CPT® Code 50405

1. Indications

The procedure of pyeloplasty is indicated for various conditions that lead to obstruction in the upper urinary tract. The following are the explicitly provided indications for performing this surgical intervention:

• Congenital Kidney Abnormality - Structural anomalies present at birth that affect the kidney's function and urine flow.
• Secondary Pyeloplasty - A follow-up surgical procedure performed due to complications or failures from a previous pyeloplasty.
• Solitary Kidney - A condition where a patient has only one functioning kidney, necessitating careful surgical intervention to preserve its function.
• Calycoplasty - A surgical procedure to repair the renal calyces, which may be performed in conjunction with pyeloplasty when there are associated issues.

2. Procedure

The pyeloplasty procedure involves several critical steps to ensure successful reconstruction of the renal pelvis and ureter. The following outlines the procedural steps as described:

• Step 1: Incision and Dissection - A skin incision is made over the kidney to access the renal pelvis. The surgeon incises Gerota's fascia, which is the connective tissue surrounding the kidney, and carefully dissects the perirenal fat to expose the underlying structures.
• Step 2: Identification of Blood Vessels - During the dissection, the surgeon identifies the blood vessels supplying the kidney and controls them by placing a loop around each vessel to prevent excessive bleeding during the procedure.
• Step 3: Exposure and Examination - The kidney and ureter are fully exposed and visually examined. Due to the obstruction, the renal pelvis is typically found to be significantly dilated, which is a critical factor in the surgical approach.
• Step 4: Creation of Y-shaped Incision - A Y-shaped incision is made in the dilated renal pelvis. The first arm of the Y is created with an anterior incision at the ureteropelvic junction, extending laterally and downward toward the hilum of the kidney. The second arm is formed by making a posterior incision in the renal pelvis in a similar manner.
• Step 5: Ureter Incision - The ureter is incised longitudinally on its lateral aspect, which is the side facing the renal pelvis. This step is crucial for facilitating the anastomosis between the ureter and the renal pelvis.
• Step 6: Trimming and Preparation - The renal pelvis flap is trimmed as necessary to ensure proper alignment and fit during the anastomosis. This preparation is vital for achieving a successful surgical outcome.
• Step 7: Placement of Tubes and Stents - Before repositioning the ureter, a nephrostomy or pyelostomy tube may be placed, and/or a ureteral splint (stent) may be introduced to maintain the diameter of the ureter and facilitate urine drainage.
• Step 8: Ureteral Anastomosis - The ureter is positioned along the incision lines in the renal pelvis and is then anastomosed, which involves suturing the ureter to the renal pelvis to restore continuity and function.
• Step 9: Drain Placement and Closure - Drains are placed as needed to prevent fluid accumulation, and the operative wound is closed around the drains to complete the procedure.

3. Post-Procedure

After the pyeloplasty procedure, patients typically require careful monitoring and post-operative care. Expected recovery may involve managing pain, monitoring for signs of infection, and ensuring proper urine output. The placement of nephrostomy or pyelostomy tubes may necessitate additional care and follow-up to assess their function and the healing process. Patients may also need to follow specific instructions regarding activity restrictions and follow-up appointments to evaluate the success of the surgery and the overall health of the kidney. It is essential to ensure that the anastomosis is functioning correctly and that there are no complications arising from the procedure.