Pyeloplasty Surgery - Procedure Indications, Types & Cost
Dept. of Urology at Pace Hospitals, is equipped with world's 1st universal surgical robotic system, advanced laparoscopic surgery equipment to perform complex and supra-major kidney surgeries.
Our team of the best urologist in Hyderabad are having extensive experience in performing robotic and laparoscopic pyeloplasty kidney surgery.
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What is Pyeloplasty Surgery and its purpose?
Pyeloplasty meaning
Pyeloplasty surgery is a surgical procedure, used to remove obstruction in the ureteropelvic junction (area that connects the renal pelvis and the ureter), enabling the easy flow of urine from the kidney to the bladder.
A human kidney, which consists of millions of nephrons, filters blood and creates urine. The urine from all the nephrons collectively drains into the renal pelvis (a funnel shape); further, it is transported to the bladder by ureters (tubes that pass urine from the kidney to the bladder).
Obstruction in the ureteropelvic junction results in the stoppage of urine reaching the bladder, resulting in a hydronephrosis condition (stretched and swollen kidneys due to urine build-up inside the kidney).
Indications for Pyeloplasty Surgery
Pyeloplasty is a surgical procedure indicated to treat ureteropelvic junction - UPJ obstruction with the presence of the following:
- Obstructed scintigraphic (a procedure that produces images of organs present inside the body) evidence
- Decreased renal function or upper renal tract infection, or calculi
- Clinical symptoms such as flank pain and recurrent infections
Contraindication for Pyeloplasty Surgery
Pyeloplasty is contraindicated in patients with the presence of the following:
- Nonfunctional kidney
- Coagulation disorders
- Acute urinary tract infections in case of robotic pyeloplasty
- Comorbidities that inhibit pyeloplasty surgery
Types of Pyeloplasty Surgery
The type of pyeloplasty procedure depends on the surgical technique used, such as:
- Open pyeloplasty surgery
- Laparoscopic pyeloplasty surgery
- Robotic pyeloplasty surgery
Open Pyeloplasty: Open pyeloplasty remains the gold standard therapeutic strategy for ureteropelvic junction obstruction - UPJ obstruction, with a 90% success rate. Open pyeloplasty is advised if the patient has had previous perirenal surgery. Among the types of open pyeloplasty, Anderson-Hynes open pyeloplasty or dismembered pyeloplasty is the most common one.
An incision is made towards the tip of the 12th rib medially to roughly 2 to 3 inches lateral to the rectus abdominus muscle (long muscle of the front abdominal wall). This incision provides the surgeon direct access to the renal hilum and ureteropelvic junction.
Once the surgeon has access to the kidney, the obstruction is removed by cleaving the obstructed area (top and bottom) with surgical tools. The cleaved ends of the renal pelvis and ureter are joined with the help of sutures.
Laparoscopic Pyeloplasty: It is a minimally invasive technique for reconstructive surgery of a constriction at the ureteropelvic junction, where the ureter joins the kidney. The process of removing the obstruction is similar to open pyeloplasty.
The renal surgeon places three to four small (1 cm) incisions in the patient's abdominal wall, followed by the insertion of a camera and surgical instruments that are used to fix the blockage/narrowing without putting their hands inside the abdomen. Once the surgeon locates the obstruction, the surgeon removes it by cleaving the obstructed part with the help of laparoscopic tools and joins the renal pelvis and ureter (reconstruction) with the help of sutures.
Compared to open surgery, laparoscopic pyeloplasty has resulted in significantly less post-operative discomfort, lesser hospital stays, and earlier return to work and daily activities, with better cosmetic results and identical outcomes.
Robotic Laparoscopic Pyeloplasty: Robotic-Assisted Laparoscopic Pyeloplasty is similar to open surgery, except the surgeon uses 3-4 tiny (1 cm) incisions instead of a major flank or abdominal incision. Portals or trocars are inserted through these keyhole incisions to enable the insertion of robotic wristed arms that allow the surgeon to remove the obstruction and complete the repair.
The surgeon controls the robotic instrumentation in real-time with a precise motion by sitting a few feet away from the patient at his/her operating desk or console. A stereoscopic lens (inserted through one of the robotic arms) provides a three-dimensional, high-definition view of the renal anatomy. By looking at the view, the obstructed area is cleaved with the help of surgical robotic arms and removed.
The ends of the renal pelvis and ureter are spatulated and sutured together to provide a clear connection.
Preparation for the Pyeloplasty surgery
The patient needs to inform the surgeon related to:
- Any known allergies to drugs or anaesthesia (local and general).
- Family history of bleeding disorders.
- Intake of medications, including over-the-counter, vitamins, herbs, and other dietary supplements.
If the patient is currently on blood thinning agents, anticoagulants, or any other medications (prescribed), that could affect the patient's blood clotting procedure. These medications may be stopped before surgery or as per the surgeon's or concerned physician's advice.
After taking the patient's medical and medication history, the renal surgeon will request the following tests:
- Preoperative urine culture (to assess the use of specific antibiotics to treat it, the test results positive) and urinalysis.
- Laboratory tests include a complete blood count, chest radiograph, and basic metabolic panel (a test used to assess the concentration of glucose, calcium, sodium, potassium, carbon dioxide, chloride, blood urea nitrogen and creatinine).
- Prior to surgery, the surgeon assesses the severity of hydronephrosis caused by the Ureteropelvic Junction (UPJ) Obstruction by obtaining the necessary imaging examinations.
- The surgeon might conduct a nuclear medicine renal scan with furosemide washout to assess the degree of blockage, and it also aids in evaluating post-operative results.
The renal surgeon or nurse will inform the patient when the patient needs to check into the hospital. The patient should abstain from drinking and eating for a specific period before the surgery as per the urologist’s advice.
The pyeloplasty surgical procedure and any risks associated with the pyeloplasty surgery will be thoroughly discussed with the patient. The patient will be given a consent form to sign, allowing the surgeon to have the surgery. Before signing, the patient should thoroughly read the consent form and ask any questions they may have.
During Pyeloplasty surgery
The steps of the pyeloplasty procedure differ depending on the surgeon's surgical technique and the patient's age. In children, open pyeloplasty is preferred, while in adults, laparoscopic or robot-assisted pyeloplasty is preferred. In general, a pyeloplasty procedure follows these steps:
- The patient will be provided with a surgical gown to change the dress; after that, the patient will be anesthetised.
- Based on the type of surgery planned, the patient will have incisions. The patient will be placed on the table at lateral decubitus posture, and the surgeon will start the procedure with an incision.
- In open pyeloplasty, the surgeon places a 2 to 3-inch long cut below the ribs lateral to the rectus abdominus muscle.
- In laparoscopic pyeloplasty, the surgeon performs insufflation through a veress needle. Post that, the surgeon makes three 1 cm incisions in the belly (abdomen) through which a camera and instruments are inserted ; the fourth port will be made for the assisting surgeon and is located lateral to the umbilicus.
- In robotic laparoscopic pyeloplasty surgery, the surgeon uses robotic trocars to insert surgical tools and a camera. The surgeon establishes the pneumoperitoneum by passing carbon dioxide gas into the abdominal cavity, post that, trocars will be placed. These trocars are placed in a straight line configuration at a paramedian position, with 8 cm between each. The second port is inserted into the renal hilum, and a 12-mm auxiliary port is placed to allow needle passage.
- Once the surgeon has access to the kidney, irrespective of the surgical technique used, the surgeon starts mobilising the organ to find out the area or the possible cause of the blockage.
- In most cases, it is due to the blockage of the ureteropelvic junction. In some cases, an extra blood vessel might cross the area and impinge the narrow ureter, causing obstruction.
- If an extra blood vessel is observed, it will be mobilised. Further dissection will be carried out to have an exposure to the renal pelvis and part of the ureter.
- Once the surgeon finds the obstruction at the ureteropelvic junction, the surgeon will cut and divide the area above and below the obstruction, clearing the blocked urine.
- A stent will be inserted to ease the flow of the urine, which will be removed after a few days post-surgery through cystoscopy.
- The surgeon places an inferior longitudinal incision (2-3 cm) towards the opposite ends of both the renal pelvis and ureter and attaches both the divided ends of the renal pelvis and ureter with the help of absorbable sutures.
- In the event of a crossing blood vessel, the vessel(s) are preserved, and the repair is performed from behind the blood vessel to avoid repeated pressure and obstruction.
- The surgeon may attach a drain bag to the patient's flank to drain any fluid around the kidney or at the site of pyeloplasty repair.
Pyeloplasty surgery post-operative care
- Depending on the approach used, the patient might extend the stay in the hospital for a few days after having pyeloplasty surgery.
- After pyeloplasty surgery, the patients will be taken into a recovery room or post-anaesthesia unit once their vital signs (heart rate, respiration rate, and blood pressure) are stabilised.
- Patients might be on liquid for the initial days post-surgery and slowly resume a solid diet. The surgeon might prescribe medicines for pain and to minimise post-operative infections.
- In the case of open pyeloplasty, absorbent gauze will be put over the area of the drain bag.
- If the drain output is less than 50 cc, the drain will be removed. Typically, the ureteral stent is removed 4 to 6 weeks after surgery.
- A Lasix renal scan will be taken one month after the stent is removed, post that, twice a year (every six months for the first year) and once annually after that.
Recovery time after Pyeloplasty surgery
The recovery time after pyeloplasty depends on the surgical technique. The internal healing after robotic or laparoscopic pyeloplasty usually takes 3 to 4 weeks, whereas it might take 8 (eight) weeks for open pyeloplasty. During this time, the patient should avoid heavy lifting, training or strenuous activity.
Complications of the Pyeloplasty surgery
While pyeloplasty procedure is very safe to do, there is always a chance of complications during or post-surgery, such as:
- Operation site bleeding
- Infections
- Adjacent tissue injury
- Leakage of urine at the site of pelvic-ureter rejoining
- Formation of scar at the stitches
- Conversion from minimally invasive techniques to open pyeloplasty
- Hernia
Patient questions post-pyeloplasty surgery
- Is the block completely removed?
- How long will it take to recover, and when can I return back to my work?
- Will there be any side effects or complications I might face after surgery? If it happens to whom should I contact?
- When can I resume my old medications, which were stopped prior to surgery?
- What kind of diet should I follow?
- When should I visit back for a follow-up?
Frequently asked questions:
Is a pyeloplasty surgery painful?
With the availability of advanced and minimally invasive techniques, the patient might feel some pain after the pyeloplasty surgery, which will be subsided within a few days. The urologist may prescribe pain medication post-pyeloplasty as a part of post-operative pain management.
Research has shown that obstruction of the ureteropelvic junction (UPJ) is one of the most common congenital anomalies of the urinary system. The left side obstruction is more common than the right by a left-to-right ratio of 5:2, and it has a male-to-female ratio of 5:2. The existence of kidney stones, infections, and scar tissue might cause the obstruction.
How long does a pyeloplasty last?
It depends on the surgical technique used and the condition of the patient. Open pyeloplasty is performed under general anaesthesia. The typical length of the operation is two to three hours, whereas minimally invasive methods such as laparoscopic or robotic-assisted laparoscopic pyeloplasty might take three to four hours.
What is the success rate of pyeloplasty surgery?
On average, pyeloplasty surgery was reported to have a success rate of more than 91%. According to one study, open pyeloplasty surgery has a high success rate of 90% in long-term follow-up findings, compared to 87.7% in overall success rate for three years follow-ups for laparoscopic pyeloplasty surgery.
Another study found that with a mean follow-up of 31.7 months, the primary success rate was 96 % in patients who underwent robotic laparoscopic pyeloplasty surgery.
How is a stent removed after pyeloplasty?
Stents are usually removed six weeks following surgery. The stent is often removed in the clinic during a cystoscopy (endoscope) procedure. The patient is made to lie down on a table, and a local anaesthetic jelly is injected into the urinary tract before the surgeon inserts a cystoscope via the urethra. Once the stent has been visible, the surgeon uses endoscopic forceps to capture the stent and gently draw it back.
What is the difference between endopyelotomy vs pyeloplasty?
Both procedures treat the obstruction in the ureteropelvic junction (between the renal pelvis and ureter).
- In the pyeloplasty procedure, the obstructed area will be ligated and removed with the help of surgical tools. Post that, the renal pelvis and ureter will be rejoined or reconstructed with the help of sutures to ease the urine flow.
- In endopyelotomy, an endoscope will be passed through the ureter and with the help of a laser probe, the obstruction will be removed. In some cases, a stunt will be placed where a space will be created for the urine to pass on to the bladder.
Does pyeloplasty improve kidney function?
Yes, pyeloplasty surgery removes the obstruction created at the ureteropelvic junction - UPJ, thereby reducing hydronephrosis (stretched and swollen kidneys as a result of urine build-up inside the kidney) condition and improving kidney function, especially in children.
What are the benefits for a patient having a robotic pyeloplasty surgery versus an open pyeloplasty surgery?
When compared to open surgery, robotic assisted laparoscopic pyeloplasty for treating symptomatic ureteropelvic junction obstruction has significant benefits for the patient, which include:
- Short hospital stays
- Scarring is minimal
- Faster healing
- Blood loss and transfusions are reduced
- Less pain and a better cosmetic approach
- Smaller incisions and a lower chance of infection
- Enhanced precision
Who is the best urologist for pyeloplasty surgery in Hyderabad?
The team of urologists at PACE hospitals have vast experience in handling critical cases of pyeloplasty kidney surgery through open, laparoscopic, and robotic surgical procedures with a high success rate.
How much does pyeloplasty surgery cost in India?
Pyeloplasty surgery cost in India, ranges vary from Rs. 68,000 to Rs. 2,62,000 (Rupees sixty-eight thousand to two lakh sixty-two thousand) due to different types of pyeloplasty procedure. However, cost of pyeloplasty surgery in India vary in different private hospitals in different cities.
- Open pyeloplasty surgery cost in India - Approx Rs. 68,000 to Rs. 94,000
- Laparoscopic pyeloplasty surgery cost in India - Approx Rs. 82,000 to Rs. 1,15,000
- Robotic pyeloplasty surgery cost in India - Approx Rs. 1,75,000 to Rs. 2,62,000
What is the cost of pyeloplasty surgery in Hyderabad?
Pyeloplasty surgery cost in Hyderabad ranges vary from Rs. 72,000 to Rs. 2,46,000 (Rupees seventy-two thousand to two lakh forty-six thousand six hundred). However, cost of pyeloplasty in Hyderabad depends upon the multiple factors such as patient age, condition, type of surgery, length of stay in hospital and CGHS, ESI, EHS, insurance or corporate approvals for cashless facility.
- Open pyeloplasty surgery cost in Hyderabad - Approx Rs. 72,000 to Rs. 98,000
- Laparoscopic pyeloplasty surgery cost in Hyderabad - Approx Rs. 88,000 to Rs. 1,25,000
- Robotic pyeloplasty surgery cost in Hyderabad - Approx Rs. 1,82,000 to Rs. 2,46,000
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