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Pyeloplasty - Indications : PUJ obstruction
Anaesthesia : General
Post-operative care
A JJ stent, bladder catheter, and a drain are left in situ. The bladder catheter serves to prevent reflux of urine up the ureter, which can lead to increased leakage of urine from the anastomosis site (reflux occurs because of the presence of the JJ stent). The drain is removed when the drain output is minimal. The stent is left in position for ~6 weeks.
Common post-operative complications and their management
- Haemorrhage
Usually arising from the nephrostomy track (if a nephrostomy tube has been left in place some surgeons leave a JJ stent and a perinephric drain, with no nephrostomy). Clamp the nephrostomy tube, in an attempt to tamponade the bleeding. If the bleeding continues, consider angiography and embolisation of the bleeding vessel if seen, or exploration.
- Urinary leak
This can occur within the first day or so. If a urethral catheter has not been left in place, catheterize the patient, to minimize bladder pressure and therefore the chance of reflux, which might be responsible for the leak. If the drainage persists for more than a few days, shorten the drain if it is in contact with the suture line of the anastomosis it can keep the anastomosis open, rather than letting it heal. If the leak continues, identify the site of the leak by either a nephrostogram (if a nephrostomy has been left in situ) or a cystogram (if a JJ stent is in place contrast may reflux up the ureter and identify the site of leakge) or an IVU. Some form of additional drainage may help dry up the leak (a JJ stent if only a nephrostomy has been left in situ, or a nephrostomy if one is not already in place).
- Obstruction at PUJ
This is uncommon, and if it occurs it is usually detected once all the tubes have been removed and a follow-up renogram has been done. If the patient had symptomatic PUJO, but remains asymptomatic, then no further treatment may be necessary. If they develop recurrent flank pain, re-operation may be necessary.
- Acute pyelonephritis
Manage with antibiotics
Serious or frequently occurring complications of pyeloplasty
Common
- Temporary insertion of a bladder catheter and wound drain
- Further procedure to remove ureteric stent, usually a local anaesthetic
Occasional
- Bleeding requiring further surgery or transfusion
Rare
- Recurrent kidney or bladder infections
- Recurrence can occur, needing further surgery
Very rarely
- Entry into lung cavity requiring insertion of temporary drainage tube
- Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack)
- Need to remove kidney at a later time because of damage caused by recurrent obstruction
- Infection, pain, or hernia of incision requiring further treatment
Alternative therapy Observation, telescopic incision, dilation of area of narrowing, temporary placement of plastic tube through narrowing, laparoscopic repair.
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