Dissection

Incision of the line of Toldt and mobilization of the colon is the first step during transperitoneal laparoscopic pyeloplasty. In right-sided cases, the Kocher maneuver may be necessary to mobilize the duodenum and expose the renal hilum. Next, the ureter is identified, and dissected free. Tenting up the ureter, the dissection is cephalad toward the ureteropelvic junction.

If a crossing vessel is identified, the ureter needs to be freed up completely from the vessel to facilitate eventual transposition. The renal pelvis needs to be freed up as much as possible to enable possible ureteral transposition and a tension-free anastomosis.

Retroperitoneal technique is usually facilitated by the fact that no extensive dissection is necessary. When dissecting in the proper anatomic space, the ureter and renal arterial anatomy should be rapidly identified. Dissection of these structures is necessary to ensure a tension-free anastomosis.

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