Ureter-first Approach and Reduction of Pelvis: Standardizing Handling of Ureteropelvic Junction During Pyeloplasty

Objective To present our ‘ureter-first’ approach as a standardized step-wise incision-making technique to deal with all types of uretero-pelvic junction (UPJ) anatomy during pyeloplasty. Pyeloplasty is a common surgery performed for UPJ obstruction, with Anderson-Hynes’ pyeloplasty being the commonest. However, there is great variability in handling UPJ and incision-making among the surgeons with no detailed standardized description that can be followed in all cases, notwithstanding broad descriptions of incision lines. We underscore this aspect of pyeloplasty and present our universal technique with a goal to minimize surgical errors. Methods A standardized step-by-step handling of UPJ and sequential incision-making was developed for pyeloplasty. It avoids unwarranted loss of any pelvis tissue before confirming individual UPJ anatomy, emphasizes preservation of lower lip of pelvis and minimizes tension on anastomosis. This standardized technique was uniformly used in all cases over 5 years. The peri-operative and functional outcome results are presented. Results 51 consecutive cases were done using ureter-first approach. UPJ was >1 cm in 8 cases. 3 of these had UPJ >2 cm. 8 other cases had a low-insertion below level of kidney while 3 had high insertion of ureter. There were no cases which were deemed to be done under tension or unsatisfactory repair by the surgeon. There were no failures requiring any kind of redo repair at mean follow up of 39 months. Conclusions A uniform standardized approach saves the surgeon from unwarranted or wrongly designed incisions on the pelvis and thus has the potential to reduce surgical mistakes.