(Dismembered Pyeloplasty (Anderson-Hynes

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Describtion

OPERATIVE TECHNIQUE
Optimal magnification with loupes is preferred for precise dissection
and closure to avoid postoperative leakage or anastomotic
stricture.
Through the flank incision, Gerota fascia should be opened
vertically as far posteriorly as possible to avoid inadvertently entering
the peritoneum (see Fig. 15.1B). The opening should be
angled posteriorly while proceeding cranially because the peritoneum
sweeps more posteriorly to include the liver (on the right)
and spleen (on the left). The dorsal perinephric fat should be
undisturbed, if possible, because this may be used later to cover
the repair. Progress can be made posteriorly by rotating the kidney
anteriorly with a sponge stick.
Once the renal hilum is seen, greater exposure can be gained
by placing a vein or Gil-Vernet retractor at the junction of the
renal parenchyma and hilum (see Fig. 15.1C). Unlike a nephrectomy,
there is no need to mobilize the entire kidney unless the
UPJ obstruction is secondary to a long segment of narrowed
ureter. The pelvis is then cleaned of fat to expose the UPJ. A
retraction suture of 4-0 SAS in the pelvis is helpful in rotating
and lifting the pelvis during dissection. With a hugely dilated
pelvis, decompression of the pelvis with a 23- or 25-gauge butterfly
needle may be required to gain exposure to the entire pelvis
(see Fig. 15.1D). In chronically obstructed systems, there is often
a thick rind that must be dissected off the pelvis, often in layers.
Bleeding from the investing fine vasculature can be controlled
with a bipolar or low-current needle point cautery, using care not
to injure the underlying pelvis.
The ureter is identified distal to the UPJ and cleaned of investing
fat and fascia. A vessel loop will aid in mobilization of the
ureter for several centimeters below the UPJ (Fig. 15.2A). Dissection
should involve as short a length of the ureter as possible with
preservation of the adventitial vessels to prevent devascularization
that could result in postoperative stenosis. For secondary procedures,
it may be easier to find normal ureter distally and then
dissect proximally toward the scarred UPJ.
One must always be on the lookout for an aberrant lower pole
vessel crossing the UPJ (see Fig. 15.2B); palpation for pulsations
can be helpful to confirm the presence of a crossing vessel
Crossing lower pole vessels are a more common cause of UPJ
obstruction in older children, particularly in those presenting with
intermittent renal colic versus isolated intrinsic narrowing of the
UPJ more commonly found in infants.
Once the pelvis, UPJ, and upper ureter are free of surrounding
fat and rind, the anatomy must be carefully analyzed to determine
the optimal technique for repair. The variations in obstruction
location include (1) at the UPJ with a high insertion on the pelvis,
with or without intrinsic narrowing, (2) at the normally positioned
UPJ due to intrinsic narrowing, (3) in the upper ureter
due to stricture, valve, or polyp within the lumen, or (4) at the
UPJ with extrinsic compression to a crossing vessel to the lower
pole of the kidney. In the latter case, intrinsic narrowing within
the lumen can coexist because of chronic irritation/compression.
If there is doubt regarding the exact position of obstruction, the
pelvis can be filled with saline through a butterfly needle to delineate
the transition point where the dilation ends.
For a short stenotic segment, it is best to excise the narrowed
and often dysplastic portion of ureter; therefore, a dismembered
repair is ideal. The dismembered repair also allows for precise
reduction in the size of the pelvis when indicated in widely dilated
systems. Failure to adequately reduce the size of the pel
cases can lead to postoperative obstruction due to kinking of the
pelvis and repaired UPJ segment. The dismembered pyeloplasty is
the most widely used repair because of its simplicity and efficacy,
but it does have greater potential for postoperative obstruction
because of scar contracture of the circular anastomosis.
Nondismembered repairs can be used for specific situations.
The Foley Y-V plasty is used in high insertion UPJ obstruction to
remodel the UPJ into a funnel shape at a most dependent position
on the pelvis. Flap techniques, such as the Culp and Scardino
repairs, may bridge the gap between the pelvis and healthy ureter
in cases with long or more distal obstructions. The Davis intubated
ureterostomy is reserved for the longest of obstructions.
Untitled-jpg-hinmaans-1.jpg                 


Dismembered Pyeloplasty (Anderson-Hynes

   
A stay suture of 4-0 SAS is placed in the anterior surface of healthy 
ureter below the obstruction parallel to its course. The ureter is
then transected in a normal segment below the stenotic segment
(Fig. 15.3). If there is intrinsic narrowing of the ureter, no urine
will drain from the pelvis at this point. In cases with a crossing
vessel, the ureter is cut below the crossing vessel and pulled to the
opposite side of it, and often little reduction in the size of the
pelvis is needed. To ensure patency of the distal ureter, gently pass
a tube down the ureter. Some feel that the tube should be passed
into the bladder to ensure that there is no coexisting distal or
ureterovesical junction (UVJ) obstruction, whereas others feel that
such a concomitant lesion is exceeding rare and that tube passage
could create edema at the UVJ that could impair necessary antegrade
drainage. A 5F feeding tube works well in most cases, but
a 3.5F umbilical vein catheter may be necessary for infants.
If not placed earlier during the dissection, a traction suture of
4-0 SAS is placed in the midportion of the anterior surface of the
renal pelvis near the parenchyma (Fig. 15.3). This allows further
anterior rotation of the pelvis. A proposed diamond-shaped incision
is then demarcated on the pelvis with a marking pen (Fig.
15.4A). A long caudal angle is created for later anastomosis into
the spatulated ureter. The ureter should be pulled cranially by its
traction suture to visualize the length of pelvis needed for the
caudal flap to bridge the gap. Although inadequate pelvic reduction
is potentially problematic, resection of too much pelvis will
compromise closure, especially in bifid systems. The incision in
the pelvis should be kept well away from the caliceal necks, which
can be surprisingly close to the edge of pelvic resection. Excision
of only a small amount of the pelvis is needed in cases with little
pelvic dilation or a crossing vessel without narrowing. Additional
stay sutures are then placed outside of the remaining angles of the
diamond before opening the pelvis. The incision of the pelvis is
then initiated along the demarcated lines using tenotomy scissors
or a No. 11 hook scalpel (see Fig. 15.4B) and completed using
tenotomy or angled Potts scissors (Fig. 15.5). The specimen containing
the excised pelvic segment and obstructed UPJ is removed.
The ureter is then spatulated along its lateral segment (away
from its vascular supply and toward the renal pelvis). Rotation of
the ureter and pelvis can lead to disorientation depending on the
approach, so one must take care to be certain of the anatomic
orientation before cutting. The traction suture on the anterior
surface of the ureter can guide proper orientation. An exception
to this rule may be in malrotated or horseshoe kidneys when the
relationship between ureter and pelvis may be anterior:posterior
rather than medial:lateral. Spatulation can be done with tenotomy
or Potts scissors; a spiral incision should be avoided. The length
of the incision should match the length of the caudal angle of the
cut pelvis (Fig. 15.6).
Before initiating the reanastomosis, a feeding tube or umbilical
vein catheter is re-placed into the ureter to prevent “back-walling”
the other side of the ureter. A 6-0 SAS apical suture is placed
from the apex of the caudal angle of the renal pelvis into the
crotch of the spatulated ureter (Fig. 15.7A). A 4-0 or 5-0 suture
may be substituted in larger patients with larger ureters. The knot
should be tied on the outside of the collecting system, and the
suture is tagged for traction. Alternatively, place a mattress stitch
with a double-armed suture; run one end up the far wall from
inside the lumen and the other up the near wall from outside.
To prevent anastomotic constriction, the needle should be
angled in order to catch a minimal amount of urothelium while
including more muscularis and adventitia (see Fig. 15.7B). Use of
the minimum-diameter needle possible will minimize leakage by
preventing holes in the wall larger than the diameter of the suture.
Cutting needles may be more precise but risk tearing the ureteral
and pelvic wall. With the apical stitch tagged, the next stitch of
equivalent-sized suture or one size larger is placed posterior to the
apical suture (Fig. 15.8A). This is facilitated by passing the apical
traction stitch underneath and medial to the anastomosis, thus
rotating the far wall into better view and allowing closure from
the outside. This suture is then run as a continuous stitch up the
far wall of the repair, locking every few passes. The suture is then
tied to itself once the top of the ureter is reached. The collecting
system should be irrigated free of any clots that could cause temporary
postoperative obstruction.
The apical traction suture is then brought back into its original
orientation to provide optimal exposure of the near (anterior)
wall. The anastomosis between the ureter and pelvis on the near
side is partially closed, and the feeding tube in the ureter is pulled.
If a stent, nephroureteral stent, or nephrostomy tube is desired,
it should be placed at this point (see later). This suture is continued
up the near wall until the suture on the far wall is encountered.
The near suture can be run up the entirety of the repair or
tied to itself above the ureteropelvic anastomosis, and a third
(suture is used to close the pelvic defect cranially (see Fig. 15.8
(Hinnmans atlas of urology fourth edition)
Untitled-jpg-hinmaans-2.jpg
Untitled-jpghimans-3.jpg
 

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    Professor   |     |  
      |   2/8/2020 10:31:22 PM
    You are my inhalation, I possess few blogs and often run out from brand :).
  • Bagot

    Professor   |     |  
      |   6/22/2020 11:55:17 PM
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  • Trivett

    Professor   |     |  
      |   5/18/2020 3:36:31 PM
    Wow! This blog looks exactly like my old one! It's on a completely different subject but it
    has pretty much the same layout and design. Great choice of colors!
  • Cordell

    Professor   |     |  
      |   7/28/2020 2:49:44 AM
    Bu yüzden makinelerin velut ve istenildiği kadar çaldatmaışması hesabına periyodik kontrollerinin mimarilması, var olan bir üretimin matlup kabilinden ilerlememesi ve çalışanların ise bir küme kazaları
    evetşamasına münasebet mümkün.

    Basınçlı kapların ve basınç şeşnda çallıkışan araba, ekipman ve tesisatların periyodik kontrol
    zorunluluğu ve kontrol kriterleri; İş Ekipmanlarının Kullanımında Dirlik ve Asayiş
    Şartları Yönetmeliği

    İş Ekipmanlarının Tasarrufında Sıhhat ve Asayiş Şartları
    Yönetmeliği’ne bakılırsa bir yapıta kullanılan makineler, aletler, kuruluş evet da tesisatlar sağlık muayenesi edilir.


    oluşturmayabilir. Flanş ve boru irtibatlarında ızdırapntı şeklinde çevreye yayılan rahatışsoyın ehil olduğu faik alev veya aşırı sıcak yüzeylere bağlantı ika
    kelam konusu kabil.

    yeniden kullanılmaya mirlamadan önce ve her seferinde
    on yılda bir periyodik olarak en az üç maaş özen süresi. Güvenlik
    valfleri en azca beş yılda bir kontrol edilmelidir.

    Yayımcı zehirli gazların ya da sıvıların dışarıya salınımları, anatomi yaşamı
    hesabına ağır tehditler oluşturabileceği üzere sözıcı hasarlara da niye
    olabilmektedir. Bu tarz şeylerin sorumluluğunu üstlenmemek ve yaşanabilecek olası
    sıkıntıları kesmek adına behemehâl matbuatçlı
    kapların periyodik kontrol uygulanması gerektiği unutulmamalıdır.


    Genleşme tankları sistemdeki tabncın kontrol şeşnda
    tutulması ve sisteme muktezi miktarda suyun katkısızlanması itibarıyla çok ...


    Kaldırma ve iletme makinalarının periyodik kontrollerinin gestaltlmaması evet da yanlış mimarilması
    iş emniyetliğini gözdağı etmektedir. Bu tür iş kazalarının yaşanmaması sinein kaldırma ve iletme
    makinalarının periyodik araştırma kontrollerinin mimarilması ve ötümlü nezaret altında tutulması gerekmektedir.


    Tankın en üst kısmına yerleştirilir ve pres tabncının 1,1 sıkına ayarlanır.
    Tank ile arasına hiçbir akış stoper eleman bulunmamalıdır.
    Güvenlik valfinin tahliye kapasitesi ile tankın hacmi beyninde
    uygunluk olmalıdır. Ağırlıklı ya da yaylı tipleri vardır.
    Muayyen aralıklarda yetkili elemanlarca bakımı, temizliği
    ve ayarları bünyelmalıdır.  Manometre: Tank deruni tabncı göstermesi karınin kullanılır.
    İşletme tabncının dü taşlıknı gösterecek
    taksimatı bulunmalı ve kolay görülebilecek şekilde yerleştirilmelidir.


    Basınçlı kapların ve mekanik tesisatların periyodik muayeneleri, tahribatsız sağlık muayenesi şekilleri ile bünyelması gerektiği durumlarda araştırma mensubunun TS EN ISO 9712
    standardına göre eğitim bilimi almış mühendisler ve aynı eğitimi almış
    teknikerler aracılığıyla konstrüksiyonlabilir.


    c) İşverence, arızaya münasebet olabilecek etkilere verilen kalmış olarak muhatara
    yaratabilecek iş ekipmanının (Matbuatçlı Kulaklı); Periyodik kontrollerini hayata geçirmeye mezun kişilerce
    periyodik kontrollerinin bünyelmasını sağlamalıdır.

    s) ile öbür aracılığıyla ısı veren bir yakacakın yakılması
    neticesinde oluşan şule ve duman gazlarının dolaştığı yollar mevcut
    kapalı kaba kazan denir. Kazanlar;

    Genel anlamda insanların koyu olarak buluntuları
    ya da topluluğa ihtimam veren alanlarda da kullanma sağlamlanır.


    İş Ekipmanlarının Tasarrufında Afiyet ve
    Güvenlik Şartları Yönetmeliği matbuatçlı kapların yılda en az 1 defa periyodik kontrolden geçmesini zaruri kılmaktadır.
  • Wekey

    Professor   |     |  
      |   8/28/2020 12:29:24 AM
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  • Musquito

    Professor   |     |  
      |   2/19/2020 7:07:07 PM
    I conceive you have observed some very interesting details, thank you for the post.
  • Shropshire

    Professor   |     |  
      |   7/15/2020 10:42:01 PM
    I think that what you posted was actually very reasonable.
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    to open the links. You might try adding a video or a pic or two to get readers interested about
    everything've written. Just my opinion, it would make your posts a little bit more interesting.
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