Anterograde Mini-Percutaneous Retropelvic Extra-Luminal Endopyelotomy: A Novel Approach to Uretero-Pelvic Junction Obstruction

Abstract

Introduction: Uretero-pelvic junction obstruction (UPJO) is a common cause of upper tract urinary obstruction. It is generally treated with various surgical options which include the endoscopic, laparoscopic, open or robotic assisted. Methods: An adult male presented with left flank pain. CT-scan revealed left-sided hydronephrosis with two discrete renal stones. Renogram performed, revealed split function of 62% left kidney due to increased surface area with diminished drainage and 38% of the right kidney. Patient was planned for supine minipercutaneous nephrolithotomy and anterograde retropelvicendopyelotomy. A 14F nephroscope was used to extract the renal stones. Later the 365 micron holmium-YAG laser fiber advanced through the scope to do full thickness pelvic wall cut. The UPJO was subsequently addressed using a wide split incision with the laser fiber within the retropelvic space. A ureteral stent and a nephrostomy tube were placed. Results: The patient's post-operative course was unremarkable. The ureteral stent was subsequently removed, with the retrograde study showing no residual UPJ stricture and he is currently symptom free. Follow up MAG3 shows split function of 57% left kidney and 43% of the right kidney, delayed excretion on the left without any obstruction. Clear endoscopic vision, minimal bleeding and an overall better identification of the UPJO is possible using this retropelvic access method. Clinically the patient is 12 months stent and symptoms free. Conclusion: We have now described a novel technique using a less invasive Mini-Perc access method, which resulted in good visualisation, minimal bleeding and achieved all the desired operative objectives.