December - Wingspan

3220 SECTION XVII ● Pediatric UrologyA B CFigure 120–11. A, Vertical flap technique may be used when a dependent ureteropelvic junction is situated at the medial margin of a large,box-shaped extrarenal pelvis. In contrast to the spiral flap, the base of the vertical flap is situated more horizontally on the dependentaspect of the renal pelvis, between the ureteropelvic junction and the renal parenchyma. The flap itself is formed by two straight incisionsconverging from the base vertically up to the apex on either the anterior or posterior aspects of the renal pelvis. As for the spiral flap, theposition of the apex determines the length of the flap, which should be a function of the length of proximal ureter to be bridged. Themedial incision of the flap is carried down the proximal ureter completely through the strictured area into normal-caliber ureter. B, Theapex of the flap is rotated down to the most inferior aspect of the ureterotomy. C, The flap is closed by approximating the edges withinterrupted or running fine absorbable sutures.A B CFigure 120–12. Anderson-Hynes dismembered pyeloplasty. A, Traction sutures are placed on the medial and lateral aspects of thedependent portion of the renal pelvis in preparation for dismembered pyeloplasty. A traction suture is also placed on the lateral aspect ofthe proximal ureter below the level of the obstruction. This suture will help maintain proper orientation for the subsequent repair. B, Theureteropelvic junction is excised. The proximal ureter is spatulated on its lateral aspect. The apex of this lateral, spatulated aspect of theureter is then brought to the inferior border of the pelvis while the medial side of the ureter is brought to the superior edge of the pelvis.C, The anastomosis is performed with fine interrupted or running absorbable sutures placed full thickness through the ureteral and renalpelvic walls in a watertight fashion. In general, the authors prefer to leave an indwelling internal stent in adult patients. The stent isremoved 4 to 6 weeks later.aspect of the anastomosis at the vertex of the spatulationis critical to ensuring a watertight closure.11. Before the repair is completed, the renal pelvis is irrigatedto remove any blood clots or debris that could obstruct theUPJ. If an indwelling double-J ureteral stent is employed,it should be placed now, with care taken to place the stentinto the bladder and renal pelvis without kinking it.12. A Penrose drain is placed adjacent to the repair and broughtout through a separate stab wound.13. The kidney is returned to its native position, and perinephricfat, if available, is placed over the anastomosis.14. Closure of the three fascial layers is readily accomplished,followed by closure of the Scarpa fascia and subcuticularskin.