| Background and PurposeIt is known to all that the first laparoscopic surgery in canine was performed by Kelling in 1901 and in human by Jacobaeus in 1910. Laparoscopic technique has been wildly used since 1980. This technique in urology is more difficult for the special location of the urinary organs which hided behind the peritoneum. The first laparoscopic nephrectomy and laparoscopic pelvic lymph node dissection fulfilled successfully by dayman in the early year of the 1990s forced the urologists to reconsider the value of the laparoscopy in urology. With the development of the equipments, the indication of the surgery expanded. Retroperitoneal laparoscopic surgery as a suitable approach became a new important technique in urology in the 1990s. Initially, only simple surgery such as Laparoscopic renal cystectomy and Laparoscopic ligation of the internal spermatic veins can be done. Finally, total territory of urology is involved in Laparoscopic surgery now. Pyeloplasty, which has nearly a 10-year-performed experience oversea, is of representation in urinary tract reconstitution surgery. With the innovation of equipment in laparoscopy in the recent 5 years, this kind of surgery undergoes significant developments. Laparoscopic dismembered pyeloplasty is rarely reported among all kinds of pyeloplasties both internal and international.Laparoscopic dismembered pyeloplasty was used to treat ureteropelvic junction obstruction (UPJO) in our hospital in the past one and a half year. In this paper, we decide to study the clinical application and the operative effect of Laparoscopic dismembered flap pyeloplasty.Data and MethodClinical DataFrom January 2005 to May 2006, laparoscopic dismembered pyeloplasty was performed in 7 patients (3 male and 4 female) who suffered from UPJO. Mean patient age was 28 years (range 18 to 45). 6 cases had disease in the left, while 5 in the right. Course of disease differed from 3 months to 3 years. Preliminary diagnosis depended on flank pain (n=7), or on ultrasonography in health examination (n=4). Final diagnosis relied on ultrasonography, KUB+IVU, RGP or MRU. 5 cases had severe hydronephrosis, and 2 intermediate.Method of treatmentCleaning enema was carried out routinely on the day before surgery. Antibiotics were given intravenously before surgery. After general anaesthesia was achieved, a urethral catheter was put. Patients were positioned at a 90-degree angle to the operating table. When artificial pneumoperitoneum using carbon dioxide at pressure of 12-15mmHg was established, a transperitoneal approach was then performed using three to four trocars. Incision below umbilicus was made for the primary 10mm port site. Incision at anterior axillary line off the umbilicus and incision at medioclavicular line on the costal margin were made for another 10mm and 5mm trocas, repectively. An additional troca was used at postaxillary line on the costal margin when needed. Lateral region of abdomen and capsule of kidney were open in the vision of 30 degree lens. Kidney and pelvis of ureter were of exposure. When total solution of the UPJ was made, stenosis of the ureter was cut off. The pelvis was reshaped to be a flap of 2.5～3cm by 1.5～2cm, then it turned over and trained to be tubiform using 4-0 absorbable suture. Unnecessary pelvis tissue was ablated at 1cm range off the renal parenchyma. Interrupted suture was performed to join pelvis flap to the ureter. Then a D-J tube was put. Methylene blue was infused to the bladder to ensure that the D-J tube was right in place. Running suture was made to closethe pelvis. Drainage rube was put and finally the incision of lateral abdomen was sewed up.Result7 cases underwent a successful operation except for one failure which converted to laparoscopic nephrectomy due to serious bleeding when separating the pelvis. Mean operating time was 112 min (range 90 to 180 min). Estimated blood loss was 50 ml (range 30 to 90 ml). The drainage tube was pulled out on day 1 or 2 after operation. Out-of-bed activity was down on day 2 or 3. Patients discharged on day 5 or 6. The D-J tube was pulled out 3 to 4 weeks after surgery. No complication was found. During 5 to 15 months' follow-up in 10 cases, flank pain disappeared. Ultrasonography and IVU turned to be normal. The case of secondary UPGO had nephroectomy half year due to stenosis of the stoma. In 6 cases hydronephrosis disappeared and urine analyses was normal.ConclusionLaparoscopic dismembered flap pyeloplasty has the advantages of both minimal invasion and full of security. It will be an alternative choice in surgery for treating high UPJO and long segment of UPJO.
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