as the pelvis dilates anteriorly and inferiorly, the ureteral insertion is carried further
proximally. In these cases, the most dependent portion of the pelvis is inadequately
drained. In at least some cases however, the high insertion itself is likely the primary
obstructing lesion.
Congenital folds are a common finding in the upper ureter of fetuses after the
4 th month of development and may persist, until the newborn period. Such folds are
mucosal infolds with as axial offshoot and adventitia that does not flatten out when
the ureter is distended or stretched. These epithelial folds are secondary to
differential growth rates of the ureter and the body of the child, with excessive
ureteral length occurring early in gestation. This provides a “length reserve” for the
ureter, which traverses a shorter distance in the new born than in the adult (Ostling,
1942) 15 . Ostling thought these folds were a precursor of UPJ obstruction, because
they were frequently discovered in babies who had a contralateral UPJ obstruction.
This concept has evolved, and “Ostling’s folds” are now considered folds that are not
obstructive and disappear with a person’s linear growth. They are rarely seen in an
older child or adult. On the other hand, persistent fetal folds containing muscle and
high insertion of a valvular leaflet at UPJ may become obstructive (Maizels and
Stephens, 1980). This type of obstruction sometimes can be relieved by dissection of
the folds and elimination of the kinking (Johnston, 1969), but more commonly the
ureteral portion containing the valve must be excised.

2. Extrinsic causes:
Proforma
An aberrant, accessory, or early branching lower pole vessel is the most
common cause of extrinsic UPJ obstruction. This is a major case of UPJ obstruction
in adults.
These vessels pass anteriorly to the UPJ or proximal ureter and contribute to
mechanical obstruction. Nixon (1953) reported that 25 of 78 cases of UPJ
obstruction were secondary to vascular compression. Other reported incidences have
varied between 15% and 52% (Ericsson et al, 1961; Williams and Kenawi, 1976,
Johnson et al, 1977; Stephens, 1982; Lowe and Marshall, 1984). Whether the
aberrant vessel causes obstruction or is a co-variable that exists along with an
intrinsic narrowing is unclear.
Stephens (1982) theorized that when an aberrant or accessory renal artery to
the lower pole of the kidney is present and the ureter courses behind it, the ureter may
angulate at both the UPJ and the point at which it traverses over the vessel as the
pelvis fills and bulges inferiorly. Further angulations of the ureter occurs as it
becomes adherent to the UPJ secondary to an inflammatory process. A two-point
obstruction ensues, with kinking of the ureter at the UPJ and at the point where the
ureter drapes over the vessel. Stephens (1982) could find no evidence of stricture or
fibrosis at these points when the ureter was freed of its adhesions and lifted off the
vessel. However, he suggested that over time, these areas may become ischemic,
fibrotic, and finally stenotic 16 .

II) Secondary or acquired causes of UPJ obstruction:
Proforma
UPJ obstruction may also be seen with severe vesico-ureteral reflux (VUR);
these conditions co-exist in 10% of cases. The ureter elongates and develops
a tortuous course in response to the obstructive element of reflux. A kink may
develop in the UPJ area, a point of relative fixation, and may cause
obstruction secondarily (Lebowitz and Blickman, 1983) 17 . In such a situation
the obstructive lesion needs to be corrected initially, even though the VUR
contributed to the initial problem.
Urothelial tumours.
Calculi at ureteropelvic junction.
Associated anomalies:
Congenital renal malformations are commonly seen in association with UPJ
obstruction. (about 50% of affected infants).
UPJ obstruction is the most common anomaly encountered in the opposite
kidney (occurs in 10-40% of cases) 6 .
Renal dysplasia and multicystic dysplastic kidney are next most commonly
observed contralateral lesions 18 .
Unilateral renal agenesis (5% of children) 19 .
Duplicated collecting system or horseshoe kidney. UPJ obstruction may
occur in either the upper or the lower moiety of duplicated collecting
system 20 .
UPJO was noted in 21% of children with VATER (vertebral defects,
imperforate anus, tracheo-esophageal fistula, radial and renal dysplasia).

Clinical features:
Proforma
The presenting symptoms of UPJ obstructions have been documented to be
varied and somewhat age dependent.
Most infants are asymptomatic:
- In children younger than 1 year old, the most common presentation has been a
palpable abdominal mass 20,21 . Any palpable flank mass in an infant should raise
the question of HN, since 50% of all palpable abdominal masses in infants and
children are of renal origin 22 . Urinary tract infection was the presenting symptom
as often as a flank mass in a large series of patients of UPJ obstruction performed
by Johnston and colleagues 23 .
In older children, urinary tract infection (UTI) with fever has been reported to
be the most common presenting complaint (30%) 24 .
Other clinical presentations include,
Abdominal or flank pain.
Chronic nausea and vomiting
Hematuria following mild or unrecognized trauma (25%).
This hematuria is believed to be caused by disruption and rupture of mucosal
vessels in the dilated collecting system (Kelalis et al, 1971)
Hypertension:
The pathophysiology is thought to be a functional ischemia with reduced
blood flow caused by the enlarged collecting system that produces a renin-
mediated hypertension (Belman et al, 1968).
Failure to thrive.

Diagnosis:
Proforma
The diagnosis of UPJ obstruction is based on the combination of clinical
manifestations, radiographic evidence of obstruction and impairment of renal
function.
Radiographic evidence plays a key role in the diagnosis of UPJ obstruction.
Radiographic studies should be performed with a goal of determining both the
anatomic site and the functional significance of an apparent obstruction
1. Excretory urography or intra venous pyelography (IVP):
Remains a cornerstone of radiographic diagnosis 24 .
Classically, findings on the affected side include:
Delay in function associated with a dilated pelvicalyceal system.
If ureter is visualized, it should be of normal caliber. In some patients,
symptoms may be intermittent and IVP in between painful episodes may
be normal. In such cases, the study should be repeated during an acute
episode when the patient is symptomatic. Alternatively, provocative
testing with a diuretic urogram may allow accurate diagnosis. The patient
should be well hydrated and the study then performed by injecting
furosemide, 0.3-0.5 mg/kg, intravenously at the time of IVP.

PHOTOGRAPH. 1 : IVP
Proforma
IVP showing bilateral dilated pelvicalyceal system due to bilateral PUJO

2. Renal ultrasound (USG) 3 :
Proforma
It is a valuable initial diagnostic study under any circumstances in which
overall renal function is inadequate to perform IVP. USG is the standard method for
identifying HN in infancy. The size of the renal pelvis (Antero-posterior diameter)
can correlate with the likelihood of obstruction, but this does not diagnose
obstruction, nor can it answer whether the HN will improve or worsen.
Postnatal USG imaging is usually deferred until day 3 of life, to allow for
improvement in the relative oliguria, which could lead to underestimation of the
degree of HN.
The fetal and neonatal kidney may appear to be hydronephrotic on USG
secondary to the sonolucent appearance of the medullary area and pyramids. This
appearance tends to resolve after parenchymal maturation, which occurs at 3 months
of age. Sequential studies become meaningful, because they define a trend with
regard to the HN. Worsening HN usually indicates obstruction, and improved HN
suggests the opposite.
In neonates and infants, the diagnosis of UPJO has generally been suggested
either by routine performance of maternal USG or by the finding of a flank mass. In
either setting, renal USG is usually the first radiographic study performed.
USG should be able to visualize dilatation of the collecting system. In UPJO,
the pelvis is visualized as a large, medial sonolucent area surrounded by smaller,
rounded sonolucent structures representing dilated calyces. At times, dilated calyces
will be seen connecting to the pelvis via dilated infundibula. Occasionally, a solid-
appearing renal cortex can be seen surrounding the sonolucent areas or separating the
dilated calyces.

Proforma
Currently computed tomography (CT) scanning is being performed in most
patients in place of USG, (Fielding et al, 1997, Dalrymple et al, 1998; Vieweg et al,
1998). Both USG and CT scanning have a role in differentiating acquired causes of
obstruction such as radiolucent calculi or urothelial tumours.
PHOTOGRAPH. 2 : RENAL USG
Renal USG showing Rt. Kidney Hydronephrosis due to PUJO
PHOTOGRAPH. 3 : CT SCAN OF KUB
CT scan showing right kidney HN due to PUJO

3. Magnetic resonance imaging (MRI) 3 :
Proforma
This offers advantages for evaluating renal blood flow, anatomy and urinary
excretion. After injection of contrast gadolinium – diethylenetriamine – penta-acetic
acid (DTPA), signal intensity from the region of interest of hydronephrotic kidneys
differed from that of non-hydronephrotic kidneys by showing less cortical decrease,
and delayed contrast excretion. These techniques are beginning to gain acceptance
and hold the promise for a single study that can provide information on both
perfusion and function. The evaluation of renal perfusion with MRI has become
feasible with the development of rapid data acquisition techniques, which provide
adequate temporal resolution to monitor the rapid signal changes during the first
passage of contrast agents in the kidneys (Bennett and Li, 1997).
PHOTOGRAPH. 4 : M.R. UROGRAM
M.R. Urogram showing dilated pelvis in the Lt. Kidney due to PUJO.

4. Radionuclide renography 3 : (Renal scientigraphy)
Proforma
IVP was in the past the primary radiographic study used to define UPJO. In
most institutions, this has been supplanted by radionuclide renography, which
provides differential renal function data and an assessment of washout from the
individual kidney. Several radiopharmaceuticals have been used, each with slightly
different properties.
Diethylenetriamine-penta-aceticacid (DTPA) is eliminated entirely by
glomerular filtration, with an extraction efficiency of 20%. It provides indirect means
of measuring the GFR.
Differential GFR can be measured by comparing the amount of uptake in each
kidney during the first 1 to 3 minutes after intra venous injection (Rowell et al, 1986).
Mercaptoacetyltriglycine (MAG-3) is cleared by the kidneys primarily by
tubular excretion and to a lesser extent by glomerular filtration. Therefore MAG-3 is
an excellent agent for estimating renal plasma flow. Differential renal plasma flow
measured with MAG-3 correlates reasonably well with differential renal function.

Proforma
PHOTOGRAPH 5 : RENAL SCIENTIGRAPHY WITH Tc-99m DTPA SCAN
A : Renal scientigraphy showing decreased function in the left kidney
B : Renal scientigraphy showing delayed excretion of dye in the left kidney

Tc-99m DTPA scan:
Procedure 25 :
Bladder catheterization should be done with Foley catheter.
Proforma
Patient is usually hydrated well intravenously with 10-15ml/kg of 5% dextrose +
0.22% normal saline for under 1 year of age and 5% dextrose + 0.45% normal
saline for over 1 year of age for 30min prior to administering the diuretic.
Administration of radiopharmaceuticals:
Tc-99m DTPA is a glomerular agent. The biological half-life is under 2.5 hrs,
95% of the administered dose is cleared by 24 hours.
The minimal administered activity for Tc-99m DTPA is about 0.5mCi. The
maximum administered activity for Tc-99 DTPA is about 10-20mCi in
teenagers who weigh over 70 kgs.
Administration of diuretic:
The dose of furosemide (Lasix) is 1.0mg/kg with maximum dose of 40mg.
The diuretic is injected at 20min or later after the radiopharmaceutical (F+20
or later) when the renal pelvis and ureter become maximally distended in HN.
Image acquisition:
The preliminary study is a dynamic renal scan with the patient in supine with
his/her back to the camera and acquisition for 20 to 30min as serial 15 to 30
sec images. After first few min, 30 to 60 sec images may be acquired.
For diuretic of F+20 or later, continuous computer and analog acquisitions are
begun one to two min prior to the administration of the diuretic (baseline
phase) and for the rest of the study the diuretic effect usually begins within 1
to 2 min after the administration of the diuretic.

Processing:
Proforma
From the dynamic renal study, careful evaluation of the parenchymal phase
reveals renal function, size and position. Cortical transit time and dilatation of
the collecting system are examined on the excretory phase.
Baseline images of the diuretic phase are used for the assessment of the
diuretic effect.
Regions of interest are drawn around the dilated pelvicalyceal system for
curve analysis and calculation of the T ½. The diuretic half time is the time at
which the time activity curve decreases to half of its maximal activity.
Residual activity can be reported by estimating the percentage of the initial
tracer activity that remains at 30min after the injection of the
radiopharmaceutical.
Interpretation criteria :
In absence of obstruction there is rapid and almost complete washout of the
radiotracer. Obstructed systems can result in delayed drainage from the
collecting system. The amount of activity proximal to the obstruction can also
increase with time.
With the injection of the diuretic after the radiopharmaceutical (F + 20 or
later), a T ½ less than 10min usually means the absence of obstruction, where
a T ½ greater than 20min identifies obstruction. The T ½ with a value between
10 and 20 is an equivocal result.
The shape of the resulting time activity curves of the washout study has been
used for differentiation of stasis from obstruction. Persistence of more than 50% of
initial immediate pre-furosemide activity for more than 20 minutes is considered to
be diagnostic of obstruction.

Proforma
A nuclear scan is also of value in predicting recoverability of function in those
cases in which IVP has revealed non-visualization. In this setting, a 99mTc-DTPA
scan can help predict recoverability of function, because essentially all kidneys that
function on such scans will improve following relief of obstruction. DTPA scan will
also be of value in differentiating dilated, non obstructed systems from those with
functional obstruction.
Roake and Sandler (1998) reviewed in detail the role of diuretic renography
for evaluation of UPJO.
5. Invasive tests:
Retrograde pyelography is indicated whenever the UPJO requires acute
decompression such as in setting of infection or compromised renal function. In such
cases, an attempt can be made to pass a floppy tipped guide wire or hydrophilic
“glide” wire, followed by open-ended ureteral catheter or internal stent, to allow
decompression of the system and thus better prepare the patient for reconstruction at
a later date.
In cases in which cystoscopic retrograde manipulation has been unsuccessful
or may be hazardous, such as in male neonates or infants placement of percutaneous
nephrostomy is an excellent alternative. This also allows the performance of
antegrade studies that will help define the nature and exact anatomic site of
obstruction.

Whitaker test 3 :
Proforma
First described by Whitaker in 1973 and then modified in 1978. The renal
pelvis is perfused at 10cc/ min with NS solution. Alternatively, dilute radiographic
contrast solution may be used and the procedure performed under fluoroscopic
control.
Renal pelvic pressure is monitored during the infusion and the pressure
gradient across the presumed area of obstruction is then determined. During infusion,
the bladder is continuously drained with an indwelling catheter to prevent
transmission of intervesical pressure. Renal pelvic pressure ranging up to 12-15 cm
of H2O during this infusion suggests a non-obstructed system.
In contrast, pressure in excess of 15-22 cm of H2O is highly suggestive of a
functional obstruction. Pressure between these extremes may be non-diagnostic. This
test has disadvantage of being invasive and indications for it are now infrequent and
used primarily when other examinations are inconclusive. No evaluation of a child
with suspected UPJO is complete until voiding cystourethrogram (VCUG) has been
done to exclude VUR.
As such there remains an important role for the urologist as a diagnostician to
correlate the clinical presentation and results of all diagnostic studies performed in
order to appropriately recommend the timing and nature of subsequent intervention.

MANAGEMENT :
Surgical management :
Proforma
The evolution in the surgical correction of UPJ obstruction has occurred on a
number of fronts, with open surgical techniques yielding way to endoscopic and
laparoscopic approaches. Although there are a variety of surgical approaches to
correction of UPJ obstruction, they can be classified into 3 categories.
1. Open surgical procedures.
2. Endoscopic (antegrade or retrograde) procedures.
3. Laparoscopic procedures.
1. OPEN SURGICAL PROCEDURES:
The open surgical techniques that have the greatest applicability can be
classified into 3 main groups.
a. The dismembered pyeloplasty
b. Flap procedures
c. The incisional - intubated type
The Anderson-Hynes pyeloplasty (1949) has become the most commonly
employed ‘open’ surgical procedure for the repair of UPJ. Open pyeloplasty for
correction of UPJO remains the gold standard against which all alternative therapies
are compared. The overall success rates of open pyeloplasty range from 90-100% 28,29 .
The technique of dismembering the ureter was borne out of necessity in the
repair of retrocaval ureter (Anderson and Hynes, 1949). There was reluctance on the
part of surgeons elsewhere because of concerns about severing the neural continuity

Proforma
between pelvis and ureter. Later work demonstrated that the bolus of urine is the
peristaltic stimulus. The principal reasons for the universal acceptance of the
dismembered pyeloplasty are:
Broad applicability, including preservation of anomalous vessels.
Excision of the pathologic UPJ and appropriate repositioning and
Successful reduction pyeloplasty.
Indications for intervention:
Presence of symptoms associated with the obstruction.
Impairment of overall renal function or progressive impairment of ipsilateral
renal function.
Development of stones or infection, rarely, causal hypertension.
A. DISMEMBERED PYELOPLASTY 3 :
This operation is easy to perform and can be accomplished by following
surgical approaches.
Anterior subcostal
Flank incision
Posterior lumbotomy
The actual repair for the modified Anderson-Hynes dismembered pyeloplasty,
as performed through an anterior subcostal incision, is explained in materials and
methods section.

FIG No. 3 : DISMEMBERED PYELOPLASTY
Proforma
UPJ obstruction UPJ excised Anastomosis in a watertight fashion
FIG No. 4 : DISMEMBERED PYELOPLASTY IN A LARGE OR REDUNDANT
Large or
redundant renal
pelvis
RENAL PELVIS
Reduction
pyeloplasty
Dependent aspect of pelvis
anastomosed to proximal
ureter

Accessory lower
pole vessel
Anastomosis done
anterior to the aberrant
vessel
Proforma
FIG No. 5 : DISMEMBERED PYELOPLASTY IN ABERRANT OR
ACCESSORY LOWER POLE VESSELS

OUTCOME :
Proforma
Adherence to sound surgical principles, minimal handling of the ureter at the
time of repair and judicious use of internal stenting or nephrostomy tube drainage
ensure a successful outcome. Success is defined as improvement in hydronephrosis
and stabilization or improvement in function on renal scan along with a decrease in
washout time. In those situations in which symptomatic presentation occurred,
resolution of flank/abdominal pain or vomiting should also occur.
Imaging of the kidneys postoperatively depends on whether a nephrostomy
tube has been used. A nephrostogram performed 10 to 14 days after surgery allows
for visualization of the anastomosis. Others have simply clamped the nephrostomy
tube for 24 hours and checked the residual in the renal pelvis. If the residual is less
than 15 ml, then the nephrostomy tube is removed (Flint et al, 1998). If a double-
pigtail ureteral stent is left indwelling, it is removed 6 to 8 weeks after the initial
procedure. A renal ultrasound is obtained 6 weeks after pyeloplasty or after stent
removal to ensure that the hydronephrosis is improving. A renal scan is obtained 1
year after the pyeloplasty to provide a relative assessment of the overall renal
function. Long-term imaging at 3 years may be obtained to look for that rare situation
of delayed cicatrisation and restenosis of the UPJ.

Selected published experience with open pyeloplasty :
Source Patients/Kidneys Success (%)
Poulsen et al., 1987 35 100
O'Reilly, 19H9 30 83-93
MacNeily el al, 1993 75 85
Shaul el al, 1994 32/33 (2 month old) 93
Salem et al, 1995 100 98
McAlcer and Kaplan, 1999 79 90
Austin el al, 2000 135/137 91
Houben et al, 2000 187/203 93
Proforma
Early complications of pyeloplasty are uncommon and usually involve
prolonged urinary leakage from the penrose drain. Depending on the amount of
drainage, observation is generally the best approach. If it persists beyond 10 to 14
days, placement of a retrograde ureteral stent can often rectify the situation.
Spontaneously delayed opening of the anastomosis has occurred as late as several
months after the repair. If a patient presents postoperatively with fever, flank pain,
and significant hydronephrosis, a nephrostomy tube may be necessary to decompress
the kidney. Lack of drainage for a prolonged period would necessitate further
intervention, including an endopyelotomy, redo pyeloplasty, or even
ureterocalicostomy. It is not advisable to embark on such a procedure before 2
months postoperatively.

B. FLAP PROCEDURES 3 :
Foley Y-V-plasty.
Culp-Deweerd spiral flap.
Scardino-Prince vertical flap.
Foley Y-V-Plasty :
Proforma
The Foley Y-V-plasty was originally designed for reconstruction of a UPJ
obstruction associated with a high ureteral insertion. As for other flap techniques,
however, its use has generally been supplanted by the more versatile dismembered
pyeloplasty.
Contraindications :
Contraindicated when transposition of lower pole vessels is required.
2. The Foley Y-V-plasty is also of little value when significant reduction of renal
pelvic size is required.
Procedure :
The pelvis and proximal ureter are exposed, and a widely based triangular or
V-shaped flap is outlined with methylene blue or fine stay sutures. The base of the V
is positioned on the dependent, medial aspect of the renal pelvis and the apex at the
UPJ. The incision from the apex of the flap (the stem of the Y) will then be carried
out along the lateral aspect of the proximal ureter. The incision in the ureter should
be long enough to completely traverse the area of stenosis and extend for several
millimeters into the normal caliber ureter.

Proforma
The pelvic flap and ureterotomy are then developed. A fine scalpel blade is
used for the initial pelvic incision, following which a Potts or a fine Metzenbaum
scissors is used to complete the flap and ureterotomy. An internal stent is now placed
and the repair performed over it. First, the apex of the pelvic flap is brought to the
apex (inferior aspect) of the ureterotomy incision using fine absorbable suture. The
posterior walls are then approximated using interrupted or running suture..
Interrupted technique is less likely to cause local ischemia. Anastomosis of the
anterior walls is then accomplished, thus completing the repair.
High insertion of
ureter
V-flap V-Y plasty
FIG No. 6 : FOLEY Y-V PLASTY

Culp-DeWeerd Spiral Flap :
Proforma
The Culp-DeWeerd spiral flap is best suited to large, readily accessible extra-
renal pelves in which the ureteral insertion is already in a dependent, oblique
position. Although most such patients are generally also good candidates for a
standard or reduction dismembered pyeloplasty, the spiral flap may be of particular
value when the UPJ obstruction is associated with a relatively long segment of
proximal ureteral narrowing or stricture.
Spiral
flap
outline
Long
proximal
ureteral
obstruction
Spiral flap
FIG No. 7 : CULP-DEWEERD SPIRAL FLAP
Anastomosis
The spiral flap is outlined with a broad base situated obliquely on the
dependent aspect of the renal pelvis. To preserve blood supply to the flap, the base is
situated in a position anatomically lateral to the UPJ, that is, between the ureteral
insertion and the renal parenchyma. The flap itself may be spiraled posteriorly to
anteriorly or vice versa. In either case, the anatomically medial line of incision
(farthest from the parenchyma) is carried down the ureter, completely through the
obstructed segment. Proper placement of the apex of the flap is determined by the
length of flap needed. This is, in turn, a function of the length of proximal ureter to

Proforma
be bridged. The longer the flap required, the farther away will be the apex from the
base. However, to preserve vascular integrity of the flap, the ratio of flap length to
width should not exceed 3:1. In general, the outline of the flap should be made longer
than what may initially be perceived as necessary, because the flap will shrink once
the pelvis is incised. If the flap is then in fact too long, excess length can safely be
reduced by trimming back the apex, thus keeping blood supply intact. Once the flap
is developed, the apex is rotated down to the most inferior aspect of the ureterotomy.
The anastomosis is then performed over an internal stent, again utilizing fine
absorbable sutures.
Scardino-Prince Vertical Flap :
The Scardino-Prince vertical flap technique has limited application today. It
may appropriately be used only when a dependent UPJ is situated at the medial
margin of a large, square ("box-shaped") extrarenal pelvis. Its use in most instances
has been supplanted by a standard dismembered pyeloplasty, although the vertical
flap may be preferable for relatively long areas of proximal ureteral narrowing.
However, whereas the vertical flap can bridge stenotic areas of average length, the
procedure cannot produce as long a flap, and thus bridge as long a stricture, as the
spiral flap.
FIG No. 8 : SCARDINO-PRINCE VERTICAL FLAP
Large, box-shaped extra renal pelvis Vertical flap
Anastomosis

Proforma
The vertical flap technique itself is similar to the spiral flap procedure except
that the base of the flap is situated more horizontally on the dependent aspect of the
renal pelvis, between the UPJ and the renal parenchyma. The flap itself is formed by
straight incisions converging from the base vertically to the apex on either the
anterior or the posterior aspects of the renal pelvis. Again, the site of the apex, and
thus the length of the flap, is determined by the length of proximal ureter to be
bridged. The medial incision is carried down the proximal ureter, completely through
the strictured area and into normal-caliber ureter, using fine scissors. The apex of the
flap is then rotated down and sutured to the most inferior aspect of the ureterotomy.
Closure of the flap is then completed with interrupted or running fine absorbable
sutures.
C. INTUBATED URETEROTOMY :
The intubated ureterotomy, popularized by Davis in 1943, is rarely used
today. Its primary role was for repair of lengthy or multiple ureteral strictures. If
these strictures are found in association with UPJ obstruction, the intubated
ureterotomy may be combined with any of the standard pyeloplasty techniques.
However, at least in principle, the Davis intubated ureterotomy would be best
combined with a spiral flap procedure. Compared with the vertical flap, the spiral
flap can be made longer. This allows more of the strictured area to be bridged by a
pelvic flap, and thus leaves a shorter area to rely on healing by "secondary intention."
In fact, though, in this specific setting, any flap technique would be preferable to a
dismembered repair, at least in regard to preservation of blood supply and subsequent
healing.

Proforma
A flap is outlined as described earlier, with the ureterotomy to be carried
completely through the long, strictured area. The flap is then developed, taking care
to use minimal dissection of the ureter in order to preserve its blood supply. In
contrast to uncomplicated pyeloplasties, nephrostomy tube drainage is routinely
applied in these cases in order to divert the urine and prevent subsequent urinoma
formation. Nephrostomy drainage in these cases also allows access for antegrade
radiographic studies during the postoperative period.
As originally described, the ureteral intubation was accomplished with a
stenting catheter that was placed across the strictured area to the distal ureter or
bladder. Proximally, it was brought out through the renal cortex alongside of a
nephrostomy tube. Currently, most urologists would use a self-retaining, soft, inert,
internal ureteral stent instead. The apex of the flap is now brought over the stent as
far down as possible on the ureterotomy, and the flap is closed with interrupted or
running absorbable suture. The distal aspect of the ureterotomy is left open to heal
secondarily by ureteral regeneration, although a few fine absorbable sutures may be
placed loosely to keep the sides of the ureter in accurate relation to the stent.
Spiral
flap
FIG No. 9 : INTUBATED URETEROTOMY
Long
ureteral
strictures
Spiral
flap
Distal
ureterotomy
left open over
ureteric stent
to heal
secondarily

Proforma
A nephrostogram should be obtained after 6 to 8 weeks. If there is no
extravasation, the internal stent is removed cystoscopically and antegrade
radiographic studies are then repeated. When ureteral patency has been ensured,
without evidence of extravasation, the nephrostomy tube is clamped and
subsequently removed.
MANAGEMENT OF FAILED OPEN PYELOPLASTY:
(“SALVAGE” PROCEDURES) 3 :
Management of a failed open pyeloplasty is a challenging problem that is
usually best managed initially using an endourologic approach. Occasionally,
however, these techniques are not applicable or have already failed, as either the
primary or the secondary procedure. In such cases, successful reconstruction can at
times be achieved utilizing one of the flap or dismembered techniques already de-
scribed. In this setting, the secondary open operative reconstruction will be aided by
preliminary cystoscopic or ante-grade placement of a ureteral catheter to aid
intraoperative identification and dissection of the ureter and renal pelvis. In these
cases, there is often a relatively long length of proximal ureteral stenosis to repair. As
such, in contrast to primary repairs in which dissection of the kidney and ureter is to
be minimized, wide mobilization of both is generally a necessity. This allows the
kidney to be displaced downward and the ureter up, thus helping to bridge the area of
stenosis and perform the secondary pyeloplasty without tension.
Several other options are available for these secondary and often complex
repairs. Many of these surgical alternatives are those generally available for any
extensive ureteral problem. Options for preserving renal function include an
ileoureteral replacement and autotransplantation with a Boari flap pyelovesicostomy.
For cases in which function of the involved kidney is already significantly compro-

Proforma
mised and the contralateral kidney is normal, consideration can also be given to
nephrectomy, especially when previous attempts at salvage have already failed or the
repair would be particularly complex for any reason. Another option, more specific to
the "failed pyeloplasty," is use of a ureterocalycostomy.
Ureterocalycostomy :
Anastomosis of the proximal ureter directly to the lower calyceal system has
become a well-accepted salvage technique for the failed pyeloplasty (Ross et al,
1990). Ureterocalycostomy may also be utilized as a primary reconstructive
procedure whenever a UPJ obstruction or proximal ureteral stricture is associated
with a relatively small intrarenal pelvis, or, in the view of some authors, when the
UPJ is associated with rotational anomalies such as horseshoe kidney (Levitt et al,
1981). In those cases, it may be of particular value because it provides completely
dependent drainage.
The ureter is isolated in the retroperitoneum and dissected proximally as far as
possible with a large amount of periureteral tissue. For secondary procedures,
extensive scarring may preclude identification and dissections of the renal pelvis
itself. The kidney is then mobilized as much as necessary to gain access to the lower
pole. An important technical point to be emphasized is that the parenchyma overlying
the lower pole calyx must be resected rather than simply incised (Couvelaire et al,
1964). The amount of parenchyma to be removed depends on the extent of cortical
thinning already present. However, again, a simple nephrotomy over a calyx will not
be adequate, because a secondary stricture may result.
The proximal ureter is spatulated laterally and the ureterocalyceal anastomosis
performed over an internal stent. Consideration should also be given to leaving a

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nephrostomy tube in these cases. The first suture is placed at the apex of the ureteral
spatulation and lateral wall of the calyx, and the second one is placed 180 degrees
away. The remainder of the anastomosis is then completed utilizing an interrupted
"open" suture technique. That is, each suture is placed but is left untied until the final
one is in place. This allows a more accurate anastomosis to be performed under direct
vision. When the full set of circumferential sutures has been placed, they are secured
down together.
Whenever possible, the renal capsule is closed over the cut surface of the
parenchyma, but not close enough to the anastomosis itself to compromise its lumen
by extrinsic compression. Rather, the anastomosis should be protected by
surrounding it with perinephric fat or a peritoneal or omental flap. A follow-up
urogram is generally obtained 1 month after stent extraction.
2. ENDOSCOPIC PROCEDURES :
Several less invasive alternatives to standard operative reconstruction are now
available. The advantages of all these newer approaches include a significantly
reduced length of hospital stay and post operative recovery. However, for many of
these procedures, the success rate does not approach that of standard open
pyeloplasty. Further more open operative intervention can be applied to almost any
anatomic variation of UPJ obstruction. Consideration of any of the less invasive
alternatives must take into account individual anatomy including, but not limited to
the degree of HN, overall and ipsilateral renal function and, in some cases, the
presence of crossing vessels or concomitant calculi.
Endourologic management of UPJO was introduced by Ramsan and
colleagues in 1984 as a “percutaneous pyelolysis” and then popularized in the US by

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Badlani and Coworkers 30 . The basic concept involves a full thickness incision
through the obstructing proximal ureter, from the ureteral lumen out to the peripelvic
and periureteral fat. The incision is stented and left to heal, based on the original
work of Davis in 1943, who used an intubated ureterotomy in the course of an open
operative procedure for UPJO. The endoscopic approach to the UPJ has been
successful in both an anterograde and retrograde fashion. The initial attempts at a
balloon dilatation have been superceded by the use of an Acucise device (Applied
Medical, Ureteral cutting balloon catheter, No. 5 Fr) 31 . Success rates ranging from
75% to 88% have been reported in different series using endopyelotomy and
endoureterotomy techniques 32,33,34 .
Types :
A. Percutaneous endopyelotomy
Indications : (are similar to open pyeloplasty)
Presence of symptoms
Progressive or overall impairment of renal function
Development of upper tract stones or infection or rarely, causal
hypertention.
Contraindications :
Long segment (>2cms) of obstruction
Active infection
Untreated coagulopathy
Impact of crossing vessels is controversial.
Significant entanglement of the UPJ by crossing vessels renders any
endourologic approach unsuccessful.

Technique :
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First, access across the UPJ is established. This can be accomplished is a
retrograde fashion cystoscopically or in an antegrade manner percutaneously.
With the patient in prone position, the site for percutaneous access is chosen
to allow easy access to the UPJ utilizing rigid instrumentation. Generally mid
posterior or superolateral calyx is chosen.
The endopyelotomy is performed using a cold-knife technique under direct
vision. With one, or preferably two wires in place across the UPJ, a direct vision
“endopyelotome” is utilized. This hook-shaped cold knife is used to completely
incise the UPJ in a full thickness manner, from the ureteral lumen out to periureteral
and peripelvic fat. This incision is extended for several millimeters into the normal
ureter. Once incision is complete, stenting is accomplished. A No 14/7 Fr
endopyelotome may be utilized and this is passed in an antegrade fashion with the
larger diameter end of the stent positioned across the UPJ. Nephrostomy is performed
to ensure proper positioning of a patent stent. Percutaneous management is ideal
when the UPJ obstruction is associated with upper tract stone disease, because the
stones can be managed concomitantly.
Results :
Excellent success rates have been achieved by many surgeons and one should
expect that 85% of patients would have good results.
Gerber and Lyon 35 , in 1994, reviewed the outcome of percutaneous
endopyelotomy in 672 patients reported from 12 centres and found a success rate
ranging from 57% to 100% (mean 73.5%) at follow-up ranging from 2 to 96
months. Currently, success rates approaching 85% to 90% are being reported at
experienced centres.
Open operative or laparoscopic intervention is generally offered to any patient
who has failed an endourologic approach.

Complications :
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1. Hemorrhage: It is a risk of any percutaneous procedure including
endopyelotomy. Treatment should be conservative to start and this includes
bed rest, hydration and transfusion as necessary. When continued bleeding
does not respond to conservative measures, selective angiographic
embolization should be done.
2. Infection
3. Persistent obstruction
B. “Cautery wire Balloon” endopyelotomy :
The use of cautery wire balloon for management of UPJO was first reported in
a clinical series by Chandhoke and associates in 1993. Only standard cystoscopic
techniques and real-time fluoroscopy are needed for its use.
Technique :
Indications and contraindication are similar to any endopyelotomy procedure.
The procedure starts with retrograde pyelogram under fluoroscopic control. A
non-conducting guide wire is passed in a retrograde fashion across the UPJ and then
cautery wire balloon catheter is passed with the cutting wire positioned in the
direction ultimately planned for incision.
At this point the 3cc low-profile balloon is partially inflated.
Hot wire electrocautery incision is then performed.
The low profile balloon is filled with another 1 to 2 cms of dilute contrast
medium as 60 to 70 W of pure cutting current are applied to the cautery balloon

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wire for 2 to 3 seconds. The balloon is kept inflated for a few minutes. During
deflation, extravasation of contrast material may often be noted at the UPJ. The
cautery wire balloon catheter is now withdrawn completely. Stenting of the ureter is
done.
Results :
Chandhoke and associates (1993) 36 reported a 67% complete resolution of
symptoms and 85% improvement in radiographic appearance. Preminger and
colleagues (1997) 37 reported an initial “Patency” rate of 77% at a mean follow-up of
7-8 months.
In 1999, Lechevallier and his associates 38 in France achieved success rate of
75% for a median of 2 years. Nadler and associates (1996) noted subjective
improvement in 61% pts and 81% patients had a patent UPJ based on domestic
xenography.
Complications:
1. Hemorrhage
2. Ureteral avulsion
3. Stent related problems
4. Detachment of cutting wire.

C. Ureteroscopic Endopyelotomy :
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The main advantages of an ureterosopic approach, compared with
fluoroscopically guided hot-wire balloon incision, is that it allows direct visualization
of the UPJ and assurance of a properly sited, full-thickness endopyelotomy incision.
If any vessels are encountered, these are easily visualized and avoided during the
procedure.
Indications and contraindications are similar to other endopyelotomy
procedure except for upper tract stones that are best managed by percutaneous
approach.
Technique : Done under GA (Or occasionally SA)
A retrograde pyelogram is performed under fluoroscopic control to locate the
ureteral insertion into the renal pelvis and the length of the obstructed segment of
ureter.
A hydrophilic guide wire is passed cystoscopically into pelvicalyceal system.
The semi-rigid ureteroscope is passed alongside the guide wire to the level of UPJ.
When using a semi-rigid ureteroscope, a 365µm holmium laser fibre is inserted
through the working channel as the ureteroscope is positioned at the proximal extent
of the UPJ of the renal pelvis itself. At a setting of 1.2 J and frequency of 10 to 15
Hz, the UPJ is incised, usually in a posterolateral direction, while the ureteroscope is
withdrawn back, down across the UPJ. This procedure is repeated and the incision
gradually deepened to extend into the peripelvic and periureteral space. Ureteric
stenting is done.

Results :
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Biyani and colleagues (1997) 39 achieved a success rate of 87.5% in a small
group of patients with a mean follow up of 12 months.
Renner and co-workers in 1998 40 reported a larger series of patients
undergoing ureteroscopic laser endopyelotomy with success rate of 85%
endopyelotomy.
Tawfiek and associates (1998) 41 reported 87.5% success rate with minimum
follow up of 6 months.
Gerber and Kim (2000) 42 and Savage and Streem reported success rates
exceeding 80% with follow-up as long as 5 years.
Complications :
Most complications are minor and related to stent migration.
3. LAPAROSCOPIC PYELOPLASTY :
Laparoscopic approach, in the hands of experienced surgeons, can provide an
excellent alternative to both less invasive and more invasive procedures. In contrast
to an endopyelotomy, this approach does allow an anatomic repair like that achieved
with an open pyeloplasty Compared with open surgical intervention, however, the
hospital stay associated with a laparoscopic approach is generally shorter and the
length of disability significantly reduced.
Indications :
The indications for a laparoscopic repair are similar to those for either an
endourologic or an open operative procedure. Essentially, the patient should have
functionally significant obstruction, as defined by the presence of symptoms,
ipsilateral upper tract infection, or progressively impaired or overall impairment of
renal function.

Contraindications :
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Specific contraindications to this approach include only a long segment of
obstruction, such that a normal-caliber proximal ureter cannot be brought to the renal
pelvis without tension. Although the presence of renal calculi does not preclude
performance of a laparoscopic pyeloplasty with simultaneous stone extraction, the
presence of one or more pyelocalyceal stones that cannot be easily accessed at the
time of the laparoscopic procedure suggests that an alternative approach may be more
appropriate.) Additional specific advantages of a laparoscopic approach, compared
with an endoscopic or an endourologic one, is the presence of aberrant crossing
vessels that require transposition. In this respect, laparoscopic pyeloplasty is similar
to open pyeloplasty. Likewise, a large, redundant renal pelvis can be reduced in size
with a laparoscopic approach, again offering the same advantage as open operative
intervention over endourologic management. Laparoscopic pyeloplasty was first
reported in 1993 both by Schuessler and coworkers and by Kavoussi and Peters, who
utilized a dismembered pyeloplasty technique.
Procedure : Explained in detail in materials and methods section.

Table
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SELECTED PUBLISHED EXPERIENCE WITH LAPAROSCOPIC
PYELOPLASTY

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POSTNATAL MANAGEMENT OF ANTENATALLY DIAGNOSED
URETEROPELVIC JUNCTION OBSTRUCTION (UPJO) :
Hydronephrosis is the most common abnormality detected on prenatal
ultrasound and accounts for approximately 50% of all prenatally deleted lesions. A
meta-analysis by Thomas in 1990 revealed that the estimated incidence of detectable
urinary tract dilatation in utero is 1 per 100 pregnancies but only 1 in 500 pregnancies
are believed to be accomplished by significant urologic problems. Approximately
50% of prenatally detected urinary tract dilatations are caused by UPJO 43,44 .
The universal use of maternal USG 45 has led to the early detection of fetal
hydronephrosis. The fetal kidney is detected by USG at 15 weeks of gestation. The
internal renal architecture is better imaged at 20 weeks when the kidney is
surrounded by fat. Fetal HN may be the result of several factors and does not
necessarily indicate obstruction. VUR, congenital non-obstructive megaureter,
transient HN, and Prune-belly syndrome are some examples of non-obstruction
collecting system dilatation. The majorities of HN cases, detected antenatally are
physiological and resolve spontaneously. In one large series of nearly 1000 woman,
antenatal HN was detected in 1.4% and confirmed in 0.65% postnatally. HN
secondary to obstruction is most commonly the result of UPJO. However, not all
cases of UPJO require surgical repair. Homsy evaluated 60 renal units with
pyelocaliectasis with renal sonogram, diuretic renography, and IVP. 21 renal units
were partially obstructed or dilated without obstruction. Of the 17 renal units
available for follow-up; 7 (41%) deteriorated, 8 (47%) improved, and 2 (12%)
remained stable. Those renal units that deteriorated did so within 6 months. Homsy

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recommended 6 months observation period and repeat diuretic renography in those
patients in whom initial obstruction cannot be documented.
With the universal use of maternal fetal USG 46 and common finding of fetal
HN, Grignon and colleagues proposed a classification of inutero urinary tract
dilatation. The classification grades dilatation on a scale ranging from 1 to 5. The
AP diameter is measured.
Classification of in utero urinary tract dilation :
Grades Caliceal dilation Size of pelvis
Grade I Physiologic 1 cm
Grade II Normal calyces 1- 1.5 cm
Grade III Slight dilation > 1.5 cm
Grade IV Moderate dilation > 1.5 cm
Grade V Severe dilation + atrophic cortex > 1.5 cm
The sonographic diagnosis of prenatal UPJO requires significant
pelvicaliectasis without an evidence of distended bladder, dilated ureter, ureterocele,
or a dilated posterior urethra. The prenatal songographic diagnosis of UPJO is thus a
diagnosis of exclusion. Current recommendations are that fetuses with an AP
diameter of the renal pelvis of greater than 10 mm, an anteroposterior renal pelvis to
anteroposterior renal cortex ratio of greater than 0.5 or with evidence of caliectasis
after 24 weeks of gestation should be evaluated postnatally. Obstruction of UPJ
usually occurs unilaterally, although the condition is bilateral in 21% to 36% of

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patients diagnosed in infancy. The prognosis of unilateral UPJO is usually favorable
because of the normal contra lateral kidney. Unilateral neonatal HN is associated
with a 3.5% to 20% risk of ipsilateral renal deterioration in the postnatal period.
Patients with bilateral UPJO are at a greater risk for poor outcome, because both
kidneys may be compromised.
POSTNATAL MANAGEMENT :
Prenatally detected HN should be confirmed postnatally after 3 days of life
because of neonatal dehydration and physiologic oliguria.
Approximately, 20% of antenatally diagnosed upper urinary tract dilatations
are not present on postnatal USG 47 . Currently, no single test can reliably predict
whether a hydronephrotic kidney will deteriorate or improve. It seems reasonable to
use USG to determine the functional significance of UPJO. The differential function
of the hydronephrotic kidney as shown on a Tc-99m DTPA scan is used as a means
of determining a threshold for intervention, with a differential function of less than
35% considered to be an indicator for surgical intervention. If renal differential
function is greater than 35% on the initial study, the patient can be followed
conservatively with repeat USG at 3 months.

FIG No. 10 : PRENATAL DIAGNOSIS OF HN 48
Postnatal USG at 3-5 days
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Normal Abnormal
VCUG VCUG
Normal VUR Normal
USG at 3 mts Prophylactic antibiotics Diuretic renal scan
< 40% Differential function >40% Differential function
Delayed drainage
Surgery Prophylactic antibiotic
DRS and USG at 3-6
months

MATERIALS AND METHODS
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The present study is a prospective randomized control trial comparing
laparoscopic pyeloplasty and open pyeloplasty in the treatment of primary
ureteropelvic junction (UPJ) obstruction conducted in the Department of Urology,
K.L.E.S. hospital and MRC Belgaum during the period of 1 year from April 2004 to
March 2005.
Total of 30 patients were evaluated and operated for primary UPJ obstruction
formed the clinical material for our study. The clearance form ethical committee was
obtained before the start of study.
Source of data :
All cases of primary UPJ Obstruction of any age group who attended
Department of Urology, K.L.E.S Hospital Belgaum, from April 2004 to March 2005
formed our study group.
Method of collection :
Sample size – 30 patients.
Sampling procedure: Total of 30 patients were selected and randomized into
Follow-up :
2 groups of 15 each using computer generated randomized table. 15 patients
under went open pyeloplasty and 15 patients under went laparoscopic
pyeloplasty.
All patients were followed-up for a period of minimum 3 months to assess
objective and subjective outcome. Routinely, in uncomplicated cases, ureteric stent
removal was done at 6 weeks. Follow-up with 99m-Tc-DTPA scan was done at 3
months to assess improvement in renal function. The total study period was for 15
months.

SELECTION CRITERIA :
a. Inclusion criteria :
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All cases of primary UPJO of any age group diagnosed clinically and / or
radiologically (including both symptomatic and asymptomatic patients).
b. Exclusion criteria :
(i) Patients of secondary UPJO.
(ii) Patients with long segments of UPJ obstruction in which normal caliber
proximal ureter cannot be brought to the renal pelvis without tension.
(iii) Patients with urinary tract infection and huge capacity pelvis.
(iv) General contra-indications for Laparoscopic surgery (e.g. morbid obesity,
major bleeding disorders, unacceptable anaesthesia risks, patients who do
not tolerate the pneumoperitoneum).
(v) Patients unfit for surgery due to comorbid medical conditions.
(vi) Redo-surgeries or failed pyeloplasty.
All patients were evaluated in detail. The diagnosis of primary UPJO was
firmly established in all patients based on history, physical examination, renal
sonography and scientigraphy. The risks of the operation were fully explained to the
patients and their parents (in case of children), and included postoperative infection,
bleeding, failed pyeloplasty, the need to convert to open surgery in case of
laparoscopic pyeloplasty, damage to other viscera and adhesion formation.

The following investigations were done in all patients :
1. Blood – complete hemogram, Bleeding time, Clotting time.
2. Urine – Routine and Microscopy.
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3. Minirenals – Random blood sugar, Blood Urea, Serum Creatinine, Serum
Electrolytes.
4. Serology –HIV, HBSAg
5. X-ray KUB
6. Renal USG
7. IVP
8. 99 mTc- DTPA scan.
9. CT scan / MR-Urogram of KUB (in selected patients).
10. Chest X-ray and Electrocardiogram.
Prior fitness was taken from a Physician/Paediatrician. Consent for surgery
was taken from patients or patient’s parents. An enema was administered the night
before surgery to ensure that the colon was empty.
Anaesthesia :
All patients were operated under general anaesthesia. A retrograde pyelogram
was done in all patients before surgery to delineate UPJO and to rule out other
associated anomalies such as VUR (vesico-ureteral reflux. An enema was
administered the night before to ensure that the colon was empty. Intraoperative
antibiotic was administered to minimize the risk of infection. The patient was
catheterised before surgery and the catheter left on free drainage during the operation.

Position:
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The patient was positioned in a lateral position and secured by placing a sand
bag to support the back. The patient was further stabilized by strapping the iliac crest
to the operating table with an adhesive bandage. The patient was placed as close to
the edge of the operating table as possible.
Surgical technique:
PHOTOGRAPH. 6 : POSITION OF THE PATIENT
1. Anderson-Hynes dismembered open pyeloplasty.
2. Laparoscopic Anderson –Hynes dismembered pyeloplasty.

1. ANDERSON-HYNES DISMEMBERED OPEN PYELOPLASTY :
Procedure :
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The anterior subcostal incision is a muscle-splitting incision that is made.
Each muscle layer encountered is split in the direction of the muscle fibers
until Gerota's fascia is identified by sweeping the peritoneum medially. The
fascia is then incised posteriorly over the lateral aspect of the kidney.
The renal pelvis is identified by medial retraction on the peritoneum and
lateral traction on the kidney. If the renal pelvis is significantly dilated, an
angiocath can be inserted to decompress the pelvis and facilitate identification
of the UPJ.
Anterior exposure is usually better when a dismembered pyeloplasty is being
performed. Once the ureter and UPJ are identified, a traction suture is placed
anteriorly through the proximal ureter to minimize subsequent handling.
The area of UPJ is dissected free to allow for a clear area to perform the
anastomosis. Traction sutures may be placed in the renal pelvis superiorly,
medially, laterally, and inferiorly to the UPJ. Once adequate ureteral length is
confirmed and the pathology of UPJ identified, the ureter can be transected at
the UPJ. If the ureter is short, the kidney is completely mobilized to determine
whether it can be brought down sufficiently to allow for a primary tension-
free anastomosis.
After transection of the UPJ, the renal pelvis may not spontaneously drain
until it is incised. This should be done after the site for anastomosis is chosen.
The ureter is spatulated on the side opposite to the traction suture using Potts
tenotomy scissors. The distance over which the ureter is opened is variable,
until healthy ureter is encountered, which springs open when forceps are
placed into it.

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The portion of pelvis is excised, usually a diamond-shaped segment that is
present within the traction sutures that were placed in the renal pelvis. It is
better to leave too much renal pelvis than too little, especially when resecting
along the medial aspect of the renal pelvis. Infundibula can be encountered if
one is not careful.
The ureter and renal pelvis are aligned to ensure that the anastomosis can be
accomplished without tension. Ureteric stent ( double J stent ) of caliber 5-6
Fr was placed in the ureter in all patients ( 3.5-4 Fr in case of children ). If a
nephrostomy tube is to be used, it is placed at this time. An inferior calix is
chosen, preferably where the overlying parenchyma is not too thick. A
Malecot catheter works well and is positioned away from the repair to
minimize the chance of the catheter causing urinary blockage through the
reconstructed UPJ.
The anastomosis is started by placing the first suture at -the apex of the "V" in
the ureter and into the tip of the inferior pelvic flap. As the suture is tied
down, the ureter and renal pelvis are brought together to minimize tension on
the repair. A small feeding tube is placed into the ureter; it can be used to
stabilize the ureter during the anastomosis. A "no-touch" technique is
employed with the ureter to minimize trauma and edema to the ureteral tissue.
Either interrupted sutures or a running closure may be used, depending on the
surgeon's preference. The area of the initial anastomosis is critical to ensuring
a watertight closure.
Before the repair is completed, the renal pelvis is irrigated to remove any
blood clots or debris that could obstruct the UPJ. If an indwelling JJ ureteral
stent is employed, it should be placed now, with care taken to place the stent
into the bladder and renal pelvis without kinking it.

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A Penrose drain is placed adjacent to the repair and brought out through a
separate stab wound.
The kidney is returned to its native position, and perinephric fat, if available,
is placed over the anastomosis.
Closure of the three fascias is readily accomplished, followed by closure of
Scarpa's fascia and subcuticular skin.
A Foley catheter, which was placed at the beginning of the procedure, may be
left in place for 24 to 48 hours postoperatively. The drain is removed
postoperatively when output is less than 5cc/ 24 hrs.

OPEN PYELOPLASTY PROCEDURE
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PHOTOGRAPH. 7 : DISSECTION OF OBSTRUCTED UPJ IN LEFT
KIDNEY
PHOTOGRAPH. 8 : TRACTION ON PROXIMAL URETER BEFORE
DISMEMBERING THE DILATED PELVIS

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PHOTOGRAPH. 9 : DISMEMBERED ANDERSON-HYNES PYELOPLASTY
BEING PERFORMED
PHOTOGRAPH. 10 : ANASTOMOSIS OF PROXIMAL URETER TO THE
REDUNDANT PELVIS IN A WATERTIGHT FASHION

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PHOTOGRAPH. 11 : COMPLETED ANTERIOR ANASTOMOSIS
PHOTOGRAPH. 12 : COMPLETED POSTERIOR ANASTOMOSIS

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PHOTOGRAPH. 13 : INCISION WOUND AFTER THE PROCEDURE WITH
DRAIN SEEN
PHOTOGRAPH. 14 : EXCISED NARROWED PROXIMAL URETER

2. LAPAROSCOPIC ANDERSON – HYNES DISMEMBERED
PYELOPLASTY 59 :
Procedure :
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The first port was inserted by open laparoscopy using a blunt Hasson cannula
through the umbilical skin crease. Purse string suture was secured tightly around the
Hasson trocar. The abdomen was insufflated with CO2 to 10 - 12 mm Hg. One
10mm and one 5mm (one 5mm and one 3mm in case of children) instrument ports
were required; however correct placement of these ports was critical to the ease of
performing the anastomosis. Occasionally an extra 5 mm port was placed for
retraction purposes. The peritoneum overlying the exposed kidney was incised just
lateral to and above the colonic flexure. The loose adventitia around the kidney was
detached from the renal capsule. Once the correct plane was identified, the renal
capsule was traced into the renal sinus until the renal pelvis was identified. The renal
pelvis was further dissected free from medial side. The UPJ and the proximal ureter
were identified. The adventitia around the proximal ureter and UPJ was cleared. The
ureter was dismembered with a small cuff of renal pelvis, leaving a 1.5 - 2.0 cm
pyelotomy to reanastomose to the ureter. The lateral wall of the ureter was opened
longitudinally and spatulated for about 1.5 - 2.0 cm along its lateral margin. The UPJ
and proximal ureter attached at this point to the spatulated ureter was then excised.
The ureteropelvic anastomosis was performed with an 18 cm, 4/0 vicryl suture on a
3/8 round body needle (or 6/0 vicryl in case of children). The first suture was placed
at the apex of the spatulaled ureter from outside in and then driven through the most
dependent part of the pyelotomy. The posterior anastomosis was completed running
up the length of the spatulaled ureter and pelvis. A 0.025 inch guidewire was then

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passed though the proximal ureter into the bladder. A 3 Fr multilength double -
pigtail catheter (or 5 Fr double-pigtail catheter in adults) was passed over the
guidewire into the bladder. The proximal end of the double pig-tail stent was then
placed within the renal pelvis. The anterior anastomosis was then completed as a
continuous layer. A Penrose drain is placed adjacent to the repair and brought out
through one of the port wound. The port wounds are closed with a single stitch using
vicryl 3/0 or 4/0.
Standard equipment for laparoscopic pyeloplasty :
10-mm laparoscope
5-mm laparoscope
Dilating trocars (one 12-mm trocar and two 5-mm trocars)
Harmonic scalpel
Macrobipolar forceps
Two needle drivers
Endoshears with disposable tip
4-0 (dyed) Vicryl on SH-1 needle

PHOTOGRAPH 15 : LAPAROSCOPIC INSTRUMENTS
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PHOTOGRAPH 16 : INSERTION OF TROCAR AND LAPAROSCOPES
PHOTOGRAPH 17 : SHOWING ENLARGED PELVIS DUE TO PUJO

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PHOTOGRAPH 18 : PELVIS BEING OPENED WITH GUIDEWIRE
BEING SEEN
PHOTOGRAPH 19 : RECONSTRUCTION OF UPJ
PHOTOGRAPH : RECONSTRUCTION OF UPJ

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PHOTOGRAPH 20 : RECONSTRUCTION OF UPJ BEING COMPLETED
PHOTOGRAPH 21 : COMPLETED LAPAROSCOPIC PYELOPLASTY
WITH A DRAIN THROUGH ONE OF THE PORT SITE

Postoperative care:
Drain was removed when less than 5 cc / 24 hrs.
Catheter was removed the next day.
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Oral fluids and feeding were started at the appearance of peristaltic bowel
sounds.
Post-operatively antibiotics and analgesics were continued for two days in all
cases.
Follow-up:
In uncomplicated cases, ureteral stent was removed after 6 weeks.
All patients were followed for urinary tract infection, and renal scientigraphy
was repeated at 3 months.

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PHOTOGRAPH 22 : PREOPERATIVE RENAL SCIENTIGRAPHY
SHOWING REDUCED RENAL FUNCTION IN THE LEFT KIDNEY
PHOTOGRAPH 23 : POSTOPERATIVE RENAL SCIENTIGRAPHY
SHOWING IMPROVED RENAL FUNCTION IN THE LEFT KIDNEY

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PHOTOGRAPH 24 : SHOWING POSTOPERATIVE SCAR AFTER 3
MONTHS IN OPEN AND LAPAROSCOPIC PYELOPLASTY DONE IN A
SAME PATIENT WHO HAD BILATERAL PUJO

ASSESSMENT OF SUBJECTIVE OUTCOME :
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The subjective outcome of there 2 groups was assessed based on response to
the pain analog and activity questionnaire of Nadler et al 49 . This questionnaire
assesses perceived pre-operative and postoperative pain on a scale of O (no pain) to
100 (worst pain) and activity levels of O (bed rest) to 100 (full/unrestricted). In
children who were less than 6 yrs of age, a pictorial pain analog scale was used and
questionnaire was given to parents to mark.
All patients received the same questionnaire. Patients were asked to comment
on pain and activity level at the time of surgery and at the time of follow-up for
ureteral stent removal, usually 6 weeks after the surgery. Pre-operative assessment of
pain was based on memory and post operative assessment was based on current
status.
ASSESSMENT OF OBJECTIVE OUT COME :
Objective out come of patients was assessed based on the results of the most
recent renal USG, IVP and renal scientigraphy. These studies were compared to pre-
operative USG, IVP and diuretic renal scans. Success was considered as
improvement in radiographic appearance (less hydronephrosis, visible UPJ, and/or
normalization of drainage or improvement in renal function on diuretic renal scan).
The success rate, post operative complications, mean operative time, mean hospital
stay/recovery time, mean time when oral feeding started and the cosmesis between
both the (laparoscopic versus open) procedures were compared.
Statistical analysis comparing the subjective and objective outcomes between
these two procedures was done using Student’s unpaired and paired ‘t’ tests. P value
was considered significant at < 0.005, very significant between 0.005-0.0001, and
highly significant at

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The analog pain and activity questionnaire assessing pre-operative and
post- operative pain and activity level 49 :
1. Please mark on the following scale the level of discomfort you experienced before
your procedure.
0____________________________________________ 100
(No pain) (Worst pain)
2. Please mark on the following scale the level of discomfort you experienced now,
(6 weeks after the procedure)
0 ____________________________________________100
(No pain) (Worst pain)
3. If before your procedure, your discomfort level was 100% what is your current
level of discomfort?
________________________________________________ (0-100%)
4. Please mark on the following scale your level of activity before your procedure.
0______________________________________________100
(Bed rest) (Full activity)
5. Please mark on the following scale your level of activity after the procedure
(6 weeks).
0______________________________________________100
(Bed rest) (Full activity)

FIGURE No. 11 : PICTORAL ANALOG PAIN SCALE
PAIN ASSESSMENT IN CHILDREN ( in less than 6 years of age )
Proforma

OBSERVATIONS & RESULTS
Proforma
Total of 30 patients with primary UPJO who attended Department of Urology
KLES and MRC Belgaum during a period of 1 year from April 2004 to March 2005
were selected for the study. All the 30 patients were randomized into 2 groups of 15
each. 15 patients under went open pyeloplasty and formed open pyeloplasty group,
and remaining 15 patients who underwent laparoscopic pyeloplasty formed the
laparoscopic pyeloplasty group. All cases were followed for a minimum of 3
months.
Sex Incidence :
Out of 15 patients in open pyeloplasty group, 11 patients were males and 4
patients were females and out of 15 patients in laparoscopic group, 11 were males
and 4 patients were females.
Table No. 1 : Sex Incidence
Sex
Open pyeloplasty
(n=15) group
Percentage
(%)
Lap pyeloplasty
(n=15) group
Percentage
(%)
M 11 73.3% 11 73.3%
F 04 26.6% 04 26.6%

Laterality :
Proforma
Out of 15 patients in open pyeloplasty group, 4 patients had primary UPJO in
the right kidney and 9 patients had UPJO in the left kidney and 2 patients had
bilateral UPJO. Out of 15 patients in laparoscopic pyeloplasty group, 6 patients had
primary UPJO in right kidney and 07 patients had UPJO in the left kidney and 2
patients had bilateral UPJO.
Table No. 2 : Laterality
Laterality
Age :
Open
pyeloplasty
group(n=15)
Percentage
(%)
Lap.
pyeloplasty
group(n=15)
Percentage
(%)
Right 04 33.33% 06 40%
Left 09 55.33% 07 46.6%
Bilateral 02 13.33% 02 13.33%
The average age of patients undergoing open pyeloplasty was 22.83 yrs
(range-5mts-48yrs) and for those who underwent laparoscopic pyeloplasty was 20.42
yrs (range-8 mts to 65 yrs).
Table No. 3 : Age
Open pyeloplasty group
(n=15)
Lap pyeloplasty group
(n=15)
Average age (in yrs) 22.83 yrs 20.42 yrs
Range 5 mts-48 yrs 8 mts- 65 yrs

Graph 2 & 3
Proforma

Symptoms :
Proforma
Most patients presented with pain in the loin region or asymptomatic mass per
abdomen or both.
Table No. 4 : Symptoms :
Presentation
Open
pyeloplasty
group (n=15)
Percentage
(%)
Lap
pyeloplasty
group (n=15)
Percentage
(%)
Pain 12 80% 09 60
Mass per
abdomen
02 13.3 05 33.33
Both 01 6.6 01 6.66
Associated anomalies:
Out of 15 patients in open pyeloplasty group, one patient had right solitary
kidney (absent left kidney) and one patient had double moiety ureter on left side with
lower moiety UPJO. Out of 15 patients in laparoscopic pyeloplasty group, one patient
had a Horseshoe kidney with a contracted kidney on the contra lateral side and
hypertension.
Table No. 5 : Associated anomalies
Associated anomaly Open pyeloplasty Lap pyeloplasty
Right solitary kidney 01 -
Horseshoe kidney - 01
Double moiety ureter on left side
with lower moiety UPJO.
01 -

Graph 4 only
Proforma

Table No. 6 : Postoperative complications
Complication
Open pyeloplasty
group n=15
Proforma
Lap pyeloplasty
group n=15
Wound infection 2 0
Post op ileus 0 2
Post op fever 1 1
Prolonged urine leak (>3 days) 0 2
Anastomotic stricture 0 0
DVT 0 0
Recurrent UTI 1 1
Stent dislodgement 0 0

Graph 6 only
Proforma

Table No. 7 : Renal function on renal scientigraphy (GFR/min) in open
pyeloplasty group (n=15)
Preoperative
(GFR/min)
Postoperative
(GFR/min)
35 55
30 60
25 50
30 55
20 45
27 53
23 50
34 58
26 52
32 60
21 46
33 56
22 49
32 53
29 56
Proforma

Graph 7
Proforma

Proforma
Table No. 8 : Renal function on renal scientigraphy (GFR/min) in laparoscopic
pyeloplasty group (n=15)
Preoperative
(GFR/min)
Postoperative
(GFR/min)
25 60
29 55
33 45
28 47
33 60
25 49
35 55
30 57
27 48
23 49
33 52
34 59
26 60
23 46
35 50

Graph 8
Proforma

Proforma
Table No. 9 Preoperative and postoperative pyeloplasty analog pain and activity
scores :
TABLE LANDSCAPE

Table No. 10 : Assessment of objective outcome :
Parameter
Operative time
(in min)
Time when
oral feeds
started
(in days)
Time when
drain removed
(in days)
Hospital stay
(in days)
Open pyeloplasty
group n=15
Laparoscopic
pyeloplasty group
n=15
Proforma
Student’s
unpaired `t’ test
Mean ± S.D Mean ± S.D P value
159.0000 21.3976 214.6667 32.2638 5.874x10 -6 (HS)
1.4667 0.5164 2.3333 0.4880 5.89x10 -5 (HS)
2.3333 0.4880 3.4000 0.6325 1.73x10 -5 (HS)
9.0667 2.9633 6.4000 2.8486 0.018019 (S)

DISCUSSION
Proforma
Gold standard for repair of UPJ obstruction is open pyeloplasty and best
clinical results are reported with complete dismembering techniques like the
Anderson-Hynes procedure. The success rates of this technique are reported to be 90-
100% 28,29 .
Open surgical techniques result in significant peri and post-operative
morbidity, post-operative pain and scar formation. In the hope of decreasing the
surgical morbidity associated with the open approach, several minimally invasive
procedures have evolved during past two decades, specifically antegrade and
retrograde endopyelotomy 50,51,52 . The cumulative experiences with these procedures
have shown fairly good success rate (61-89%) and a significant risk of bleeding.
These minimal invasive endoscopic procedures were reported to have a good initial
success rate; however long-term results even in highly selected cases are poor.
Endopyelotomy became popular in the 1980’s and 1990’s as a minimally
invasive technique with low complication rates, relatively short operating times and
short convalescence period. The greatest drawback associated with these treatments
is the risk of vascular injury. Sampaio has shown that, 72.2% of cases, crossing
vessels can be found either anterior or posterior to the UPJ. These vessels can be
injured during UPJ incision without prompt intra operative recognition, leading to
significant bleeding. Faerber et al. reported two bleeding complications in their
Acucise series of 32 patients (6.2%). Merety K et al. reported bleeding that required
transfusion in 95 and 16% in their series of antegrade and retrograde
endopyelotomies, respectively. Shalhav et al. compared the out comes obtained with
the antegrade and the retrograde approach for treatment of UPJO. The objective
success rate was 89% and 71% and 77% and 83% for primary and secondary non-
calculus UPJO with the antegrade and retrograde approach, respectively.

Proforma
More recently, laparoscopic procedures to treat UPJO have combined the
advantages of minimally invasive procedures and safety and high success rates
obtained with open surgical procedures. Since the end of the last decade,
laparoscopic pyeloplasty has become increasingly popular. Success rates are quoted
to be between 87-100% 53,54,55 . The procedure allows the identification of crossing
vessels, excision of the diseased UPJ plus or minus a reduction pyeloplasty and a
watertight anastomosis. In addition, the analgesic requirement, hospital stay and
recovery period are considerably reduced compared to the open pyeloplasty.
Schuessler et al. first introduced laparoscopic pyeloplasty in 1993 and a variety of
authors have reported on their clinical experiences with this promising new
technique. The techniques described, differed mainly in the way to perform
pyeloplasty utilizing either a complete dismembering or a non-dismembering
technique. Laparoscopic pyeloplasty can be performed via retroperitoneal or
transperitoneal approach. Equivalent success rates have been quoted in the literature.
In our study, we used transperitoneal approach for all patients in laparoscopic
pyeloplasty group, as this approach offers ease in identifying, dissecting and
mobilizing intra-abdominal structures, while the potential disadvantages include
prolonged ileus, adhesion formation, and injury to adjacent viscera. The major
advantage of retroperitoneoscopic approach is that it provides a direct route to the
UPJ and thus allows access without interference from intra-abdominal structures.
However, working space is limited, and the absence of anatomic landmarks makes
dissection more cumbersome.

Proforma
Soulie et al 56 , reported the results of a multi-institutional study in which 55
retroperitoneal laparoscopic pyeloplasties were performed. The conversion rate was
5.4%, the mean operative time was 185 minutes, and the complication rate was
12.7%. Two patients required a secondary procedure because of anastomotic
strictures, with an overall objective success rate of 88.9%.
Bauer et al 57 . showed in his transperitoneal approach for laparoscopic
pyeloplasty, an objective and subjective success rate of 98% and 90% respectively,
with one surgical failure. Similarly, Moore et al. demonstrated a low incidence of
complication, associated with no surgical failures, no open conversions, and a 97%
objective success rates in their series. Recently, Jarrett et al. reported the results of
their first 100 laparoscopic pyeloplasty cases. Of the 100 patients, 83 had primary
UPJO and 20 underwent concomitant pyelolithotomy. The average operative time,
blood loss, and hospital stay was 4.2 hours, 181ml, and 3.3 days respectively.
Crossing vessels were found in 57% of the cases complications occurred in 13
patients, and blood transfusion was necessary in 2 surgical failure was observed in 4
patients, all of which occurred in first post operative year. The overall success rate
was 96%. Importantly, the long follow-up period in this series (upto 6 years)
confirmed the durability of results.
In our present study, total of 15 patients who underwent open pyeloplasty,
were in the age group of 5 months to 54 yr (mean age = 22.82yrs), male to female
ratio was 2.75:1, Laterality, that is, involvement of right to left kidney was in the
ratio of 1:2.25 and 2 cases had bilateral involvement (13.33%), both had undergone
open pyeloplasty earlier in our institute. The associated anomaly was found in 2 of
the 15 patients (13.33%). One of those had double moiety ureter on left side with
lower moiety ureter UPJO and other patient had right solitary kidney. Other 15

Proforma
patients who underwent laparoscopic pyeloplasty by transperitoneal approach, were
in the age group of 9mts – 65 yrs (mean age = 20.42yrs), male to female ratio was
2.75:1, Laterality that is involvement of right to left kidney was in the ratio of 1:2.25
and 2 cases had bilateral involvement (13.33%), both had undergone open
pyeloplasty, one at our institute and other outside. The associated anomaly was found
in one patient in laparoscopic pyeloplasty group (6.66%) who had a horseshoe
kidney.
In the literature, it is mentioned that, UPJO occurs more commonly in males
than females and the ratio that exceeds 2:13 and left sided lesions predominate
(approximately 67%) and bilateral UPJO is present in 10-40% of cases. Our patient
demographics are in concordance with the literature.
The assessment of pain and activity level were assessed both pre- operatively
and post-operatively using pain analog scale and activity questionnaire of Nadler et
al. In both the groups the pain and activity level pre-operatively was assessed just one
day prior to the surgery and post operatively pain and activity level were assessed
after 6wks at the time of ureteral stent removal. Statistical analysis was done using
student's unpaired and paired ‘t’ test.
The mean pre-operative pain level in the open pyeloplasty group was
61.3333%±S.D18.0739 and mean post-operative pain level at 6weeks was
18%±S.D12.6491. The mean pre-operative activity level was 54.66%±S.D9.9043 and
mean post-operative activity level at 6 weeks was 90.66%±S.D7.9881. The mean pre-
operative pain level in laparoscopic group was 59.0%±S.D14.4173 and mean post-
operative pain level at 6 weeks was 5.33%±S.D7.43223. The mean pre-operative
activity level was 48.66%±3.5187 and mean post-operative activity level at 6weeks
was 96.33%±4.8058. From the results we can assess that the difference between
mean pre-operative pain level between open and laparoscopic pyeloplasty group was

Proforma
not significant (P=0.69885, Student’s unpaired ‘t’ test) and the difference between
mean pre-operative activity level between both the groups was not significant
(P=0.1524, Student’s unpaired ‘t’ test). But, pain level between pre and post-
operative levels in open and laparoscopic pyeloplasty group was significant
(P=1.375x10 -8 for open pyeloplasty, P=1.55847x10 -13 for laparoscopic pyeloplasty
group Student’s paired ‘t’ test) and the difference between activity level in both the
groups was significant (P=6.156x10 -12 for open pyeloplasty, P=1.6167x10 -23 for
laparoscopic pyeloplasty group, Student’s paired ‘t’ test). These results conclude that,
laparoscopic pyeloplasty group patients had significant improvement in pain and
activity level post operatively than those patients who had undergone open
pyeloplasty.
The renal scientigraphy with 99m-TC-DTPA was done pre-operatively to
assess the split renal function and to know the severity of UPJ obstruction in all
patients. Post-operatively, the renal scan with 99m-TC-DTPA was repeated at 3
months of follow-up period in all patients. All patients in both the group showed
improvement in glomerular filtration rate and demonstrated good drainage.
The mean pre-operative GFR/min on 99m-TC DTPA renal scan in open
pyeloplasty group was 34.600±S.D27.3673 and post-operative mean GFR/min at 3
months was 53.20±S.D4.6012. The mean pre-operative GFR/min in laparoscopic
pyeloplasty group was 29.2667±S.D4.337 and post-operative mean GFR/min at 3
months was 52.800±S.D5.4929. There was no statistical significant difference
between pre-operative (P=0.4621965, Student’s unpaired ‘t’ test) and post-operative
(P=0.8303954, Student’s unpaired ‘t’ test) improvement in GFR on renal scan
between both the groups. All patients from both the groups showed improvement in
GFR and demonstrated good drainage.

Proforma
Postoperative complications were observed in both the groups. 4 patients out
of 15 in open pyeloplasty group had post op complications (26.66%). Out of 4
patients, 2 patients had wound infection, 1 patient had post-operative fever and 1
patient had post-operative recurrent UTI and 1 patient had post operative fever.
Wound infected patients were treated with appropriate antibiotics after wound culture
and sensitivity. Patient with recurrent UTI was also treated with appropriate
antibiotic after urine culture and sensitivity report. Patient with post operative fever
responded to conservative management. In the laparoscopic pyeloplasty group, 5
patients had post operative complications (33.33%). Prolonged urine leak for more
than 4 days was observed in 2 patients. Post operative paralytic ileus was observed in
2 patients, as the laparoscopic procedure was done by transperitoneal approach. For
these 2 patients, oral feeds were started on 3 rd post operative day. 1 patient had post
operative recurrent UTI, who was treated with appropriate antibiotic after urine
culture and sensitivity report. No patient had significant intra operative or post
operative complications.
In the laparoscopic pyeloplasty group, conversion to open was not done in any
patient. No anastomotic stricture was observed in any patient which was confirmed
by USG or IVP post-operatively. The success rate was 100% in both the groups. The
cost of treatment for laparoscopic pyeloplasty was almost 3 times more than that of
open pyeloplasty. The post-operative scar was almost unnoticeable in case of
laparoscopic pyeloplasty patients (better cosmesis), compared to open pyeloplasty
patients post-operative scar.
The mean operative time was 159±S.D21.3976 minutes in open pyeloplasty
group and 214.6667±S.D32.2638 minutes in laparoscopic pyeloplasty group
(P= 5.874x10 -6 , Student’s unpaired ‘t’ test).

Proforma
The mean time when oral feeds were started in open pyeloplasty group was
1.4667±S.D.0.5164days and 2.33±S.D.0.4880days in laparoscopic pyeloplasty group
(P=5.89x10 -5 , Student’s unpaired ‘t’ test).
The mean time when drain removed was 2.333±S.D.0.4880 days in open
pyeloplasty group and 3.4±S.D.0.6325days in laparoscopic pyeloplasty group
(P=1.73x10 -5 , Student’s unpaired ‘t’ test). The mean hospital stay was
9.0667±S.D2.9633 days and 6.4±S.D.2.8486 days in open and laparoscopic
pyeloplasty group respectively (P=0.018019, Student’s unpaired ‘t’ test). The
average intra-operative blood loss was 150 cc and 60 cc for open pyeloplasty and
laparoscopic pyeloplasty group respectively.
In the literature, only few studies have compared objective and subjective out
comes between open versus laproscopic pyeloplasty. A study conducted by H.
Christoph Klingler et al 58 , compared open versus laparoscopic pyeloplasty techniques
in treatment of UPJ obstruction and the study was conducted between September
1999 to September 2002 Laparoscopic pyeloplasty was done on 40 patients and open
pyeloplasty on 55 patients. The results showed that post-op VAS score was lower in
the laparoscopic group (day 1 3.5 ± 1.6 v/s 5.4 ± 3.1, days 0.9 ± 1.2 v/s 3.1 ± 1.8, P =
0.001) length of skin incision was 4.1 ± 0.7 v/s 23.8 ± 9.1 cms and hospital stay was
5.9 ± 2.1 v/s 13.4 ± 3.8 days for laparoscopic and open pyeloplasty respectively.
Success rate was 96.9% v/s 93.4% for laparoscopic and open pyeloplasty
respectively. 2 patients had abdominal wall herniation and 1 patient had
thromboembolism in open pyeloplasty group.

Proforma
Other study conducted by John. J Bauer and Louis R. Kovoussi 57 compared
laparoscopic v/s open pyeloplasty with respect to objective and subjective outcome.
The results showed that out of 42 laparoscopic group patients, 90% were pain free
and 62% had significant improvement in flank pain 2 patients had minor
improvement and 2 had no improvement in pain, surgery failed in only 1 patient with
complete obstruction. A patent UPJ was demonstrated in 98% of the laparoscopic
group on the most recent radiographic study. Mean follow-up was for 15 months. Of
the 35 open surgery group patients, 91% were pain free, 31% patients significantly
improved after surgery one patient had only minor improvement and 2 were worse.
Another study by D. Duane Baldwin et al 59 , showed single-center comparison
of laparoscopic pyeloplasty, Acucise endopyelotomy and open pyeloplasty. The
study showed success rates of 56%, 94% and 86% for Acucise endopyelotomy,
laparoscopic pyeloplasty and open pyeloplasty respectively. There were no
significant difference between the endopyelotomy and laparoscopic pyeloplasty and
open group in age, ASA score, length of follow-up, blood loss, hospital stay, cost or
analgesic requirement. The laparoscopically treated patient demonstrated lower
analgesic requirements (27.2 v/s 12.42 mg morphine sulfate, P=0.02) and shorter
hospital stay (1.4 v/s 3.0 days P=0.03) than open surgery patient.

SUMMARY AND CONCLUSIONS
Proforma
UPJ is the most common site of upper urinary tract obstruction occurring in 1
in 1500 births and is the most common obstructive uropathy in children. Many
treatment options exist for the management of UPJ obstruction. Open pyeloplasty has
high success rate & has been considered the gold standard with success rate 90-
100%. But there is a significant postoperative pain & long recovery time in open
pyeloplasty surgeries. In an attempt to minimize the postoperative morbidity of open
surgical UPJ correction many minimally invasive options have been developed.
These include balloon dilation, antegrade endopyelotomy, retrograde endopyelotomy,
Acucise endopyelotomy and laparoscopic pyeloplasty. More recently, laparoscopic
procedures to treat UPJO have combined the advantages of minimally invasive
procedures and safety and high success rates obtained with open surgical procedures.
Since the end of the last decade, laparoscopic pyeloplasty has become
increasingly popular. Success rates are quoted to be between 87-100%. The
procedure allows the identification of crossing vessels, excision of the diseased UPJ
plus or minus a reduction pyeloplasty and a watertight anastomosis. In addition, the
analgesic requirement, hospital stay and recovery period are considerably reduced
compared to the open pyeloplasty.
In our present study, we compared prospectively the objective and subjective
outcomes of open and laparoscopic pyeloplasty procedures in the treatment of
primary or congenital UPJ obstruction. Total of 30 patients included in the study
were randomized into two groups of 15 each. 15 patients formed open pyeloplasty
group and other 15 patients formed the laparoscopic pyeloplasty group. The mean

Proforma
age group, laterality of involvement of kidney, sex ratio was almost similar between
both the groups. The pre-operative pain (P=0.69885) and activity (P=0.1524) level
and renal function on renal nucleotide scan (P=0.4621) was almost similar and
comparable between the two groups. But, there was significant post-operative
improvement in pain (P=1.375x10 -8 for open group, P=1.558x10 -13 for laparoscopic
group) and activity level (P=6.156x10 -23 for open group, P=1.626x10 -23 for
laparoscopic group) and improvement in renal function in each group (P=1.048x10 -13
for open group, P=0.0074 for laparoscopic group). In our study we found that,
improvement in pain and activity level post-operatively was much better in
laparoscopic pyeloplasty group patients compared to open pyeloplasty group patients.
But, improvement in renal function on renal scientigraphy which was done at 3
months post-operatively, there was no much difference between both the groups.
Both groups showed significant improvement in renal function and all patients
showed good drainage. There were no major intra-operative complications noted in
either group. Post-operative complications and also time when oral feeds started and
drain removed were slightly more in laparoscopic group owing to transperitoneal
approach. Hospital stay and convalescence period was less in laparoscopic group, but
the mean operative time was more in laparoscopic group (214.6±32.2 minutes)
compared to open pyeloplasty group (159±21.3minutes). There was no conversion to
open procedure done in any of laparoscopic cases. The success rate was 100% in both
the groups. The post-operative cosmesis was better in laparoscopic pyeloplasty
patients compared to open pyeloplasty patients.

The advantages of laparoscopic pyeloplasty procedure are,
Less post-operative morbidity
Short convalescence period
Less post-operative pain
Early recovery of activity.
Success rate almost similar to open pyeloplasty procedure.
Lesser hospital stay.
Better cosmesis.
The disadvantages of laparoscopic pyeloplasty procedure are,
Technically difficult to perform.
Longer operative time.
Proforma
Risk of intra-operative bleeding and conversion to open procedure.
In unskilled hands, the intra and post-operative complications are
more.
Cost of the procedure is more.
Our present study was done on a small number of patients and post-operative
follow up was only for 3 months. It is difficult to draw conclusion from such study.
Hence; large randomized controlled trials with long period of follow up studies are
needed to establish the role of laparoscopic pyeloplasty in the treatment of UPJ
obstruction.

Proforma
The results of laparoscopic pyeloplasty from several institutions reporting on
adult series suggest that this procedure is a viable alternative to both open and
endoscopic procedures with increasing training and experience, the success rate has
clearly exceeded that of endoscopic approaches and is similar to that of open
pyeloplasty. The potential advantages of laparoscopic pyeloplasty over open
pyeloplasty are decreased postoperative pain, shorter hospitalization, short
convalescence and improved cosmesis. An important caveat, as was concluded by
Bauer et al 57 . is that neither open nor laparoscopic pyeloplasty can universally
guarantee complete pain relief.
Laparoscopic pyeloplasty in children is even more technically challenging
than in adults because of the smaller operative space and the need for finer suture
material. However, laparoscopic pyeloplasty has been demonstrated to be feasible
and to have satisfactory early results.
After a decade laparoscopic pyeloplasty has emerged as a durable elective
technique for the management of UPJ obstruction. Laparoscopic pyeloplasty is
continuing to progress and offers promise for some of the most challenging
circumstances. As the technology advances and the clinical experience increases, this
technique may universally replace open pyeloplasty as the gold standard.
Laparoscopic pyeloplasty is a technically challenging procedure and is still in
its infancy and practiced at only few medical centers around the world. With recent
technological advances, laparoscopic pyeloplasty has become a valid alternative to
endoscopic pyelotomy and the gold standard of open pyeloplasty.

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Proforma
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LIST OF ABBREVIATIONS
Proforma
99m –TcDTPA : Technetium labeled Diethylenetriamine - penta-acetic acid.
cm of H2O : Centimeter of water
DRS : Diuretic renal scan
Fr : French unit ( 3 Fr = 1 mm )
GFR / min : Glomerular filtration rate per minute
HN : Hydronephrosis
Hrs : hours
IVP : Intravenous pyelography
Kg : kilogram
MAG-3 : Mercaptoacetyltriglycine.
mCi : milli curie
mg : milligram
min : minute
ml : millilitre
MRI : Magnetic resonance imaging
S.D. : Standard deviation
UPJ : Ureteropelvic junction
UPJO : Ureteropelvic junction obstruction
USG : Ultrasonograghy
UTI : Urinary tract infection
v/s : versus
VCUG : Voiding cystourethrogram
VUR : Vesico-ureteral reflux

Background:
ABSTRACT
Proforma
Ureteropelvic junction obstruction (UPJO) is the most common obstructive
uropathy in children. UPJO can occur in all the age groups. In most cases UPJO is
due to congenital pathology. Open pyeloplasty is considered as gold standard for the
treatment of UPJO. But there is a significant post-operative morbidity. During last
decade, advances in endourological techniques have resulted in significant progress
in the development of minimally invasive surgical procedures to treat UPJ
obstruction. These include balloon dilation, antegrade endopyelotomy, retrograde
endopyelotomy, Acucise endopyelotomy and Laparoscopic pyeloplasty. Since the
end of the last decade, laparoscopic pyeloplasty has become increasingly popular.
Success rates are quoted to be between 87-100%. Only few retrospective studies have
been conducted regarding laparoscopic versus open pyeloplasty. Success rates are
comparable for laparoscopic pyeloplasty and open pyeloplasty.
Aims and objectives of the study:
To compare the efficacy of laparoscopic pyeloplasty versus open pyeloplasty
in the treatment of primary UPJ obstruction with respect to the SUBJECTIVE
OUTCOME (Postoperative pain, activity level, time when oral feeds are started) and
OBJECTIVE OUTCOME (success rate, complications, improvement in renal
function, operative time, recovery time/hospital stay, cost of the treatment and
cosmesis) between laparoscopic and open pyeloplasty.

Materials and methods:
Proforma
Total of 30 patients of congenital UPJO were evaluated and operated. All 30
patients were randomized into two groups of 15 each. One group formed open
pyeloplasty group and other formed laparoscopic pyeloplasty group. All patients
were assessed for objective and subjective outcomes post-operatively and all patients
were followed up for minimum of 3 months. Results were analyzed using Student’s
paired and unpaired ‘t’ tests.
Results:
The mean age group, laterality of involvement of kidney, sex ratio was almost
similar between both the groups. The pre-operative pain (P=0.69885) and activity
(P=0.1524) level and renal function on renal nucleotide scan (P=0.4621) was almost
similar and comparable between the two groups. But, there was significant post-
operative improvement in pain (P=1.375x10 -8 for open group, P=1.558x10 -13 for
laparoscopic group) and activity level (P=6.156x10 -23 for open group, P=1.626x10 -23
for laparoscopic group) and improvement in renal function in each group
(P=1.048x10 -13 for open group, P=0.0074 for laparoscopic group). In our study we
found that, improvement in pain and activity level post-operatively was much better
in laparoscopic pyeloplasty group patients compared to open pyeloplasty group
patients. But, improvement in renal function on renal scientigraphy which was done
at 3 months post-operatively, there was no much difference between both the groups.
Both groups showed significant improvement in renal function and all patients
showed good drainage. There were no major intra-operative complications noted in
either group. Post-operative complications and also time when oral feeds started and
drain removed were slightly more in laparoscopic group owing to transperitoneal

Proforma
approach. Hospital stay and convalescence period was less in laparoscopic group, but
the mean operative time was more in laparoscopic group (214.6±32.2 minutes)
compared to open pyeloplasty group (159±21.3minutes). There was no conversion to
open procedure done in any of laparoscopic cases. The success rate was 100% in both
the groups. The post-operative cosmesis was better in laparoscopic pyeloplasty
patients compared to open pyeloplasty patients.
Conclusions :
Our present study was done on a small number of patients and post-operative
follow up was only for 3 months. It is difficult to draw conclusion from such a study.
Hence; a large randomized controlled trials with long period of follow up studies are
needed to establish the role of laparoscopic pyeloplasty in the treatment of UPJ
obstruction.
The results of laparoscopic pyeloplasty from several institutions reporting on
adult series suggest that this procedure is a viable alternative to both open and
endoscopic procedures with increasing training and experience, the success rate has
clearly exceeded that of endoscopic approaches and is similar to that of open
pyeloplasty. The potential advantages of laparoscopic pyeloplasty over open
pyeloplasty are decreased postoperative pain, shorter hospitalization, short
convalescence and improved cosmesis. Laparoscopic pyeloplasty is a technically
challenging procedure and is still in its infancy and practiced at only few medical
centers around the world. With recent technological advances, laparoscopic
pyeloplasty has become a valid alternative to endoscopic pyelotomy and the gold
standard of open pyeloplasty.

PROFORMA
Name of the patient : I.P.No. :
Age : DOA :
Sex : DOS :
Residence : DOD:
CHIEF COMPLAINTS :
1.
2.
3.
EXAMINATION FINDINGS :
Vitals :
Pulse : BP: mm of Hg RR :
Temp :
Per Abdomen :
INVESTIGATIONS :
1. CBC :
2. Urine Analysis : Routine :
Microscopy :
Proforma
3. Minirenals : RBS : Serun electrolytes :
Blood Urea : Sodium :
Serum creatinine : Potassium :
Cloride :
Bicarbonate :

4. HIV :
HBSAg :
5. X-ray KUB Findings : A.
6. USG abdomen findings : A.
7. IVP findings : A.
8. MR Urogram /99mTc-DTPA scan findings : A.
9. Panendoscopy Report :
10. Chest X-ray :
11. ECG
12. Other investigations :
FINAL DIAGNOSIS :
SURGICAL TREATMENT GIVEN :
INTRA-OPERATIVE FINDINGS :
COMPLICATIONS IF ANY :
B.
C.
B.
C.
B.
C.
B.
C.
Proforma

ASSESSMENT OF OBJECTIVE OUTCOME
Proforma
The analog pain and activity questionnaire assessing pre-operative and
post- operative pain and activity level : (Nadler et al.) 49
1. Please mark on the following scale the level of discomfort you experienced
before your procedure.
0____________________________________________ 100
(No pain) (Worst pain)
2. Please mark on the following scale the level of discomfort you experienced
now, (6 weeks after the procedure)
0 ____________________________________________100
(No pain) (Worst pain)
6. If before your procedure, your discomfort level was 100% what is your
current level of discomfort?
________________________________________________ (0-100%)
7. Please mark on the following scale your level of activity before your
procedure.
0______________________________________________100
(Bed rest) (Full activity)
8. Please mark on the following scale your level of activity after the
procedure (6 weeks).
0______________________________________________100
(Bed rest) (Full activity)

ASSESSMENT OF OBJECTIVE OUTCOME
a. Operative time (in minutes) :
b. Hospital stay (No. of days) :
c. Time when oral feeds started :
d. Time when drain removed :
e. Post-operative 99m-Tc DTPA scan findings after 3 months :
f. Antibiotics / Analgesics given :
g. Cosmesis :
h. Cost of treatment :
i. Others :
Proforma

52
SELECTED PUBLISHED EXPERIENCE WITH LAPAROSCOPIC PYELOPLASTY 61
Source
No. of
Cases
Operative
time (Min)
Hospital
stay (days)
Technique Approach
Open
conversions
rate (%)
Success
Rate (%)
Schuessler et al. 1993 5 210-420 3 Dismembered Transperitoneal 0 100
Kavoussi et al. 1993 1 480 3 Dismembered Transperitoneal 0 100
Recker et al. 1995 5 190-390 8 Dismembered Transperitoneal 20 100
Nakada et al. 1995 4 465-645 4 Dismembered Culp-De
Weerd
Transperitoneal 0 100
Janetschek et al. 1996 16 240-360 5.1 Dismembered Transperitoneal 0 100
Puppo et al. 1997 11 150-240 3.3 Dismembered Retroperitoneal 0 100
Moore et al. 1997 30 135-480 3.5 (Dismembered Y-V Plasty Transperitoneal 0 97
Eden et al. 1997 9 150-230 3 Dismembered Retroperitoneal 11 100
Chess et al. 1998 57 138-480 3.3 DismemberedY-V Plasty Transperitoneal 0 97
Bauer et al. 1999 42 - - Dismembered Y-V Plasty Transperitoneal 0 98
Janetschek et al. 2000 67 90-120 4.1 Fenger (63) Y-V (4) Trans & Retro
peritoneal
0 98
Ben Slama et al. 2000 15 100-250 4.8 Dismembered (7) Fenger
(7)
Retroperitoneal 7 100
Soulie et al. 2001 55 100-260 4.5 Dismembered (48) Fenger Retroperitoneal 5 88
Eden et al. 2001 50 120-240 2.6 Dismembered Retroperitoneal 4 98
Turk et al. 2002 49 90-240 3.7 Dismembered Transperitoneal 0 98
Jarnett et al. 2002 100 120-480 3.3 Dismembered Heineke –
Mekulicz
Transperitoneal 0 96
Review of

91
1.Pain
PREOPERATIVE AND POSTOPERATIVE PYELOPLASTY ANALOG PAIN AND ACTIVITY SCORES
Parameter
-Preoperative 61.3333
Open pyeloplasty group
(n=15)
Laparoscopic
pyeloplasty group
(n=15)
Mean ± S.D Mean ± S.D
(0-100)
18.0739 59.00
(0-100)
Student’s
unpaired `t’
test
P value
14.4173 0.69885(NS)
-Postoperative 18.0(0-100) 12.6491 5.33(0-100) 7.43223 0.00235989 1.375x10 -8 (HS)
-Difference -43.333 -53.67
2.Activity
-Preoperative 54.66(0-100) 9.9043 48.66(0-100) 3.5187 0.1524(NS)
Student’s paired ‘t’ test
P value
Open group Lap group
1.55847x10 -13 (HS)
-Postoperative 90.66(0-100) 7.9881 96.33(0-100) 4.8058 0.02580719(S) 6.156x10 -23 (HS) 1.6167x10 -23 (HS)
-Difference 40.00 47.67
3.GFR/min on renal scan
-Preoperative 34.6000 27.3673 29.2667 4.3337 0.4621965(NS)
-Postoperative 53.2000 4.6012 52.800 5.4929 0.8303954(NS) 1.048x10 -13 (HS) 0.0074303(VS)
-Difference -18.600 -23.53
Observati o n s &