Laparoscopic Pyeloplasty using the Postanastomotic Dismemberment Method: Technique and Results

Despite excellent results, widespread acceptance of the laparoscopic dismembered Anderson-Hynes pyeloplasty (AH) is hampered by its steep learning curve. Laparoscopic nondismembered pyeloplasty techniques, although simpler, have not matched the results of AH. We have been using a technical modification of AH to combine its excellent outcome with technical ease of nondismembered pyeloplasties. We describe the procedure and results of laparoscopic postanastomotic dismemberment (PAD) pyeloplasty for primary ureteropelvic junction (UPJ) obstruction.PAD technique involves an initial partial division of the dilated pelvis and ureteral spatulation without dismembering the UPJ. Both layers of ureteropelvic anastomosis are completed before dismemberment and pelvic reduction. Forty-one PAD procedures in 40 patients with UPJ obstruction and follow-up of at least 3 months were evaluated. Mean age was 37.2 years (range 2-82 years) with 22 patients younger than 15 years. The UPJ was dependent in 31 and had high insertion in 10 (24.4%). The stenotic segment was long (or =1.5 cm) in 18 (43.9%). Crossing vessels and secondary calculi were observed in six (14.6%) and seven (17.1%) units.Mean (+/- SD) blood loss, hospital stay, convalescence, and analgesia requirement were 68.1 +/- 37.6 mL, 3.8 +/- 1.1 days, 11.4 +/- 3.9 days, and 204.8 +/- 60.5 mg diclofenac, respectively. The mean operative time was 97.6 +/- 22.1 minutes. There was one intraoperative complication in the form of injury to a renal vein tributary, with no transfusions or conversions. Postoperative complications included pain after stent removal, persistent drainage, and pyelonephritis in 1, 2, and 4 patients, respectively. Mean follow-up was 19.5 months (range 3-58 months), with a success rate of 95.1%. Failures were not attributable to UPJ configuration, length of stenosis, or age.The PAD technique has several practical advantages with a shorter operative time compared with other historical series of laparoscopic pyeloplasty (LP). It combines the ease of nondismembered LP with the excellent outcome of dismembered techniques.