upjo , although usually a congenital disease , can present clinically at any age , with an incidence rate of 1:1000 at time of birth .
primary upjo can be associated with other renal anomalies , such as horseshoe kidney and ectopic kidney , in which upjo is present in 30% and 40% , respectively .
concomitant nephrolithiasis can be present in about 20% of upjo patients [ 3 , 4 ] .
laparoscopic pyeloplasty as a minimally invasive procedure is now considered the standard technique for the treatment of upjo , with equal success results as open surgery [ 58 ] , however , the presence of another pathology represents further surgical challenge for laparoscopic surgeons to perform laparoscopic pyeloplasty , as the ability to perform this operation and the related complications are affected significantly by the complexity of the surgical procedure and the surgeon 's experience . in this case series , we present 6 patients who were managed for upjo and at the same time had concomitant pathology , such as renal stones , hepatomegaly due to multiple large hepatic cysts , para - pelvic renal cyst , umbilical hernia , renal ptosis , and renal malrotation . in all these cases ,
upjo was managed successfully with laparoscopic pyeloplasty , with auxiliary surgical intervention according to the concomitant pathology .
by retrospective analysis of all laparoscopic pyeloplasty cases in our institute and after exclusion of all cases with only upjo with no other pathology , six patients who underwent laparoscopic pyeloplasty between september 2010 and june 2012 were included in this study .
this cohort included 4 females and 2 males with an average age of 44 years old and a range of 27 to 60 years .
three patients were left sided ( 50% ) and 3 were right sided ( 50% ) .
in addition to upjo , 2 patients had renal stones , one patient had both renal ptosis and an umbilical hernia , 3 patients had a para - pelvic cyst ( 5x4 cm ) , hepatomegaly due to multiple hepatic cysts ( largest was 20 cm ) , and malrotated kidney , respectively .
all patients presented with mild to moderate flank pain and were investigated with ultrasound , ct or ivu , and renal isotope scan that revealed salvageable split kidney function of the affected renal unit in all patients . after obtaining
informed written consent , including the possibility for open conversion , laparoscopic pyeloplasty was performed .
pneumoperitoneum was created by mini laparotomy technique through a small incision in the periumbilical ring .
the other 2 ports ( 5 and 12 mm ) were fixed in the midclavicular line under direct vision .
four patients ( 66% ) had a crossing vessel towards the lower pole of the kidney that was successfully preserved in all cases .
after dissection of the peripelvic tissue , the renal pelvis was fixed by a staying suture to the lateral abdominal wall .
the pyeloplasty was performed with dismembered anderson- hynes technique and the ureter was spatulated towards the medial border of the kidney to avoid ureteral rotation during suturing .
anastomosis was performed by 4/0 vicryl starting by suturing the apex of the ureteral spatulation to the most dependent part of the pylotomy after transpositioning of the ureter above the crossing vessel .
a double j stent was fixed in the antegrade way through the upper lateral port before completing the anastomosis by running watertight suturing .
a drain was fixed at the end and the port sites were closed in layers . in the 2 cases with renal stones , the first case had multiple lower calyceal stones , thin parenchyma due to
a small lower pole nephrotomy was performed by mono - polar hook and the stones were retrieved by laparoscopic grasper .
the lower calyx was irrigated by suction to wash out any blood clots or small gravels .
the nephrotomy was closed by continuous 0/0 vicryl suturing and the suture was controlled by abs luck ( figure 1 ) .
the second case had a single lower calyceal stone with slightly normal parenchyma and a wide calyceal neck .
after division of the renal pelvis during laparoscopic pyeloplasty , flexible urs was advanced through the 12 mm port into the renal pelvis and the lower calyx and the stone was retrieved ( figure 2 ) .
left sided ureteropelvic obstreuction with single lower calyceal stone . in the third case with a huge hepatic cyst ,
the challenge in performing laparoscopic pyeloplasty was the anatomical changes , as the kidney was in a lower position than normal due to the effect of the space occupying cyst ; therefore , the working space was very limited .
during minilaprotomy at the start of the operation , some resistance beneath the peritoneum was felt by the finger due to the liver , which was retracted up and laterally by the finger before opening the peritoneum and fixation of the camera port .
the other two ports were fixed in a triangular manner but in lower than usual sites .
the hepatic laceration could be easily controlled by compression with a sponge , then application of synthetic haemostatic material ( figure 3 ) .
the fourth patient had ipsilateral renal ptosis and an umblical hernia that was first reduced and then an incision was carefully created over the hernial site , and the port was fixed under direct vision to avoid bowel injury .
the kidney was grasped higher than its normal anatomical position and fixed from gerota 's fascia to the lateral abdominal wall by a stay suture from outside , then pyeloplasty was performed in this position .
after pyeloplasty , nephropexy was performed by suturing the renal capsule to the posterolateral abdominal wall by two 0/0 absorbable interrupted sutures .
after removal of the trocars , the umbilical incision was extended laterally by 1 cm on each side .
the peritoneum was released all around the hernial defect and closed with 3/0 absorbable sutures .
the hernial defect was closed in double layer by the fascia over fascia technique ( figure 4 ) .
renal isotope scan showing obstructed pattern of the right kidney with low position due to renal ptosis .
the fifth patient had a para - pelvic cyst ( 5x4 cm ) that was masked the renal pelvis .
the cyst was dissected first from the renal pelvis and de - roofed with mono - polar hook , then pyeloplasty was performed ( figure 5 ) . left sided ureteropelvic obstruction with para - pelvic cyst . in the sixth case with malrotation , difficulty of pyeloplasty
it was then re - rotated and fixed through the pelvis by a staying suture in a position suitable for intra - corporeal suturing .
the ureter was spatulated towards the lower pole after partial cutting of the renal pelvis and before complete division to avoid disorientation and subsequent ureteral rotation .
all patients presented with mild to moderate flank pain and were investigated with ultrasound , ct or ivu , and renal isotope scan that revealed salvageable split kidney function of the affected renal unit in all patients .
after obtaining informed written consent , including the possibility for open conversion , laparoscopic pyeloplasty was performed .
pneumoperitoneum was created by mini laparotomy technique through a small incision in the periumbilical ring .
the other 2 ports ( 5 and 12 mm ) were fixed in the midclavicular line under direct vision .
four patients ( 66% ) had a crossing vessel towards the lower pole of the kidney that was successfully preserved in all cases .
after dissection of the peripelvic tissue , the renal pelvis was fixed by a staying suture to the lateral abdominal wall .
the pyeloplasty was performed with dismembered anderson- hynes technique and the ureter was spatulated towards the medial border of the kidney to avoid ureteral rotation during suturing .
anastomosis was performed by 4/0 vicryl starting by suturing the apex of the ureteral spatulation to the most dependent part of the pylotomy after transpositioning of the ureter above the crossing vessel .
a double j stent was fixed in the antegrade way through the upper lateral port before completing the anastomosis by running watertight suturing .
a drain was fixed at the end and the port sites were closed in layers . in the 2 cases with renal stones , the first case had multiple lower calyceal stones , thin parenchyma due to
a small lower pole nephrotomy was performed by mono - polar hook and the stones were retrieved by laparoscopic grasper .
the lower calyx was irrigated by suction to wash out any blood clots or small gravels .
the nephrotomy was closed by continuous 0/0 vicryl suturing and the suture was controlled by abs luck ( figure 1 ) .
the second case had a single lower calyceal stone with slightly normal parenchyma and a wide calyceal neck .
after division of the renal pelvis during laparoscopic pyeloplasty , flexible urs was advanced through the 12 mm port into the renal pelvis and the lower calyx and the stone was retrieved ( figure 2 ) .
left sided ureteropelvic obstreuction with single lower calyceal stone . in the third case with a huge hepatic cyst ,
the challenge in performing laparoscopic pyeloplasty was the anatomical changes , as the kidney was in a lower position than normal due to the effect of the space occupying cyst ; therefore , the working space was very limited .
during minilaprotomy at the start of the operation , some resistance beneath the peritoneum was felt by the finger due to the liver , which was retracted up and laterally by the finger before opening the peritoneum and fixation of the camera port .
the other two ports were fixed in a triangular manner but in lower than usual sites .
the hepatic laceration could be easily controlled by compression with a sponge , then application of synthetic haemostatic material ( figure 3 ) .
the fourth patient had ipsilateral renal ptosis and an umblical hernia that was first reduced and then an incision was carefully created over the hernial site , and the port was fixed under direct vision to avoid bowel injury .
the kidney was grasped higher than its normal anatomical position and fixed from gerota 's fascia to the lateral abdominal wall by a stay suture from outside , then pyeloplasty was performed in this position .
after pyeloplasty , nephropexy was performed by suturing the renal capsule to the posterolateral abdominal wall by two 0/0 absorbable interrupted sutures .
after removal of the trocars , the umbilical incision was extended laterally by 1 cm on each side .
the peritoneum was released all around the hernial defect and closed with 3/0 absorbable sutures .
the hernial defect was closed in double layer by the fascia over fascia technique ( figure 4 ) .
renal isotope scan showing obstructed pattern of the right kidney with low position due to renal ptosis .
the fifth patient had a para - pelvic cyst ( 5x4 cm ) that was masked the renal pelvis .
the cyst was dissected first from the renal pelvis and de - roofed with mono - polar hook , then pyeloplasty was performed ( figure 5 ) . left sided ureteropelvic obstruction with para - pelvic cyst . in the sixth case with malrotation , difficulty of pyeloplasty
it was then re - rotated and fixed through the pelvis by a staying suture in a position suitable for intra - corporeal suturing .
the ureter was spatulated towards the lower pole after partial cutting of the renal pelvis and before complete division to avoid disorientation and subsequent ureteral rotation .
all patients were treated successfully for upjo and the concomitant pathologies , except hepatomegaly and malrotation . estimated blood loss was less than 50 ml .
there were no intra or postoperative complications except the hepatic laceration in the third patient , which was easily managed .
the 2 patients with renal stones both had a postoperative stone free abdominal computed tomography .
renal function assessment by renal isotope scan mag3 at 3 , 12 months post operative revealed stabilized function as pre operative values with no more deterioration or obstruction .
many publications confirmed that laparoscopic pyeloplasty has equal success rates in comparison to the open technique with less morbidity for the patient [ 58 ] . in our experience , we usually fix the first port for the camera in the periumbilical ring for better cosmotic results , provided that the patient 's bmi is within normal , as in the patients included in this study . in obese patients
upjo can be associated with other pathologies , either congenital such as malrotation or parapelvic cysts or acquired pathologies such as renal stones , hepatomegaly , and renal ptosis .
these pathologies can be just concomitant and not directly related to the upjo , or may be as a result of obstruction and inadequate urinary drainage , such as in renal stones .
presence of concomitant pathology with upjo makes laparoscopic pyeloplasty more complex and challenging for surgeons , especially those who are starting laparoscopic pyeloplasty , because the associated pathology either needs auxiliary surgical intervention to be corrected , or at least makes laparoscopic pyeloplasty more difficult due to anatomical changes or limited working space .
although robotic assisted laparoscopic pyeloplasty can be a good alternative to conventional laparoscopy in complex situations , the very high financial cost is still the main limiting factor . although the volume of this study is small , it represents a wide variety of pathologies that may be associated with upjo .
yin z. and colleagues reported on successful management of upjo with stones in sixteen patients using laparoscopic pyeloplasty and flexible urs .
juan g r and colleagues reported on successful management of renal stones during laparoscopic pyeloplasty using flexible urs in eight patients and laparoscopic grasper in four patients .
associated renal stones can be treated by different methods ; for example , laparoscopic pyelolithotomy , laparoscopic nephrolithotomy , fexible urs , or pcnl .
this depends on the stone number , location , degree of hydronephrosis , and parenchymal thickness .
we used laparoscopic nephrolithotomy in the first case , as the stone burden was located in the lower calyx and the parenchyma was thin .
in the second case , flexible urs was considered less invasive , as the parenchyma was quiet thick and the calceal neck was wide [ 13 , 14 ] .
percutaneus approach by performing pcnl and endopylotomy incision can be an alternative for laparoscopy in upjo with renal stones , but the lower success rate of endopylotomy in comparison to laparoscopic pyeloplasty in primary upjo makes this approach questionable .
para - pelvic cyst was excised to avoid mechanical compression over the pelvis that may affect urine flow from the kidney , with subsequent persistence of the symptoms .
renal ptosis was corrected by nephropexy to exclude this factor as a cause for postoperative flank pain hepatomegaly and malrotation were considered uncorrectable pathologies , but they represented difficult situations due to a small working space and difficult access for intracorporial suturing .
laparoscopic pyeloplasty can be performed in complex situations due to associated pathologies , provided that the surgeon has enough experience . however , bigger series are needed to assess the feasibility of laparoscopic pyeloplasty in these complex cases .
 introductionlaparoscopic pyeloplasty is considered a standard treatment for ureteropelvic junction obstruction ( upjo ) 
 . however , the presence of another pathology makes it a more challenging operation and guides the surgeon towards open conversion . in this study , we present our experience in difficult pyeloplasty cases managed by laparoscopy.material and methodssix patients ( 4 females and 2 males ) with an average age of 44 and a range of 27 to 60 years old , were diagnosed for upjo . 
 three were on the left side and 3 on the right side . 
 in addition to upjo , 2 patients had renal stones , one patient had both renal ptosis and an umbilical hernia , 3 patients had a para - pelvic cyst , hepatomegaly and malrotated kidney , respectively . 
 all patients had a preoperative ultrasound , ct or ivu , and a renal isotope scan . 
 laparoscopic pyeloplasty was performed according to the dismembered anderson - hynes technique with auxiliary maneuver , according to the pathology.resultsall patients were treated successfully for upjo and the concomitant pathologies , except hepatomegaly and malrotation . 
 mean operative time was 125 minutes and estimated blood loss was < 50 ml.conclusionslaparoscopic pyeloplasty can be performed in difficult situations provided that the surgeon has enough experience with laparoscopy . 
INTRODUCTION
MATERIAL AND METHODS
Preoperative evaluation
Operative technique
RESULTS
DISCUSSION
CONCLUSIONS
CONFLICTS OF INTEREST