Laparoscopic Pyeloplasty Surgery in India

What is it?

A laparoscopic pyeloplasty is an operation where a narrowing or scarring at the junction of the kidney with the ureter is repaired using keyhole surgery.

Why do I need a laparoscopic pyeloplasty?

Your surgeon will have explained that your urine is not draining from the kidney properly because of a narrowing at the pelviureteric junction (PUJ). This may be causing you pain. He has chosen this method of surgery to reduce the length of your recovery and to allow you to resume a normal life in a shorter period of time when compared to the more conventional open method of repairing the narrowing.

What preparations should be made

The operation takes approximately 2-3 hours, pre operative checks are necessary to ensure safety. Blood tests, urine tests, x rays and ECG may be done a week to 2 weeks before the operation date at a pre operative assessment clinic. This is to check that your general health is satisfactory. Alternatively these checks may take place on the day before surgery. The total hospital stay will be on average 5 days.

How is the operation performed?

The operation is performed under general anaesthetic (you are put to sleep). 2 The surgeon will usually make 3-4 small stab wounds on the abdomen. Through one of these wounds a telescopic camera is passed to allow the surgeon to see the kidney and surrounding organs. Through the other wounds instruments are passed which can cut, diathermy and stitch the blood vessels and organs inside. A stent will then be inserted into the ureter (pipe connecting kidney to bladder) to prevent any blockage of the ureter due to swelling from the wound site and aid healing. This will allow the easy passage of urine into the bladder. This will be removed at a later date and this is usually performed under a local anaesthetic. (Please see information leaflet on ‘having a ureteric stent’). At the end of the operation a catheter tube is often placed into the bladder through your water pipe, a wound drain will sometimes be inserted.

What happens afterwards?

After your operation you will be taken back to the ward, and you will be able to drink sips of later. A light diet may be taken the day after your surgery. You will have a drip in your arm to keep you hydrated, which will be stopped when you are eating and drinking normally. To control any discomfort or pain you may have a pump which will administer a pain-killing drug automatically. If not, strong pain-killing injections or suppositories will be given. You may experience pain in the shoulder and have a bloated feeling in the abdomen. These are both temporary and will resolve over the first few days. The catheter tube will monitor your urine output and will be removed when you are up and mobile. The wound drain will be removed when the drainage is minimal, usually after 48 hours. The wound sites will be covered with a light dressing and any stitches to these sites will dissolve in 2-3 weeks, alternatively you may have steri strips over these sites and these can be removed after 5-7 days.

Preparation for surgery

Medications to Avoid Prior to Surgery-

Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix and some other arthritis medications can cause bleeding and should be avoided 1 week prior to the date of surgery (Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting the prescribing doctor to get their approval).

Bowel Preparation and Clear Liquid Diet-

Do not eat or drink anything after midnight the night before the surgery and drink one bottle of Magnesium Citrate (can be purchased at your local pharmacy) the evening before your surgery.Drink only clear fluids for a 24-hour period prior to the date of your surgery. Clear liquids are liquids that you are able to see through. Please follow the diet below.

Clear Liquid Diet-

Remember not to eat or drink anything after midnight the evening before your surgery. Clear liquids are liquids that you are able to see through. Please follow the diet below.

Water
Clear Broths (no cream soups, meat, noodles etc.)
- Chicken broth
- Beef broth
Juices (no orange juice or tomato juice)
- Apple juice or apple cider
- Grape juice
- Cranberry juice
- Tang
- Hawaiian punch
- Lemonade
- Kool Aid
- Gator Aid
Tea (you may add sweetener, but no cream or milk)
Coffee (you may add sweetener, but no cream or milk)
Clear Jello (without fruit)
Popsicles (without fruit or cream)
Italian ices or snowball (no marshmallow)

THE SURGERY

The Operation

Laparoscopic pyeloplasty is performed under a general anesthetic. The typical length of the operation is 3-4 hours. The surgery is performed through 3 small (1cm) incisions made in the abdomen. A telescope and small instruments are inserted into the abdomen through these keyhole incisions, which allow the surgeon to repair the blockage/narrowing without having to place his hands into the abdomen.

Open Procedure

Ureteropelvic Junction (UPJ) Obstruction

Laparoscopic Procedure

Patient Positioning

A small plastic tube (called a ureteral stent) is left inside the ureter at the end of the procedure to bridge the pyeloplasty repair and help drain the kidney. This stent will remain in place for 4 weeks and is usually removed in the doctor's office. A small drain will also be left exiting your flank to drain away any fluid around the kidney and pyeloplasty repair.

Potential Risks and Complications

Although this procedure has proven to be very safe, as in any surgical procedure there are risks and potential complications. The safety and complication rates are similar when compared to the open surgery. Potential risks include:

Bleeding: Blood loss during this procedure is typically minor (less than 100 cc) and a blood transfusion is rarely required. If you are still interested in autologous blood transfusion (donating your own blood) prior to your surgery, you must make your surgeon aware. When the packet of information is mailed or given to you regarding your surgery, you will receive an authorization form for you to take to the Red Cross in your area.
Infection: All patients are treated with broad-spectrum intravenous antibiotics prior to starting the surgery to decrease the chance of infection from occurring after surgery. If you develop any signs or symptoms of infection after the surgery (fever, drainage from your incision, urinary frequency, discomfort, pain or anything that you may be concerned about) please contact us at once.
Hernia: Hernias at incision sites rarely occur since all keyhole incisions are closed carefully at the completion of your surgery.
Tissue / organ injury: Although uncommon, possible injury to surrounding tissue and organs including bowel, vascular structures, spleen, liver, pancreas and gallbladder could require further surgery. Injury could occur to nerves or muscles related to positioning.
Conversion to open surgery: this surgical procedure may require conversion to the standard open operation if extreme difficulty is encountered during the laparoscopic procedure. This could result in a larger standard open incision and possibly a longer recuperation period.
Failure to correct UPJ obstruction: Roughly 3 % of patients undergoing this operation will have persistent blockage due to recurrent scarring. If this occurs additional surgery may be necessary.

WHAT TO EXPECT AFTER SURGERY

During your hospitalization

Immediately after the surgery you will be taken to the recovery room and transferred to your hospital room once you are fully awake and your vital signs are stable.

Hospital Stay: The length of hospital stay for most patients is approximately 1-2 days.
Diet: You can expect to have an intravenous catheter (IV) in for 1-2 days. (An IV is a small tube placed into your vein so that you can receive necessary fluids and stay well hydrated until you are able to tolerate a diet; in addition it provides a way to receive medication). Most patients are able to tolerate ice chips and small sips of liquids the day after surgery and regular food the next day. Once on a regular diet, pain medication can be given by mouth instead of by IV or shot.
Postoperative Pain: Pain medication can be controlled and delivered by the patient via an intravenous patient-controlled analgesia (PCA) pump or by injection (pain shot) administered by the nursing staff. You may experience some minor transient shoulder pain (1-2 days) related to the carbon dioxide gas used to inflate your abdomen during the laparoscopic surgery.
Nausea: You may experience some nausea related to the anesthesia or pain medication. Medication is available to treat persistent nausea.
Urinary Catheter: You can expect to have a urinary catheter draining your bladder (which is placed in the operating room while the patient is asleep) for approximately 2 days after the surgery. It is not uncommon to have blood tinged urine for a few days after surgery.
Drain: You will have a drain coming out of a small incision in your side. This drain is placed in the operating room around the operative site to prevent blood and fluid from building up around the kidney and pyeloplasty repair. The drainage typically appears blood-tinged. It is usually removed the day the urinary catheter is removed. If persistent high volume drainage occurs, you may have to go home with the drain and have it removed in your doctor's office

Fatigue is common and should subside within a few weeks following surgery.

Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections by using an incentive spirometry device (these exercises will be explained to you during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.
Ambulation: On the day after your surgery it is very important to get out of bed and begin walking under the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can expect to have SCD's (sequential compression devices) along with tight white stockings to prevent blood clots from forming in your legs.
Constipation/Gas Cramps: You may experience sluggish bowels for several days following surgery as a result of the anesthesia. Suppositories and stool softeners are usually given to help with this problem. Taking a teaspoon of mineral oil daily at home will also help to prevent constipation. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.

What to expect after discharge from the hospital

Pain control: You can expect to have some pain that may require pain medication for up to a week after discharge, and then Tylenol should be sufficient to control your pain.
Showering: You may shower after returning home from the hospital. Your wound sites can get wet, but must be padded dry immediately after showering. Tub baths are not recommended in the first 2 weeks after surgery as this will soak your incisions and increase the risk of infection. You will have adhesive strips across your incisions. They will fall off in approximately 5-7 days on their own. Sutures underneath the skin will dissolve in 4-6 weeks.
Activity: Taking walks are advised. Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible, but should be taken slowly. Driving should be avoided for at least 1-2 weeks after surgery. Absolutely no heavy lifting (greater than 20 pounds) or exercising (jogging, swimming, treadmill, biking) until instructed by your doctor. Most patients return to full activity on an average of 3 weeks after surgery. You can expect to return to work in approximately 2-4 weeks.
Follow up appointment: You will need to call the Johns Hopkins Out Patient Urology Clinic at 410-955-6707 after your surgery date to schedule a follow up appointment as instructed by your surgeon...
Stent follow up: The stent will remain in place for approximately one month and will then be removed in the doctor's office through a cystoscope (a small telescoped passed down the urethra to retrieve the stent). It is not uncommon to feel a slight amount of flank fullness and urgency to void, which is caused by the stent. These symptoms often improve over time.

What are the possible complications?

Occasionally infection and pain may occur at the wound site. A hernia of the incision site may occur which would require further treatment. There is a rare chance that the surgeon may have to proceed to open repair should he encounter problems such as bleeding during surgery. A blood transfusion may also be very rarely required. Very rare complications include injury to organs/blood vessels near the kidney, which then require conversion to open surgery.

At Home

It may take 6 weeks for you to fully recover from this surgery. It is important to avoid heavy lifting and strenuous exercise during this period. We recommend that you should avoid driving for 2 weeks. You will be given an appointment to have your stent removed in 6 weeks time. You will be seen in out patients approximately 3 months after surgery.