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Excising lower part of upper moiety ureter
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Laparoscopic transperitoneal upper moiety nephroureterectomy for renal duplications in pediatric patients
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Harmonic scalpel is used to go between the plane of cleavage seen between the upper and lower moiety and used to divide the tissue. Effort is made to prevent ant damage the renal capsule of lower moiety. Here if needed the division can be done trans-calyceal through the upper moiety.
The upper moiety dilated ureter is divided in its middle part do that further mobilisation of the upper moiety can be done. This will help in untangling the ureter from the main renal pedicle.
The Upper moiety pelvis and the ureter almost always travel behind the main renal pedicle and this need to be flipped out from the renal hilum. Gentle dissection her will allow to pull out the ureter from the main pedicle and will further help in dissection of the upper moiety and its removal.
Once the upper moiety is released the superior surface of the lower kidney is inspected for any tissue remnants and bleeding. The raw surface seen is with intact renal capsule and is well preserved. The colour of the normal kidney is also intact and is unharmed from any vascular insult. If required haemostasis is done with diathermy.
Keywords
- Renal capsule
- Lower moiety
- Upper Moeity
- Renal Capsule
- Upper Moeity Pelvis
- Renal Hilum
Conflict of Interest
The author declares no conflict of interest.
About this video
- Author(s)
- Ravi P. Kanojia
- First online
- 14 April 2021
- DOI
- https://doi.org/10.1007/978-981-16-1798-0_7
- Online ISBN
- 978-981-16-1798-0
- Publisher
- Springer, Singapore
- Copyright information
- © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021
Video Transcript
And we are now initiating the dissection of the upper moiety nephrectomy. And we have started removing it. We can very well appreciate that there is a clear plane between the two moieties of the kidney, and you have to stay strictly in this plane.
However, if it is difficult sometimes, because of balance pyelonephritis and extensive inflammation in addition, this plane will result in some kind of hemorrhage. So it is better to stay towards the dysplased, big moiety rather than the normal renal moiety in order to avoid any capsular damage or hemorrhage within the normal lower renal mighty.
So that you can see that we have gone through the calyces, the dilated calyces of the upper moiety. And we are trying to lift it up and then cut in the plane which is visible over there.
Now, at this point of the time, it can be visualized that it is always a very constant anatomy that the ureter and the pelvis of this dysplastic moiety is looping beneath the main renal pedicle and then going down towards the bladder.
So at this point, you will have to unloop and untangle the ureter and the pelvis of this dysplastic moiety. And you have to take it off and untangle it from the lower moiety. So this is what is exactly happening over here.
So before we can actually do that, we will have to divide the ureter at some place in the middle area. So we are now dividing the dilated upper moiety ureter somewhere in the mid-ureteric area so that this can be pulled away.
So the ureter is divided now, and now it is ready to be unlooped from the main renal pedicle. So there you can go down. There you can see that now we can easily pull it off. And now the entire upper moiety as well as the upper part of the divided ureter is entirely above the lower moiety. And you can safely proceed with your dissection of excising the upper moiety.
So you can see that there is a very clear plane between the two moieties. And you have to stay strictly within this plane. So we are now almost done. We are completing the upper moiety removal. The last bit is done, also done by harmonic scalpel. The other options would be using ENSEAL or even electrocautery device.
You can see that the color of the lower moiety is well maintained. And this proves that the vascular supply to the lower moiety is intact. So this upper moiety was sitting on top of the lower moiety as a polar cap and had got a dilated pelvicalyceal system.
So once you get into the right plane, you will be able to shave it off from the upper surface of the lower moiety. This is one of the last few bits of excision of the upper moiety. There you go, the upper moiety has not been completely taken off from the upper pole of the lower moiety.
Now, all you are left with is excision of the lower part of the ureter. Before you go on to do that, you will be inspecting the upper pole of this kidney to look for any kind of bleeding areas. As you can see that the capsule of the lower moiety is intact, and there are no bleeding areas in this portion of the kidney.
So this is the raw surface with the intact superior pole of the lower moiety. The capsule of the lower moiety is intact. The escalator is intact. And the color of the kidney is intact.