explain me all types of pyeloplasty done for puj obstruction
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pyeloplasty "ureteropelvic junction" obstruction techniques
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I now have comprehensive information from Campbell-Walsh-Wein Urology and Hinman's Atlas of Urologic Surgery. Let me compose the full, detailed answer.
Pyeloplasty for Pelviureteric Junction (PUJ) Obstruction - All Types
Pyeloplasty is the gold-standard surgical treatment for PUJ (UPJ) obstruction. The goal is to excise or reconfigure the obstructed/aperistaltic segment, creating a wide, dependent, funnel-shaped anastomosis that allows gravity-assisted urine drainage. The overall success rate of open dismembered pyeloplasty is approximately 95%, and minimally invasive approaches achieve equivalent outcomes.
Classification Overview
| Category | Techniques |
|---|---|
| Dismembered (excisional) | Anderson-Hynes pyeloplasty |
| Non-dismembered (flap) | Foley Y-V plasty, Fenger (Heineke-Mikulicz) pyeloplasty, Spiral flap, Vertical flap, Tubularized flap |
| Non-dismembered (other) | Davis Intubated Ureterotomy, Hellstrom Vascular Hitch |
| By surgical approach | Open (flank/lumbotomy), Laparoscopic, Robotic-assisted, LESS (single-site) |
| Endoscopic (non-reconstructive) | Endopyelotomy (antegrade/retrograde), Balloon dilation |
I. DISMEMBERED PYELOPLASTY
Anderson-Hynes Dismembered Pyeloplasty (GOLD STANDARD)
The most universally applicable technique and the standard against which all other interventions are compared. Success rate ~95%.
Principle: The UPJ is completely excised (dismembered), the obstructed/aperistaltic segment removed, the ureter spatulated laterally, and a tension-free, dependent anastomosis constructed between the renal pelvis and healthy ureter. A redundant pelvis can be reduced simultaneously.
Advantages:
- Applicable to virtually all anatomical configurations (high insertion, dependent UPJ, anomalous vasculature)
- Permits complete excision of the dysplastic/aperistaltic segment
- Allows transposition of the UPJ anterior to crossing lower pole vessels
- Redundant pelvis can be reduced (reduction pyeloplasty)
- A tortuous proximal ureter can be straightened
Technique (key steps):
- Open Gerota's fascia; expose the UPJ and free the lower renal pole
- Place stay sutures on the medial and lateral pelvis and on the ureter below the obstruction
- Dismember the UPJ; reduce the pelvis if redundant
- Spatulate the ureter along its lateral border, well into healthy tissue
- Bring the apex of the lateral spatulated ureter to the inferior border of the pelvis; the medial ureter to the superior edge
- Complete anastomosis with interrupted or running 5-0/6-0 absorbable monofilament on a round needle - watertight, tension-free
- Place a ureteral stent (internal double-J or externalized nephro-ureteric stent, per surgeon preference)
Specific indication for accessory vessels: The dismembered technique allows the ureter to be swung anterior to crossing lower pole vessels so the new anastomosis lies ventral to them.
Contraindications: Long/multiple proximal ureteral strictures; small, intrarenal pelvis with limited access.
- Campbell-Walsh-Wein Urology, p. 2605; Campbell-Walsh-Wein block19
II. NON-DISMEMBERED (FLAP) PYELOPLASTIES
These techniques keep the UPJ intact and use pelvic or ureteral flaps to widen the obstructed segment. They are contraindicated when crossing vessels need transposition. They are largely replaced by Anderson-Hynes but remain useful in specific anatomical scenarios.
1. Foley Y-V Plasty
Original indication: PUJ obstruction secondary to high ureteral insertion into the pelvis (ureter inserts into the apex/superior wall of the pelvis rather than dependently).
Principle: A V-shaped (triangular, widely-based) flap is fashioned from the inferior/dependent part of the renal pelvis, with the apex at the UPJ. The incision (stem of the Y) extends down the lateral aspect of the proximal ureter through the stenotic segment. The pelvic flap is then advanced down and sutured into the ureterotomy, converting the Y incision into a V (or V into Y, depending on perspective) - effectively widening the UPJ.
Technique:
- Outline a V-shaped flap with the base on the dependent, medial pelvis and apex at the UPJ
- Incise from the apex down the lateral ureter, past the stenosis into normal ureter
- Advance the apex of the pelvic flap to the inferior end of the ureterotomy
- Close in a Y configuration with fine absorbable sutures
Limitations/Contraindications:
-
Cannot be used when lower pole vessel transposition is needed
-
Of little value if pelvis reduction is required
-
Success rate ~86% vs. 95% for Anderson-Hynes (Szydelko et al.)
-
Specifically contraindicated in the presence of a crossing vessel requiring anterior transposition
-
Campbell-Walsh-Wein Urology, p. 2612
2. Fenger Pyeloplasty (Heineke-Mikulicz Pyeloplasty)
Principle: Based on the Heineke-Mikulicz pyloroplasty principle - a short longitudinal incision across the UPJ is closed transversely, widening the narrowed segment without excising it.
Indication: Short, intrinsic UPJ narrowing without high insertion or need for vessel transposition. Suitable for short stenoses.
Technique:
- A longitudinal incision is made across the narrowed UPJ (spanning the stenosis)
- The incision is then closed transversely with interrupted absorbable sutures
- This converts a short longitudinal stricture into a widened lumen
Limitation: Only applicable to very short, localized stenoses. Not versatile. Largely replaced by dismembered pyeloplasty.
- Hinman's Atlas of Urologic Surgery; Smith and Tanagho's General Urology, p. 176
3. Spiral Flap Pyeloplasty (Culp-DeWeerd / Scardino-Prince)
Indication: Long proximal ureteral stenosis where tension-free primary anastomosis (as in Anderson-Hynes) is impossible. Used when the UPJ is already in a dependent position but a long segment of proximal ureter is obstructed.
Principle: A long spiraling flap is developed from the renal pelvis, with its base at the dependent UPJ. The flap spirals posteriorly-to-anteriorly (or vice versa). The medial incision of the flap is carried down through the entire strictured proximal ureteral segment. The apex of the flap is then rotated down to bridge the ureteral defect.
Key rule: Flap length-to-width ratio must not exceed 3:1 to preserve vascular integrity of the flap.
Fig. 42.8 - Vertical flap technique; the spiral flap follows similar principles with oblique base orientation. (Campbell-Walsh-Wein)
- Campbell-Walsh-Wein Urology, block19, Fig. 42.9
4. Vertical Flap Pyeloplasty
Indication: Similar to spiral flap - used for long proximal ureteral obstruction when the UPJ is at the medial margin of a large, box-shaped extrarenal pelvis.
Difference from spiral flap: The base of the flap is oriented more horizontally (between the UPJ and renal parenchyma), and the flap is formed by two straight converging incisions from the base up to the apex (anterior or posterior pelvic wall). The apex is rotated down to the inferior ureterotomy.
5. Tubularized Flap Pyeloplasty
Indication: Significant upper ureteral defect after excision of a long UPJ stricture - when a 3+ cm ureteral gap exists and primary anastomosis is impossible.
Technique: A wide-based pelvic flap is created and tubularized (rolled over a stent/catheter) to bridge the ureteral gap. The flap is sutured over itself to create a new ureteral tube.
Laparoscopic version described by Kaouk et al. (2002): Used a four-port transperitoneal approach with intracorporeal freehand suturing for a 3 cm ureteral defect.
- Campbell-Walsh-Wein Urology, p. 2612
III. OTHER UPJ RECONSTRUCTION TECHNIQUES
Davis Intubated Ureterotomy
Indication: Lengthy or multiple ureteral strictures at or near the UPJ - rarely used today.
Principle: A longitudinal incision is made through the entire length of the strictured segment. A stent (intubated ureterotomy stent) is left in situ for 4-6 weeks. Urothelial regeneration occurs over the stent, healing the incised stricture by secondary re-epithelialisation.
Limitation: High recurrence rate; unpredictable healing. Largely abandoned in favor of pyeloplasty.
Hellstrom Vascular Hitch (Vascular Relocation / "Laparoscopic Hitch")
Indication: PUJ obstruction caused exclusively by an anterior crossing lower pole vessel with no intrinsic UPJ stenosis. The ureter and UPJ itself are functionally normal.
Principle: The crossing vessel is mobilized off the UPJ and "hitched" (sutured) cranially onto the renal pelvic tissue, removing the extrinsic compression without any ureteral reconstruction.
Patient selection criteria (Gundeti et al.): Moderate hydronephrosis, no calyceal dilation, preserved renal cortex, poor drainage with preserved split function, lower pole crossing vessel confirmed - AND intraoperatively: normal-caliber ureter and UPJ with active peristalsis.
Caution: Long-term results are limited compared to Anderson-Hynes. Only appropriate when truly no intrinsic obstruction exists.
- Campbell-Walsh-Wein Urology, block19, Fig. 42.15
IV. BY SURGICAL APPROACH
A. Open Pyeloplasty
Approaches:
- Flank incision - most common; subcostal or transcostal
- Posterior lumbotomy (dorsal lumbotomy) - prone position; reserved for infants and toddlers (increasing dorsal musculature with age makes this difficult); gives direct posterior access to the UPJ
- Anterior (subcostal/transabdominal) - useful for horseshoe or malrotated kidneys
- Transmesocolic approach - for left-sided cases, incision through the mesocolon without mobilizing the colon; ideal for pediatric/thin patients, horseshoe kidneys, malrotated kidneys with distorted pelvic anatomy
Success rate of open pyeloplasty: ~95% (Clark and Malek, 1987 - 111 patients, 15-year review: 95% symptomatic success, 91% radiographic decompression).
B. Laparoscopic Pyeloplasty
First described in 1993 (Kavoussi and Peters). Now the method of choice at many centers, with success rates >95% in experienced hands.
Approaches:
- Transperitoneal (transabdominal) - most widely used; largest working space; familiar anatomy; standard for adults
- Retroperitoneal (retroperitoneoscopic) - avoids peritoneal cavity; shorter path to UPJ; preferred at some centers, especially for redo cases or prior abdominal surgery; some evidence of shorter hospital stay and faster recovery vs. transperitoneal
- Hand-assisted - bridge technique for surgeons building laparoscopic skills
Most laparoscopic pyeloplasties use the Anderson-Hynes technique. Y-V plasty, Heineke-Mikulicz, Davis intubated ureterotomy, Hellstrom vascular relocation, and tubularized flap have all been described laparoscopically.
A meta-analysis (Autorino et al., 2014) confirmed laparoscopic pyeloplasty outcome is comparable to open surgery, with robotic as an attractive alternative.
- Smith and Tanagho's General Urology, 19th ed., p. 176
C. Robotic-Assisted Pyeloplasty
First published ~2004 (Olsen and Jorgensen; Kutikov et al.). Has become increasingly popular, particularly in pediatric urology.
Advantages:
- Articulated wristed instruments ease intracorporeal suturing (the most technically demanding part)
- Shorter learning curve than pure laparoscopy
- Especially useful in children where the working space is limited
- Comparable success rates to laparoscopic and open pyeloplasty
Approaches:
- Standard multiport robotic (transperitoneal) - most common
- Retroperitoneal robotic
- Single-port robotic (SP robot) - emerging; comparable outcomes with better cosmesis (meta-analysis Yang et al., 2025, PMID 40016552)
A 2025 meta-analysis (Kuiqing et al., J Robot Surg 2025) confirmed robotic-assisted pyeloplasty is equivalent or superior to conventional laparoscopic pyeloplasty in pediatric patients across efficacy, safety, and age-stratified outcomes.
D. Laparoendoscopic Single-Site (LESS) and Robotic LESS (R-LESS) Pyeloplasty
Principle: All instruments and the camera enter through a single port (typically at the umbilicus via a multichannel port such as GelPoint). Produces near-invisible cosmetic result.
Technique: 2 pediatric robotic trocars + 2 standard 12 mm trocars (camera + assistant), placed 3 cm apart in a diamond configuration at the umbilicus.
Success rate: ~93% symptomatic and radiographic success (Harrow et al., 2013).
Limitation: Technically demanding due to instrument clashing ("swordfighting"); future robotic purpose-built systems will improve adoption.
- Hinman's Atlas of Urologic Surgery, p. 207
V. ENDOSCOPIC (ABLATIVE / NON-RECONSTRUCTIVE) APPROACHES
These are not true "pyeloplasties" but are included for comparison as they address PUJ obstruction.
Endopyelotomy
Routes:
- Antegrade (percutaneous) - access via percutaneous nephrostomy tract; rigid nephroscope visualizes UPJ; lateral full-thickness incision with cutting balloon (or cold knife/Acucise wire) until periureteral fat is seen; endopyelotomy stent left for 6 weeks
- Retrograde (ureteroscopic) - access via urethra and ureter; laser or cold knife incision of UPJ
Results: Significantly inferior to pyeloplasty - success rate ~65-75% (vs. 95% for pyeloplasty). Best results with: short strictures (<1 cm), no crossing vessel, and preserved renal function.
Contraindication: Crossing lower pole vessel (risk of hemorrhage).
- Hinman's Atlas of Urologic Surgery, p. 164
Summary Table
| Technique | Best For | Key Feature | Success Rate |
|---|---|---|---|
| Anderson-Hynes | All scenarios (gold standard) | Dismembered; full excision; vessel transposition possible | ~95% |
| Foley Y-V | High ureteral insertion | Non-dismembered V flap; no vessel transposition | ~86% |
| Fenger (H-M) | Short intrinsic stenosis | Longitudinal incision closed transversely | Limited use |
| Spiral flap | Long proximal ureteral stricture, dependent UPJ | Long spiraling pelvic flap bridges defect | Good, limited data |
| Vertical flap | Long stricture, box-shaped extrarenal pelvis | Straight flap, horizontal base | Similar to spiral |
| Tubularized flap | Large ureteral gap (3+ cm) | Pelvic tissue tubularized to form new ureter | Case reports |
| Davis intubated ureterotomy | Long/multiple strictures (rare) | Incise + stent; heals by re-epithelialization | Poor; abandoned |
| Hellstrom vascular hitch | Crossing vessel, NO intrinsic stenosis | Vessel repositioned cranially | Comparable to dismembered (select cases) |
| Laparoscopic (transperitoneal/retroperitoneal) | Standard minimally invasive | Any of above techniques; ~same success as open | >95% |
| Robotic-assisted | Children, complex cases | Easier intracorporeal suturing | >95% |
| LESS/R-LESS | Cosmetically conscious patients | Single umbilical incision | ~93% |
| Endopyelotomy | Short stricture, no crossing vessel | Incisional only; no reconstruction | ~65-75% |
Key Points from Campbell-Walsh-Wein
- Anderson-Hynes dismembered pyeloplasty is the gold standard - applicable to almost all clinical scenarios, especially when crossing vessels are present.
- Flap techniques (Y-V, spiral, vertical) are reserved for specific anatomical situations - high insertion or long proximal ureteral strictures. They cannot be used when vessel transposition is needed.
- Laparoscopic and robotic approaches achieve equivalent outcomes to open surgery with less morbidity.
- Stenting is preferred by most surgeons (external nephro-ureteric or internal double-J) to reduce anastomotic leaks and urinary ascites.
- Retroperitoneal approach offers shorter hospital stay and faster recovery but is more technically demanding, especially in adults.
- Endopyelotomy yields inferior results compared to any form of pyeloplasty and should be avoided when crossing vessels are present.
Sources: Campbell-Walsh-Wein Urology, 3-Volume Set (Dismembered Pyeloplasty p. 2605, Other Reconstructive Procedures p. 2612, Laparoscopic/Robotic pp. 2100-2151); Hinman's Atlas of Urologic Surgery (Pyeloplasty p. 164, Transmesocolic p. 207, LESS p. 207); Smith and Tanagho's General Urology, 19th ed. (p. 176); Recent meta-analyses: PMID 40753141 (robotic vs. laparoscopic, 2025), PMID 40016552 (single-port vs. multiport robotic, 2025)
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Pyeloplasty Quick Reference
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What's inside (8 pages, A4):
| Page | Section |
|---|---|
| 1 | Cover page with contents list |
| 2 | Section I - Anderson-Hynes Dismembered Pyeloplasty (gold standard, step-by-step, crossing vessel note) |
| 3 | Section II - All Non-Dismembered Flap Techniques (Foley Y-V, Fenger, Spiral, Vertical, Tubularized) |
| 4 | Section III - Other UPJ Methods (Davis, Hellstrom Hitch, Bypass, Ureterocalicostomy) |
| 4-5 | Section IV - All Surgical Approaches (Open incisions, Laparoscopic trans/retroperitoneal, Robotic multiport/SP/LESS) |
| 6 | Section V - Full Comparison Summary Table (12 techniques, color-coded success rates, contraindications) |
| 7-8 | Section VI - Stenting options + Key Clinical Points (technique selection, crossing vessel management, operative tips, follow-up, complications) + Hellstrom Gundeti selection criteria box |
Sourced from Campbell-Walsh-Wein Urology, Hinman's Atlas, Smith & Tanagho, and 2025 meta-analyses.
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