Retroperitoneoscopic heminephrectomy for a non-functioning upper moiety with a previously punctured ureterocele in the bladder

The laparoscopic approach has increasingly assumed a central role in the management of benign and malignant urological diseases. Laparoscopy is less morbid than open surgery and requires small incisions. We present the case of an heminephrectomy, with a stepwise approach for the identification of the landmarks and dissection of the main vessels. This video is recommended for advanced laparoscopic urologists.

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Retroperitoneoscopic heminephrectomy for a non-functioning upper moiety with a previously punctured ureterocele in the bladder

Authors

Abstract

The laparoscopic approach has increasingly assumed a central role in the management of benign and malignant urological diseases. Laparoscopy is less morbid than open surgery and requires small incisions.
We present the case of an heminephrectomy, with a stepwise approach for the identification of the landmarks and dissection of the main vessels.
This video is recommended for advanced laparoscopic urologists.

Classification

routine cases

Keywords

retroperitoneoscopic heminephrectomy, non-functioning upper moiety, punctured ureterocele, bladder

Media type

Surgical video

Duration

08'00''

Publication

2009-01

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E-publication

WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2512.htm

Retroperitoneoscopic heminephrectomy for a non-functioning upper moiety with a previously punctured ureterocele in the bladder

1. Indication for surgery 00'10''

The indication for surgery is a non-functioning upper moiety with a previously punctured ureterocele in the bladder.

2. Exposure 00'20''

The dissecting balloon is used to create an initial space outside Gerota’s fascia. Using scissors and diathermy, a window is created in Gerota’s fascia to expose the kidney. As with a nephrectomy, the posterolateral surface of the kidney is exposed with a combination of sharp and blunt dissection. It is essential to expose both moieties of the duplex kidney. Both ureters should be identified and the anatomy confirmed. The dysplastic upper moiety with its associated dilated ureter can now be seen.

3. Dissection and control of vessels 02'10''

Having confirmed the anatomy, the vessels supplying the upper moiety should be identified and individually clipped and divided. The affected moiety is frequently associated with an aberrant blood supply and a careful search should always be made for vessels entering the kidney both posteriorly and anteriorly. Exposure of the more anteriorly placed vessels can be facilitated by lateral retraction of the upper ureter. On some occasions, only small segmental vessels arise from the main renal vessels. The segmental branches of the main renal vessels should be individually clipped and divided. Blanching of the devascularized upper moiety can now be clearly seen.

4. Removal of the affected moiety 04'34''

The upper moiety ureter is divided close to the pelviureteric junction leaving a short proximal stump, which will facilitate retraction for placement of the Endoloop. Monopolar diathermy is used to mark the junction between the upper and lower moieties where the Endoloop will be placed. A 2/0 Vicryl Endoloop is placed at the junction between the upper and lower moieties and securely tied. Placement of this Endoloop will reduce the risk of hemorrhage and urine leak. Using hook scissors, the affected moiety is then excised distal to the location of the Endoloop. If the Endoloop is divided or becomes dislodged, this must be replaced. In the presence of vesicoureteric reflux, the distal ureter is ligated and excised. When there is no associated reflux into the affected moiety, the distal ureter can be divided and left open.

5. Specimen extraction 07'56''

The specimen is retrieved directly through the camera port.