PMC7292093_01
(a) Retrograde pyelogram shows left hydronephrosis with high ureteral insertion and intrarenal UPJO area (arrow). (b) Contrast-enhanced CT-KUB in the delayed phase. The left lower calyx (arrow) is adjacent to a renal cyst (*).
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He was suspected of having obstructive uropathy, and retrograde pyelography indicated that a left UPJO existed and that the site of obstruction might be intrarenal (Fig. 1a). Contrast-enhanced CT showed dissolution of the left hydronephrosis and large renal cyst(s) directly adjacent to the left lower renal calyx (Fig. 1b).
Intraoperative image showing intrarenal UPJ adjacent to the renal artery and vein.
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He underwent transperitoneal laparoscopic pyeloplasty using a four-port technique, as described previously.3 Upon dissection of the upper ureter close to the renal hilum, the UPJ was revealed to be intrarenal and adjacent to the renal artery and vein, which forced us to switch the surgical technique to LUC (Fig. 2).
(a) Illustration showing how to get direct access to the lower calyx by LFRC, and (b) an intraoperative image of lower pole renal cysts (*) observed under usual laparoscopy (c) and with a help of illumination by the ureteroscope. (d) Illustration showing how the lower calyx looked like after LFRC. (e) An intraoperative image of the outer surface of the lower renal calyx after LFRC illuminated by the ureteroscope. Arrows indicates the border between the renal parenchyma and lower renal calyx. (f) Outer surface of the lower renal calyx right after fenestration of the calyceal wall. Note that the opening was located close to the border between the renal parenchyma (arrow). (g) End of the surgery. Green curve indicates the suture between the cyst wall and quadratus lumborum muscle. Arrows indicate the edge of the cyst wall.
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To ensure that this idea was feasible, we used a flexible ureteroscope (Fig. 3a). The ureteroscope was transurethrally inserted into the left lower renal calyx, and a laparoscopic camera detected the strong light of the ureteroscope through the wall of the lower pole renal cyst, indicating direct contact of the lower calyx with the cyst (Fig. 3b,c). After fenestration of the renal cyst, the wall of the lower renal calyx was exposed, and the border between the calyx and renal parenchyma was illuminated by the light (Fig. 3d,e). The outer wall of the dilated lower calyx was excised to create an opening close to the renal parenchyma to receive a good blood supply (Fig. 3f). The wall of the fenestrated renal cyst was hitched caudally to the fascia of the lumbar quadrate muscle to assure tension-free anastomosis (Fig. 3g).
(a) Postoperative retrograde pyelogram at 1 month shows free flow of contrast medium into the renal collecting system and a leak from the site of anastomosis (arrow). (b) Postoperative contrast-enhanced CT (CT-KUB) at 2 months shows patency of the anastomosis (dotted circle) with no leakage.
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A retrograde ureteropyelogram at 4 weeks confirmed patency of the anastomosis and a tiny collection of contrast medium around the anastomosis site, which we did not recognize as a leakage, but a part of the lower calyx previously was hidden by the retraction caused by a huge renal cyst (Fig. 4a). A 2-month postoperative contrast-enhanced CT scan showed complete disappearance of the leakage and patency of the anastomosis (Fig. 4b).