title: Dismembered percutaneous endopyeloplasty: a new procedure.
abstract: OBJECTIVE
  We recently described a novel technique of percutaneous non-dismembered endopyeloplasty (Fenger type). Herein, we extend this transrenal technique further and report percutaneous dismembered endopyeloplasty (Anderson-Hynes type).
  
  
  METHODS
  In five pigs with unilateral ureteropelvic junction (UPJ) obstruction created 3 to 6 weeks earlier, percutaneous dismembered endopyeloplasty was performed. Percutaneous transrenal access to the UPJ was obtained, and the UPJ was completely dismembered from within the renal pelvis through the solitary percutaneous tract. The dismembered proximal ureter was circumferentially mobilized, and in two animals, the UPJ segment was completely excised and removed. A spatulated end-to-end endopyeloplasty anastomosis (Anderson-Hynes) was created transrenally with 5 to 10 interrupted sutures using a novel nephroscopic suturing device (Sew-Right SR-5; LSI Solutions, Rochester, NY). In two animals, the entire percutaneous procedure was performed with CO2 insufflation instead of fluid irrigation.
  
  
  RESULTS
  The technique was developed in three pigs. Subsequently, two pigs were treated and sacrificed at 2 and 5 weeks. All UPJs were dismembered successfully, and a precisely sutured mucosa-to-mucosa anastomosis was created. Intraoperative bleeding was negligible, and the operative time ranged from 3 to 5 hours, with the majority of the time dedicated to transrenal retroperitoneal dissection of the scarred, fibrotic UPJ. Carbon dioxide insufflation was efficacious because it minimized fluid extravasation and tissue edema and additionally enhanced visibility. Postoperative pyelograms revealed an adequately funneled UPJ, with good flow into the distal ureter. The two survival animals had minimal apparent morbidity from the procedure, and retrograde pyelograms at euthanasia revealed a patent anastomosis without extravasation. A 6F catheter easily crossed the reconstructed UPJ at autopsy in all animals.
  
  
  CONCLUSIONS
  Dismembered percutaneous Anderson-Hynes endopyeloplasty is technically feasible and is promising. Further technical experience and additional functional outcome analysis in the survival model are necessary. With the technique described herein, we introduce the concept of percutaneous intrarenal reconstructive surgery (PIRS), wherein advanced intrarenal and retroperitoneal dissection with reconstruction can be performed endourologically, further broadening the horizons of conventional percutaneous techniques.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Sharp
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
authors.forename: Wilson R
authors.initials: WR
authors.lastname: Molina
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Spaliviero
authors.forename: Sidney C
authors.initials: SC
authors.lastname: Abreu
authors.forename: Anup P
authors.initials: AP
authors.lastname: Ramani
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000714:Anastomosis, Surgical; D000818:Animals; D002245:Carbon Dioxide; D005240:Feasibility Studies; D005260:Female; D006869:Hydronephrosis / Q000601:surgery; D007327:Insufflation; D007682:Kidney Pelvis / Q000000981:diagnostic imaging / Q000601:surgery*; D023421:Models, Animal; D013536:Suture Techniques; D013552:Swine; D014517:Ureteral Obstruction / Q000000981:diagnostic imaging / Q000601:surgery*; D014567:Urography
chemical_list: D002245:Carbon Dioxide