Preoperative Preparation

Prior to surgery, the patient should refrain from oral intake after midnight the day before surgery, and receive a mechanical bowel preparation. A bottle of magnesium citrate should suffice. An orogastric tube should be placed to deflate the stomach. This precaution should decrease the risk of injury to the stomach during trocar placement. Antibiotic prophylaxis such as a first-generation cephalosporin should be given. Pneumatic compression stockings should be placed to prevent deep venous thrombosis.

Patient positioning is dictated by the anatomic approach chosen. For the retroperitoneal approach, the patient is placed in full flank position, with the surgical table flexed and kidney rest deployed to maximize the space between the costal margin and iliac crest. If the transperitoneal approach is preferred, the patient is placed in a 60° lateral decubitus position. The patient should be carefully strapped to the surgical table. The patient should be sufficiently secured to permit maximal tilt of the table to either side. During the case, the tilt of the table can be adjusted to maximize gravity-assisted retraction of the bowels. Also, the patient should be well padded at all pressure points to avoid neurological injury.

Although not technically a preoperative measure, stent placement is an important step prior to laparoscopic pyeloplasty. Prepyeloplasty stent placement is much easier than intraoperative placement.

Selection of a stent at least 2 cm larger than the estimated required stent length is crucial. With division of the ureteropelvic junction, the natural elastic properties of the tissue result in retraction. If the stent is too short, it may not be easy to replace in the renal pelvis. The added length facilitates positioning of the proximal stent during anastomosis.

After stent placement, a Foley catheter should be placed in the bladder and left to gravity drainage.

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