Laparoscopic Pyeloplasty in a Solitary Kidney

Nauman Zafar; John Leyland; Nimish C Shah*

Disclosures

Nat Clin Pract Urol. 2007;4(11):625-629. 

In This Article

The Case

A 40-year old male was referred from a district general hospital with non-specific right-sided abdominal pain. Examination revealed tenderness in the right renal angle. Initial blood tests including full blood count, renal function and C-reactive protein level were all normal. An ultrasound performed at the referring hospital showed mild hydronephrosis in the right kidney and absent left kidney. A CT scan demonstrated ureteropelvic junction (UPJ) obstruction to the right kidney, with a lower pole crossing vessel as a probable contributing cause of obstruction to the UPJ (Figure 1).

Figure 1.

A CT image showing the ureteropelvic junction with the lower pole-crossing vessel on the right side.

The patient was discharged with outpatient investigations and follow-up planned, but was readmitted a few weeks later with similar pain. A subsequent 99mTc-mercaptoacetyltriglycine (MAG3) scan confirmed UPJ obstruction in a solitary right kidney (Figure 2). On account of the patient's recurrent symptoms and the presence of significant UPJ obstruction, laparoscopic pyeloplasty was scheduled as an urgent elective procedure.

Figure 2.

99mTc-MAG3 study shows a non-functioning left kidney. The right kidney shows slow tracer uptake and virtually no excretion phase. Further, no tracer activity is visible beyond the ureteropelvic junction, suggesting outflow tract obstruction at this level. Abbreviation: MAG3, mercaptoacetyltriglycine.

Laparoscopic pyeloplasty was performed using a transperitoneal approach. A crossing lower pole artery was confirmed intraoperatively. Dismembered Anderson­Hynes pyeloplasty was performed with preservation and posterior transposition of the crossing lower pole artery (Figures 3 and 4). A JJ stent was inserted in an antegrade fashion. The total operative time was 2 hours and intraoperative blood loss was less than 50 ml.

Figure 3.

Laparoscopic view of the newly constructed ureteropelvic junction (Anderson­Hynes pyeloplasty) with the posteriorly transposed crossing vessel.

Figure 4.

Completion of the pyeloplasty with the transposed lower pole vessel (inferiorly) and the liver and perirenal fat (superiorly).

The postoperative recovery was uneventful and the patient was discharged home on the third postoperative day. The JJ stent was removed using flexible cystoscopy at 4 weeks postoperatively. A MAG3 scan performed 3 months later showed a normal uptake and excretion pattern with resolution of the outflow tract obstruction (Figure 5). At 4-month follow-up, the patient was symptom free with no postoperative complications. A further MAG3 scan and an outpatient appointment was scheduled after 12 months.

Figure 5.

The 99mTc-MAG3 study shows normal tracer uptake and excretion consistent with normal function. There is no current outflow tract obstruction. Abbreviation: MAG3, mercaptoacetyltriglycine.

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