Pyeloplasty

Etiology

Hydronephrosis occurs in around 1 in every 300 pregnancies. It can impair kidney function and/or cause flank pain. Early intervention is essential

Pyeloplasty is performed to correct congenital obstruction of the uteropelvic junction (UPJ)

Procedure

Surgery can be performed using a

Dorsal lumbotomy

• An incision along the paraspinous muscle group - pt in prone or lateral position. This is a muscle-splitting procedure and, as such, is associated with less pain and fewer incisional hernias
• May have abdominal padding

Flank/subcostal incision

• Axillary roll to avoid brachial plexus injury. The dependent lower leg is flexed at the knee and hip, and the overlying leg is kept straight
• Padding between knees
• In older children, the kidney rest at the break of the table can be used

The operation is usually performed with exposure of the upper ureter and renal pelvis. End-to-end anastomosis is where the abnormal UPJ is excised. The patient may have either a Penrose drain, a urethral stent, or a nephrostomy tube

Preoperative considerations

Surgical Time 

2.5-3 hrs.

EBL

Minimal

Morbidity

Bleeding, infection, ileus

Pain Score

Flank 10, lumbotomy 5

Anesthetic Considerations

Urethral catheter to monitor U/O

Monitor preop lab work - stage of renal failure

Avoid drugs eliminated by the kidneys

Consider respiratory, cardiac, and GI issues related to possible renal failure

Risk of anemia if in renal failure (decreased production of erythropoietin)

Consider atracurium 0.4-0.5 mg/kg for intubation

• Hoffman’s elimination

If blood transfusion, use the freshest blood to minimize the K⁺ load

• K⁺ increases with storage time

A-line in significant renal failure patients

Protect all pressure points

Monitor eyes frequently in prone/lateral position

Avoid morphine – fentanyl OK to use