Laparoscopic pyeloplasty is one of the most significant advancements in minimally invasive urology. It is the procedure of choice for correcting ureteropelvic junction (UPJ) obstruction, a condition where urine flow is blocked between the renal pelvis and ureter. In his lectures, Dr. R. K. Mishra, a pioneer in laparoscopic surgery and a renowned educator, explains the principles, techniques, and outcomes of laparoscopic pyeloplasty with clarity, making it an essential reference for surgeons and trainees worldwide.

Introduction

Dr. Mishra begins his lecture by emphasizing the importance of pyeloplasty in restoring normal renal drainage and preventing progressive renal damage. UPJ obstruction can be congenital or acquired and often presents with flank pain, hydronephrosis, recurrent urinary tract infections, or renal function deterioration. Traditionally, open Anderson-Hynes pyeloplasty was the gold standard, but laparoscopy now provides similar success rates with the benefits of minimal invasiveness, shorter hospital stay, less pain, and improved cosmesis.

Indications for Laparoscopic Pyeloplasty

Dr. Mishra highlights the main indications for surgery, which include:

Symptomatic UPJ obstruction with flank pain

Progressive hydronephrosis seen on imaging

Declining renal function on diuretic renogram

Recurrent infections or hematuria

Presence of crossing vessels causing obstruction

He stresses that not every case of hydronephrosis requires intervention; the decision is based on symptoms, function, and imaging results.

Patient Evaluation and Preparation

A thorough preoperative evaluation is essential. Dr. Mishra details the work-up, including:

Ultrasound and CT urography for anatomical assessment

Diuretic renography (DTPA or MAG-3 scan) for functional evaluation

Urinalysis and culture to rule out infections

Renal function tests for baseline assessment

Patients are counseled regarding the benefits and risks of the laparoscopic approach. Antibiotic prophylaxis is given, and proper hydration is ensured before surgery.

Surgical Technique

Dr. Mishra explains the operative steps systematically, mirroring his teaching style at World Laparoscopy Hospital.

Anesthesia and Positioning

The patient is placed in a flank or lateral decubitus position.

General anesthesia is administered, and a Foley catheter is inserted.

Port Placement

Pneumoperitoneum is created using a Veress needle or Hasson technique.

Ports are placed in a triangulated fashion: typically a 10 mm camera port at the umbilicus and two 5 mm working ports along the midclavicular and anterior axillary lines.

Exposure

The colon is mobilized to expose the ureteropelvic junction and renal pelvis.

Careful dissection identifies the UPJ, avoiding injury to vessels.

Resection of Narrowed Segment

The obstructed segment of the ureter is excised.

If a crossing vessel is present, the repair is transposed anteriorly (vascular hitch).

Anastomosis

The renal pelvis is spatulated, and a tension-free, watertight anastomosis is performed with fine absorbable sutures.

Dr. Mishra emphasizes the importance of intracorporeal suturing skills, which are the cornerstone of laparoscopic pyeloplasty.

Stent Placement

A double J ureteral stent is inserted to ensure drainage during healing.

The anastomosis is completed, and a drain may be placed if required.

Closure

Ports are removed, pneumoperitoneum released, and wounds closed.

Technical Pearls from Dr. Mishra

In his lectures, Dr. Mishra provides invaluable insights for surgeons:

Dissection must be meticulous to prevent ureteral injury.

Always confirm the presence of crossing vessels and manage them appropriately.

Maintain precise suturing technique—continuous or interrupted—ensuring no gaps or leaks.

Use magnification and advanced laparoscopic instruments for better precision.

A tension-free anastomosis is key to long-term success.

Postoperative Care

Patients are mobilized early and oral intake is resumed within 24 hours.

Analgesic requirements are minimal compared to open surgery.

The drain, if placed, is removed within 48 hours once output is minimal.

The ureteral stent is typically left in place for 4–6 weeks.

Follow-up imaging with ultrasound or renogram is performed to confirm resolution of obstruction.

Outcomes

Dr. Mishra notes that laparoscopic pyeloplasty achieves success rates above 90–95%, comparable to open surgery but with reduced morbidity. Patients experience:

Shorter hospital stays (2–3 days)

Faster return to daily activities

Minimal scarring and improved cosmetic satisfaction

Long-term relief of symptoms and preservation of renal function

Complications

While rare, potential complications include:

Urinary leakage from the anastomosis

Infection or sepsis

Stent-related discomfort

Anastomotic stricture requiring revision surgery

Dr. Mishra stresses that such complications are minimized with proper surgical training and adherence to technique.

Conclusion

In his lecture, Dr. R. K. Mishra highlights laparoscopic pyeloplasty as a landmark procedure in urological surgery. It combines the principles of open pyeloplasty with the benefits of laparoscopy, offering patients safe, effective, and durable results. Mastery of intracorporeal suturing is essential, and with structured training, surgeons can achieve excellent outcomes.

Laparoscopic pyeloplasty is a prime example of how minimally invasive surgery has redefined modern urology, providing patients with rapid recovery while maintaining the gold-standard success rates of traditional open surgery.