Pyeloplasty treats the anatomical and functional obstruction at the pelvi-ureteric junction (PUJ). This chapter discusses the endoscopic performance of this operation. Embryology, antenatal findings, postnatal investigations, and treatment options (including follow up and indications for surgical intervention) are not discussed, as these can be found in other textbooks addressing these issues.

Pyeloplasty can be performed in a variety of ways and by a number of different approaches. The technique described in detail here is endoscopic retroperitoneal pyeloplasty. A pyeloplasty aims to produce better drainage from the affected kidney. This goal is achieved by creating dependent drainage from the pelvis, by fashioning the pelvis and ureter to resemble a funnel. The original description of this procedure by Anderson and Hynes incorporates the excision of the narrowed segment of the PUJ, and the anastomosis of the spatulated ureter to the trimmed pelvis (Fig. 37.1).

In recent years, laparoscopic pyeloplasties have been performed with increasing frequency and in ever-younger patients. As surgeons’ experience increases and instrumentation improves, this method of pyeloplasty has become the method of choice in paediatric hospitals. Access to the kidney can be via either the retroperitoneal route or via a transperitoneal approach.

I prefer retroperitoneoscopic pyeloplasty, which is described in further detail here. This approach avoids the need to mobilise other organs (colon) or unnecessarily open anatomical planes. It also lessens the risk of injury to other structures and avoids the sequelae of an intraperitoneal leak of urine, which irritates the peritoneum.

The patient is placed close to the edge of the operating table and in the kidney position (Fig. 37.2).

The surgeon and assistant stand behind the patient, with the monitor screen facing them. The nurse is positioned opposite the surgeons, and can observe the operation on another monitor (Fig. 37.3).

A small (5-mm) incision is made close to the angle between the lowest rib and the vertical paraspinal muscles. A pair of Metzenbaum scissors is used to dissect and spread the muscle fibres to reach the retroperitoneum (Fig. 37.4).

An inflation device is used to create a space posterior to the kidney, lifting it medially off the psoas muscle. A 5-mm port is inserted into this space and secured (Fig. 37.5).

The central port is used for the telescope and the other two ports are used for the operating instruments (Fig. 37.6).

Cross sectional anatomy of a normal kidney (Fig. 37.7).