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Pyelovesicostomy

Pyelovesicostomy (also vesicopyelostomy or pyelo-vesicotomy) is a direct anastomosis between the renal pelvis and the bladder, completely bypassing the ureter. It is feasible only when the kidney lies close to the bladder — a renal allograft in the iliac fossa or a pelvic ectopic kidney — or when the bladder can be mobilized sufficiently (typically with a Boari flap) to reach the pelvis. Small selected series report successful drainage, including 2 transplant patients followed for 20 years. These reports do not establish an overall success rate or freedom from late complications.[1][2][4][5]

The defining anatomic prerequisite is a tension-free anastomosis between the dependent renal pelvis and the bladder.[1][7]

Lineage​

  • 1973 — Kennelly, Konnak, and Herwig first described vesicopyelostomy in 2 transplant patients with ureteral loss; both allografts functioned at 20-year follow-up.[5]
  • 1985 — Carini et al. reported pyelovesicostomy as an alternative to UPJ-plasty in pelvic ectopic kidneys.[2]
  • 1986 — Rajfer et al. landmark series of 8 transplant patients (2 mo–11 yr); no functional deterioration despite free pyelovesical reflux.[1]
  • 1998 — del Pizzo et al. direct pyelovesicostomy in 5/20 transplant patients requiring total ureteral reconstruction; 100% success.[6]
  • 2005 — Davis and Wolf first laparoscopic pyelovesicostomy for UPJO in a pelvic kidney.[3]
  • 2009 — Kumar and Panigrahy five laparoscopic pyelovesicostomies for complex UPJO in pelvic kidneys / giant hydronephrosis.[7]
  • 2020 — Kim et al. robot-assisted pyelovesicostomy for transplant ureteral strictures.[8]

Indications​

Renal transplantation​

  • Complete ureteral necrosis — entire donor ureter absent, necrotic, or diseased.[1][6]
  • Long or multisegment ureteral strictures refractory to endoscopic management.[9][6]
  • Failed prior ureteral reconstruction (ureteroureterostomy, ureteroneocystostomy, pyeloureterostomy).[1]
  • Absent or unusable recipient native ureter that would otherwise allow pyeloureterostomy.[1]

Pelvic ectopic kidneys​

  • UPJ obstruction in a congenital pelvic kidney where a short, tortuous ureter makes pyeloplasty technically difficult.[2][7][10]
  • Failed prior pyeloplasty in a pelvic kidney (especially solitary kidney).[2]
  • Giant hydronephrosis with a dependent pelvis lying adjacent to the bladder.[7]

Other​

  • Crossed fused ectopia with UPJO.[7]
  • Salvage when all other reconstructive options have been exhausted.[4][1]

Surgical Technique​

Open, laparoscopic, or robotic.[1][3][8][7]

Open (transplant setting)​

  1. Exposure. Use the original transplant incision or an iliac-fossa approach; identify and excise the necrotic or strictured ureter.[1][6]
  2. Bladder mobilization. Mobilize the bladder superiorly and laterally toward the renal pelvis. The contralateral superior vesical pedicle may be divided to gain additional reach.[6]
  3. Pelvic preparation. Open the renal pelvis at its most dependent point and spatulate the opening for a wide-mouthed anastomosis.[1]
  4. Anastomosis. Tension-free, mucosa-to-mucosa, single- or two-layer closure with absorbable suture (4-0 or 5-0 polyglycolic acid).[1][6]
  5. Stenting. Internal ureteral stent or nephrostomy across the anastomosis, typically 4–6 weeks.[6][8]
  6. Drainage. Closed-suction drain in the perivesical space.[6]

Pyelovesicostomy with Boari flap (transplant setting)​

When the renal pelvis cannot reach the bladder directly:[9]

  1. Full-thickness rectangular or trapezoidal flap from the anterior bladder wall.
  2. Swing cranially and tubularize to reach the renal pelvis.
  3. Anastomose the tubularized flap to the renal pelvis.
  4. Kroczak n = 10 reported 100% success with graft function salvaged in all cases and no stricture recurrence at mean 18-month follow-up.

Laparoscopic (pelvic kidney)​

Kumar/Panigrahy standardized approach:[7]

  1. Four-port technique: two 10-mm (umbilicus + lateral border of ipsilateral rectus) + two 5-mm.
  2. Identify pelvic kidney, dissect renal pelvis free, mobilize bladder dome.
  3. Anastomose the most dependent part of the renal pelvis to the bladder dome with intracorporeal suturing.
  4. Suprapubic Foley as an across-anastomosis stent.
  5. Mean OR time 140 min and mean blood loss 50 mL describe the whole 9-patient mixed-procedure cohort, including 5 pyelovesicostomies; no intraoperative complications were reported.

Robotic (transplant setting)​

Kim n = 5 (3 pyelovesicostomy + 2 ureteroneocystostomy):[8]

  • Mean LOS 2.2 d.
  • All 5 successful with no strictures or delayed leaks at mean 97 d.
  • Demonstrates robotic feasibility; this uncontrolled 5-patient cohort cannot establish lower tissue trauma or morbidity than open repair.

Outcomes​

SettingnSuccessFollow-upKey finding
Transplant — direct[1]8100%2 mo–11 yrNo functional deterioration; free reflux tolerated
Transplant — vesicopyeloplasty[5]2100%20 yrBoth allografts functioning
Transplant — Boari flap + pyelovesicostomy[9]10100%18 mo (mean)No stricture recurrence; graft function salvaged
Transplant — direct (subset)[6]5100%28 mo (mean)Part of 20-pt series (15 Boari, 5 direct)
Transplant — robotic[8]3 pyelovesicostomies within 5 repairsAll 5 repairs successful97 d (mean for the mixed cohort)LOS 2.2 d for the mixed cohort
Pelvic kidney — laparoscopic[7]5100%VariableAnastomotic patency confirmed
Pelvic kidney — open[2]2100%VariableSterile urine; stable function
Pelvic kidney — laparoscopic[3]1100%—First laparoscopic case; OR 207 min

The Reflux Question​

The anastomosis is inherently refluxing — there is no antireflux mechanism between the bladder and the renal pelvis. Small selected series reported stable function despite reflux. They do not establish that reflux is harmless in every bladder or transplant:[1][6][5]

  • Rajfer n = 8 at up to 11 yr — no deterioration attributable to reflux or anastomotic obstruction.
  • Kennelly n = 2 at 20 yr — both allografts functioning despite free reflux.
  • del Pizzo — reflux into the transplant pelvis in 6/20 (Boari + direct combined) without functional decline.

Bladder storage pressure, emptying, recurrent infection and graft function must be assessed rather than assumed normal. Kumar and Panigrahy advised double voiding in their series; tailor emptying management to the patient and maintain long-term renal and drainage surveillance.[7][11]

Complications​

  • UTI — an important complication; the small heterogeneous series do not establish a dependable procedure-specific rate.[4][7]
  • Persistent hydronephrosis — mild residual collecting-system dilatation may persist without obstruction on diuretic renography.[2][6]
  • Anastomotic obstruction — monitor even when early drainage is satisfactory; absence in small reports does not exclude late risk.[1][6][5]
  • Urine leak — prolonged high-volume drain output (mean 22 d) in the Boari-flap subgroup, not in direct pyelovesicostomy.[6]
  • Graft dysfunction or loss — distinguish obstruction and infection from rejection and other transplant causes; reconstruction does not eliminate these risks.[4][1]

Subcutaneous Pyelovesical Bypass Graft (SPBG) — Salvage Alternative​

For transplant patients with extended strictures not eligible for open ureteral reconstruction, a percutaneous prosthetic stent tunneled subcutaneously from renal pelvis to bladder offers a last-resort salvage:[12][13]

  • Muller 15-yr experience (n = 7) — no encrustation or dislodgment at mean 6 yr, but infection in 3/7 patients (the abstract prints 47%, inconsistent with that denominator) including 1 death from septic shock due to fungal colonization.
  • Azhar n = 8 — 7/8 grafts functioning (mean GFR 58.5 mL/min/1.73 m²) at 19.4 mo, but 1 graft lost to persistent SPBG infection.

SPBG is reserved for patients in whom conventional pyelovesicostomy or Boari-flap reconstruction is not feasible.[13]

Choosing Among Reconstructive Options​

Direct pyelovesicostomy requires the bladder to reach a suitable dependent renal pelvis. A Boari flap may bridge an additional gap if bladder capacity, compliance and perfusion are adequate. Both avoid bowel harvest but may still be complex reoperations around transplant vessels.[6][8][9]

Ileal ureter and renal autotransplantation have different bowel, vascular and renal prerequisites. Cross-series success percentages should not be used to rank these anatomically different options.

Pyelovesicostomy vs Calicovesicostomy​

When the renal pelvis is intrarenal (small or absent extrarenal pelvis), direct pyelovesicostomy may be infeasible. Calicovesicostomy — anastomosis of a lower-pole calyx directly to the bladder — is an alternative. Kumar and Panigrahy performed calicovesicostomy in 1 patient with intrarenal pelvis with successful drainage on follow-up nephrostogram. The authors advised double voiding and long-term surveillance; emptying management must reflect the individual bladder.[7]

See Also​

References​

1. Rajfer J, Koyle MA, Ehrlich RM, Smith RB. Pyelovesicostomy as a form of urinary reconstruction in renal transplantation. J Urol. 1986;136(2):372–375. doi:10.1016/s0022-5347(17)44872-5

2. Carini M, Selli C, Grechi G, Masini G. Pyelovesicostomy: an alternative to ureteropelvic junction-plasty in pelvic ectopic kidneys. Urology. 1985;26(2):125–128. doi:10.1016/0090-4295(85)90043-3

3. Davis DE, Wolf JS. Laparoscopic pyelovesicostomy for ureteropelvic junction obstruction in a pelvic kidney. J Endourol. 2005;19(4):469–470. doi:10.1089/end.2005.19.469

4. Novacescu D, Abol-Enein H, Latcu S, et al. Ureteric complications and urinary tract reconstruction techniques in renal transplantation: a surgical essay. J Clin Med. 2025;14(12):4129. doi:10.3390/jcm14124129

5. Kennelly MJ, Konnak JW, Herwig KR. Vesicopyeloplasty in renal transplant patients: a 20-year followup. J Urol. 1993;150(4):1118–1120. doi:10.1016/s0022-5347(17)35702-6

6. del Pizzo JJ, Jacobs SC, Bartlett ST, Sklar GN. The use of bladder for total transplant ureteral reconstruction. J Urol. 1998;159(3):750–752; discussion 752–753.

7. Kumar S, Panigrahy B. Laparoscopic management of complex ureteropelvic junction obstruction. J Laparoendosc Adv Surg Tech A. 2009;19(4):521–528. doi:10.1089/lap.2008.0397

8. Kim S, Fuller TW, Buckley JC. Robotic surgery for the reconstruction of transplant ureteral strictures. Urology. 2020;144:208–213. doi:10.1016/j.urology.2020.06.041

9. Kroczak T, Koulack J, McGregor T. Management of complicated ureteric strictures after renal transplantation: case series of pyelovesicostomy with Boari flap. Transplant Proc. 2015;47(6):1850–1853. doi:10.1016/j.transproceed.2015.02.020

10. Cinman NM, Okeke Z, Smith AD. Pelvic kidney: associated diseases and treatment. J Endourol. 2007;21(8):836–842. doi:10.1089/end.2007.9945

11. Kristjansson A, Mansson W. Renal function in the setting of urinary diversion. World J Urol. 2004;22(3):172–177. doi:10.1007/s00345-004-0431-y

12. Muller CO, Meria P, Desgrandchamps F. Long-term outcome of subcutaneous pyelovesical bypass in extended ureteral stricture after renal transplantation. J Endourol. 2011;25(8):1389–1392. doi:10.1089/end.2011.0085

13. Azhar RA, Hassanain M, Aljiffry M, et al. Successful salvage of kidney allografts threatened by ureteral stricture using pyelovesical bypass. Am J Transplant. 2010;10(6):1414–1419. doi:10.1111/j.1600-6143.2010.03137.x