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Optimization of the Antegrade Ureteral Stenting During Laparoscopic Dismembered Pyeloplasty: An Easy, Cheap and Without Additional Port Technique to Identify the Ureter and the Renal Pelvis
Lessandro Curcio; Juan Renteria; Antonio Cláudio Cunha; Moacir Cavalcante; Marcus Augusto Marinho; Frederico Bastos; Geraldo Dibiase
Department of Urological Laparoscopy of Urology Service at Hospital Geral de Ipanema.
ABSTRACT
Introduction- One of the greatest controversies in pyeloplasty is if Double J stent must be passed in a retrograde or
an antegrade fashion. We show a technique, where at the same time we search for an easy way to find the ureter, identify
the renal pelvis and pass the DJ stent from the kidney to the bladder.
Technique- We performed a retrograde pyelography
and inserted a 7 F ureteral catheter below the ureteropelvic junction. This facilitates the identification of the ureter, following
it until the pelvis (it was facilitated by injection of saline solution through the tip of the catheter). After the posterior
wall anastomosis execution, we passed the guidewire through left-hand trocar, it entered into the ureteral catheter and
leaved through the urethra of the patient, and then we passed a DJ stent under it and finished the anastomosis.
Discussion- Clayman has already emphasized that the antegrade route of the DJ stent is one of factors that facilitates the
technique. Rodrigues had described a similar technique with previous use of facial dilators sets. Andreoni used a
cholangiography device. Maldani and cols used a laparoscopic Hook to catheterize the ureter.
Conclusion-Our technique of antegrade catheterization of ureter is neither better nor worse than the others, it is only an alternative to other techniques. It is
a feasible procedure in services where laparoscopy surgery is in its initial stage and in hospitals that offer
medical internships programs. It represents a great benefit to public services where scarcity of instruments is common.
Key words: Ureteropelvic junction; Obstruction; Laparoscopy; Stents; catheterization.
Bras. J. Video-Sur, 2008, v. 1, n. 2: 051-056
| Accepted after revision: March, 17, 2008. |
INTRODUCTION
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ince the first laparoscopic pyeloplasty (LP) was performed by Schuessler in 19921,
several technique innovations were described to facilitate
this procedure. The most efficient technique in all
kinds of ureteropelvic junction (UPJ) stenosis is
the laparoscopic dismembered pyeloplasty, which achieve better results in enlarged pelvis and
crossing vessels2. Debates continue on the ideal technique
of ureteral stenting. Several surgeons prefer
retrograde Double J stent insertion before the
laparoscopic procedure3.
As an inconvenience this technique causes deflation of the renal pelvis, in addition to that
to perform the ureteropyelic anastomosis is
demanding and time consuming.
We will describe our technique in which a retrograde ureteropyelography is performed,
the identification of the ureter and renal pelvis is
favored, the anastomosis is easily and quickly performed
and the antegrade insertion of a Double J stent.
SURGICAL TECHNIQUE
With the patient in lithotomic position, a cystoscopy is performed with the accomplishment
of a retrograde ureteropyeloghaphy (Photo 1). Afterwards, a 7 F ureteral catheter is inserted
with one tip placed bellow the ureteropelvic junction
and the other outside the urethra connected to an 8
F Levine catheter. (Figure1).
 |
Photo 1 - Retrograde pyelography performed before the
procedure depicting the ureteropelvic junction because of an aberrant vessel. |
 |
Figure 1 - Diagrammatic representation of the exact position
of the catheter over the UPJ and the other distal tip outside
the urethra. |
Then, the patient is placed in dorsal decubitus position
(45o). The catheters are placed on the abdomen and after the asepsis and antisepsis of
the operative field it will be inserted (Photo 2).
 |
Photo 2 - Detail of the tip of the ureteral catheter where a
saline solution will be injected and a guidewire will be inserted. |
Transperitoneal access was used; however, retroperitoneal access is also feasible. The
intra-ureteral catheter facilitates its identification (Figure
2 and Photo 3). The ureter is traced cephalad
toward the renal pelvis. NS (normal saline) 0,9% can also
be injected through Levine catheter to distend even
more the renal pelvis facilitating its identification (Figure
3 and 4). A 3.0 long straight needle could be
passed percutaneously or not to lift the pelvis and
therefore saving a trocar (Photo 4).
 |
Photo 3 - Hard consistency of the ureter due to indwelling catheter. |
 |
 |
 |
Figure 2 - Diagrammatic representation of the ureteral catheter increasing the ureter consistency. |
Figure 3 - Diagrammatic representation of an empty pelvis. |
Figure 4 - Pelvis was being filled with saline solution. |
 |
Photo 4 - 3.0 Nylon transfixing the skin to facilitate pelvis dissection |
After the section of the stenosed area, the ureter spatulation (Photo 5) and the completion of
the posterior wall anastomosis (Photo 6), the
Levine catheter is disconnected from the ureteral catheter
and a retrograde hydrophilic guidewire is inserted
through the external orifice of the ureteral catheter which
will be exposed by the left hand trocar (Photo 7 and
Figure 5) with care in order to avoid the anastomosis
posterior stitches to tear (during this manipulation if possible
an atraumatic forceps should be maintained).
 |
Photo 5 - Spatulation of the ureter. |
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Photo 6 - Constructing the posterior wall of the anastomosis. |
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Photo 7 - Retrograde passage of the guidewire guided by an atraumatic forceps outside the left hand port. |
 |
Figure 5 - Diagrammatic representation of the retrograde passage of the guidewire. |
The Ureteral catheter is withdrawn and an antegrade Double J stent is passed over the
guidewire (Photo 8). A pusher is used to insert the catheter
into the renal pelvis (Photo 9). Then, always holding
the Double J stent in the uteropelvic junction with
an atraumatic forceps the vesical probe is withdrawn
and afterwards the guidewire. Once again we pass
the vesical probe in order to push any tip of the
catheter that could be in the urethra. Next the anterior
wall anastomosis is performed (Photo 10, 11, 12 and
Figure 6). An abdomen X-ray is performed
postoperatively to ensure the proper position of the Double J stent.
 |
Photo 8 - Anterograde passage of the Double J stent through the lef port. |
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Photo 9 - Double J stent pusher completing its passage. |
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Photo 10 - Removal of the guidewire through the urethra of
the patient after removing the vesical probe and the Double-J stent
by twisting its tip. |
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Photo 11 - Completing the anterior wall of the anastomosis. |
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Photo 12 - The final aspect of the pyeloplasty. |
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Figure 6 - The final aspect of the surgery before suturing
the anterior wall. |
DISCUSSION
Some authors consider antegrade double-J stent ureteral catheterization as one of the
three sustainers of quickness and efficiency of a Laparoscopic
Pyeloplasty4, and the other two are the left hand trocar midline insertion over the
12th rib and use of a continuous suture for the anastomosis
with double-armed knotted suture.
Some techniques on antegrade double-J stent during laparoscopic pyeloplasty have already
been described. Mandhani5 described a technique in
which the guidewire is introduced through the lumen of a
5 mm hook or suction canula via a subcostal port.
Andreoni6 described antegrade double-J
catheter through 5mm cholangiogram guide built for
biliary surgery passed through the uppermost trocar.
The main disadvantage of the techniques mentioned
above is the necessity of instruments built to other
purposes that increase the cost of the procedure.
Rodrigues et cols.7 reported
antegrade insertion through an abdominal puncture with an
18G needle placed cephalad to the anastomotic site at
the ureteral axis. Afterwards a guidewire is
inserted through the needle and then into the ureter. The
route is dilated with dilators from a nephrostomy set
until number 8F with the double-J stent then inserted
through the guidewire, right after the bladder is filled
with methylene blue to ensure that the stent is
properly placed.
Eichel et al4 described the insertion of a
stent in this way: 8/10 F Amplatz sheath/ dilator system
is passed by the lateral or uppermost 5mm port. So, a
5 F Kumpe catheter is passed with the tip placed in
the ureter, and a guidewire is inserted through this
catheter. The Kumpe catheter is removed, then a 10F sheath
is placed and a double-J stent is inserted into it.
Tan8 also reported a technique for antegrade stenting
in which a puncture in the anterior abdominal wall
with 19 F needle is necessary. The disadvantage of
these techniques is the necessity of an additional
puncture to antegrade placement of a double-J stent.
Noiura et cols9 in their excellent
manuscript, first described a retrograde insertion of the
guidewire and the antegrade insertion of a double-J
stent, however the author did not worry to place the
ureteral catheter bellow the UPJ, but at the
ureterovesical junction entry , and yet the pelvis was not
insufflated to help its identification. Thus, our technique is
a combination of the different techniques that
have already been mentioned, as a distinguishing feature
it facilitates the identification of the ureter through
its different consistency due to an indwelling catheter,
in addition to facilitate the renal pelvis
identification (through ureteral saline injection) causing a
better dissection as well as avoiding vascular injuries
(for example an retropyelic artery). In our services
the double J stent was placed in less than 6 minutes in
the 5 operative cases, which is a great learning
opportunity to our medical internships.
CONCLUSION
Our technique is neither better nor worse than the ones described above; it is simply
an alternative to ureteral catheterization during Laparoscopic Anderson-Hynes Pyeloplasty. It is
a feasible procedure in services where
laparoscopic surgery is in its initial stage and where there are
a number of medical internships because it
facilitates the ureter and the renal pelvis identification,
besides it does not complicate the anastomosis of the
posterior wall in spite of the absence of double-J stent
at this moment. Therefore, as this technique does
not require expensive instruments, costs are
reduced which represent a great benefit to public
services where scarcity of instruments is common.
REFERENCES
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and Preminger, G.M.: Laparoscopic dismembred pyeloplasty.
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2. Turk IA, Davis JW, Winkelmann B, et al.
Laparoscopic dismembered Pyeloplasty , the method of choice in
the presence of an enlarged renal pelvis and crossing vessels.
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3. .Jarret,T.W., Chan, D.Y., Charambura,T.C., Fugita,O.
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7. .Rodrigues, H., Rodrigues,P., Ruela,M., Bernabé,A.
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9. Nouira Y, Horchani A.: How to Insert a Double J Stent
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