Retroperitoneal laparoscopic dismembered pyeloplasty

A Single Institute's Experience in Retroperitoneal Laparoscopic Dismembered Pyeloplasty: Results with 86 Consecutive Patients

Giorgio R. Martina, Paolo Verze, Pierluigi Giummelli, Salvatore Scuzzarella, Federico Cantoni, Giacomo Caruso, Marco Remotti and Vincenzo G. Mirone.

Journal of Endourology. June 2011, 25(6): 999-1003. doi:10.1089/end.2010.0683.

Department of Urology, Azienda Ospedaliera Valtellina e Valchiavenna, Ospedale di Sondalo, Sondalo, Italy.

Department of Urology, University Federico II of Naples, Naples, Italy.

Abstract

Purpose: To report our institute's retroperitoneal technique of laparoscopic pyeloplasty (LP) and present results of 86 consecutive patients.

Patients and Methods: From January 2004 to January 2009, 86 patients who were affected with ureteropelvic junction obstruction (UPJO) underwent retroperitoneal LP. In all operations, a four-port, balloon-dissecting, retroperitoneal approach was used and a simple "personalized" modification of the conventional Anderson-Hynes technique consisting of an approaching and stabilizing stitch made between the renal pelvis and proximal ureter. A needle introductor at the level of the surgical assistant's trocar was used as well to facilitate the Double-J stent introduction. Follow-up studies were performed postoperatively with intravenous urography and renal ultrasonography at 6, 12, and 18 months.

Results: All operations were completed laparoscopically, and no open conversions were needed. The mean operative time was 79.3 minutes (range 65–125 min). The mean blood loss was 10 mL (range 5–40 mL), and the mean postoperative hospitalization stay was 5.7 days (range 3–14 d). No intraoperative complications occurred. Aberrant crossing vessel and primary stricture as the cause of UPJO were noted in 31 and 55 patients, respectively. Transient anastomotic leakage occurred in six patients and was successfully treated by conservative management. A persistent UPJO was detected at first follow-up visit in three patients and was treated by conservative management in two cases and by performing an open pyeloplasty in one case. A mean follow-up of 29 months (range 18 to 48 mos) was performed and showed a 96.6% success rate after the first operation.

Conclusions: Our experience with LP in accordance with the Anderson-Hynes procedure has demonstrated that this technique is an effective treatment for UPJO, with a high overall success rate, a short hospital stay, and a negligible incidence of early complications.

Ureteropelvic junction obstruction (UPJO) represents an abnormality of the ureter caused by functional or anatomic abnormalities. It has had excellent surgical treatment outcomes since Anderson and Hynes first described the dismembered pyeloplasty technique more than 50 years ago. The open Anderson–Hynes procedure continues to be the gold standard with an overall success rate of 90%.1 First described in 1993 by Schuessler and colleagues,2 laparoscopic pyeloplasty (LP) has emerged as a feasible and reliable treatment of UPJO in the last two decades, with a success rate equivalent to that of the open procedure, yet associated with minimal morbidity and significant reduction of hospital care costs.

The aim of the present study is to report our personal experience with 86 consecutive patients who were affected with UPJO and who underwent LP in accordance with the Anderson-Hynes procedure.

Patients

We reviewed the charts of 86 consecutive patients who were affected with UPJO and who had previously undergone retroperitoneal laparoscopic dismembered pyeloplasties from January 2004 to January 2009. All patients included in the study presented a primary UPJO, while the patients with secondary strictures from preceding ureteral manipulation were excluded. Study population characteristics are reported in Table 1. The mean age was 35 years (range 18 to 59 y), and of the 48 women and 38 men, 57 presented UPJO on the right side and 29 on the left side. Mild to moderate flank pain was reported by 51 symptomatic patients, 8 of whom presented with a concomitant urinary tract infection. The remaining 35 asymptomatic patients discovered their UPJO incidentally while receiving renal ultrasonography for different reasons.

All patients were subject to a preoperative evaluation including renal ultrasonography and intravenous urography (IVU) with a high-volume contrast medium or a CT scan that revealed the presence of severe hydronephrosis associated with net obstruction of the ureteropelvic junction (UPJ) as indicated by the missing transit of the contrast medium downward to the UPJ. In 38 cases where a clear obstruction of the UPJ was not detected at the initial imaging study, diuretic renography was performed to confirm the obstructive etiology of the hydronephrosis and to exclude the presence of anatomic variants (such as extrarenal pelvis) that are not associated with true obstruction. Stones were detected in the renal pelvis in six patients. In seven of the women, a concomitant severe renal ptosis was detected.

Laparoscopic techniques

General anesthesia was used for all patients. Patients were positioned in the classic lateral decubitus position and adequately secured to the surgical table. A four-port balloon dissecting retroperitoneal laparoscopic approach was used. The first incision was performed at the level of the midaxillary line, and the retroperitoneal fat and the retroperitoneal space were separated by digital dissection. An adequate space in the retroperitoneum was created by balloon dilation. Three ports were guided by the index finger and placed at the subcostal anterior axillary line (10-mm trocar for assistant), the posterior axillary line (5-mm trocar for surgeon), and the anterior axillary line at the level of the iliac crest (5-mm trocar for surgeon). A 10-mm autoanchoring trocar for a 0° telescope was placed at the level of the first incision.

The lower pole of the kidney was identified. The dilated renal pelvis and the upper ureter were then fully mobilized using blunt and sharp dissection, and the cause of UPJO was evaluated.

Our personalized modification of the Anderson-Hynes procedure consists of placing a single 5-0 absorbable monofilament stitch between the posterolateral aspect of the proximal ureter, 0.5 cm distal to the obstructed position and renal pelvis, before proceeding with dismembering and resection of the UPJ. The stitch is intended to precisely gather the normal tracts of the ureter and renal pelvis that will be subsequently joined with sutures and concomitantly expose the obstructed segment of the UPJ that will then be resected and removed. The stitch is able to maintain a correct orientation during the resectioning of the obstructed UPJ tract, thereby avoiding irritating movements and leading to a more precise incision between exact anatomic landmarks. When an anomalous crossing vessel is detected, it is then necessary to remove the stitch to perform a decrossing manoeuver so as to anteriorly transpose the UPJ and eliminate the cause of the obstruction. In our experience, we found that the placement of the approaching stitch is also useful when a crossing vessel is detected and it becomes necessary to remove it, because in this way, we are able to perform a more precise sectioning of the UPJ obstructed tract.

The renal pelvis was partly divided from the most dependent part and adequately reduced in size, while the proximal ureter was spatulated with an incision on its lateral wall by using laparoscopic 10-mm Pott scissors.

The posterior pelvis-ureter anastomosis was performed using a running 5-0 monofilament absorbable suture, with the first suture positioned from the most inferior point of the ureteral spatulation to the most dependent portion of the pelvis. Before performing a similar running suture on the anterior wall of the anastomosis, a Double-J stent was inserted in antegrade fashion using a needle introductor placed at the level of the surgical assistant's trocar. The use of this technique allows for an extremely easier insertion of the Double-J stent, because all operative trocars (two for the surgeon and one for the assistant) can be used. With this method the surgeon is able to accurately direct the tip of the stent and facilitate its ureteral progression with the use of graspers inserted at the level of both his operative trocars, while the surgical assistant can push the Double-J stent through the needle introductor and keep an optimal exposure of the anatomic site with the laparoscopic blunt retractor inserted at the level of the trocar.

All sutures were tied by a freehand intracorporeal technique, with the knots placed outside the lumen. Stones in the renal pelvis (six patients) were removed with graspers under direct laparoscopic vision. In seven cases of concomitant severe renal ptosis, a 3-0 nonabsorbable fixation stitch was placed at the level of the upper renal pole and adjacent psoas muscle. A closed suction drain was positioned by way of a port incision into the perirenal space adjacent to the repair. Hemostasis was closely monitored after lowering the pressure of the retroperitoneal cavity. Three consecutive doses of 2 g of a third-generation cephalosporin were routinely prescribed on the same day of the operation.

Intraoperative and postoperative records were collected, including operative time, blood loss, and early and delayed complications.

The mean follow-up was 29 months (range 18–48 mos). Renal ultrasonography and IVU were performed 6, 12, and 18 months postoperatively, and thereafter a yearly follow-up with either IVU or renal ultrasonography was indicated.

All operations were successfully performed laparoscopically without conversion to open surgery. The results are summarized in Table 2. The mean operative time was 79.3 minutes (range 65–125 min). The mean blood loss was 10 mL (range 5–40 mL), and no blood transfusions were necessary. In 31 patients, an anomalous crossing vessel was detected and the UPJ was transposed anteriorly using the previously described technique. In the remaining 55 patients, a primary stricture of UPJ was noted. All removed UPJ segments were analyzed by a pathologist, and in all cases, the presence of an hypertrophic musculature and pyelitis with intense inflammation was reported. No intraoperative complications were observed. The Foley catheter was removed 2 or 3 days postoperatively. The closed suction drain placed in the retroperitoneal cavity was subsequently removed if the drainage output had not increased and was less than 10 mL in 24 hours after the Foley catheter removal. A transient anastomotic leakage occurred in six patients and necessitated prolonged suction drainage.

The Double-J stent was removed 4 weeks postoperatively. The mean postoperative hospital stay was 5.7 days (range 3–14 d). All 51 preoperatively symptomatic patients reported a complete resolution of symptoms after the operation. The radiologic follow-up showed a patent UPJ and a significant reduction in preoperative hydronephrosis in all patients except for three (3.4%), whereby a persistence of a partial UPJ obstruction and moderate to severe hydronephrosis was detected at the first postoperative follow-up visit at month 6. Two of these patients were conservatively treated by retrograde insertion of a Double-J stent that was left in place for 3 months with a consequent complete recovery of the postoperative obstruction. In only one patient who had recurrent UPJ obstruction after stent removal was a successful open dismembered pyeloplasty performed.

The six patients who presented with a stone in the renal pelvis were stone free at consecutive follow-up visits.

Discussion

The surgical management for UPJO includes various options, such as different types of open pyeloplasty, antegrade or retrograde endopyelotomy, and laparoscopic pyeloplasty.3,4 Today, open pyeloplasty remains the gold standard approach because of its extensive use and high success rate. The advantages of minimally invasive procedures over traditional open pyeloplasty include a shortened hospital stay and significant morbidity reduction over the conventional open procedure that necessitates a large incision, associated pain, and risk of nerve injury.5 A comparison of antegrade and retrograde endopyelotomy showed no significant difference in success rates between these two procedures, although retrograde endopyelotomy is characterized by a shorter hospital stay, fewer complications, and lower costs.6 The most common retrograde approaches are based on the use of a hot-wire balloon endopyelotomy or, alternatively, an holmium laser endopyelotomy. Success rates are comparable for both retrograde techniques, although holmium laser endopyelotomy is associated with fewer hemorrhagic complications, as reported in a comparative study.7

More recently, with the extensive use of the laparoscopic approach in urologic practice, laparoscopic Anderson-Hynes dismembered pyeloplasty has increasingly become the more popular procedure in the management of UPJO, with adequate final outcomes. A comparative study conducted with 42 cases of LP and 35 cases of open pyeloplasty showed a success rate of 98% in a laparoscopic group and 94% in an open group, with no differences in terms of functional results, as proven by the resolution of preoperative hydronephrosis.8 Furthermore, the results of another comparative study of laparoscopic dismembered pyeloplasty and open dismembered pyeloplasty showed that the success rate was 96.0% (24 of 25 patients) for the laparoscopic approach and 93.4% (14 of 15 patients) for the open approach.9

Both of these comparative studies confirm that the laparoscopic approach guarantees high success rates and, in addition, offers the advantage of a minimally invasive procedure in terms of low morbidity, shortened hospital stay, and fast postoperative recovery. LP can be performed by using either a transperitoneal or, alternatively, a retroperitoneal approach. The transperitoneal operation offers the advantages of a larger working space and promptly identifiable anatomic landmarks, while the retroperitoneoscopic technique has the advantage of direct access to the urinary tract and a preferable detection of crossing vessels that leads to the avoidance of manipulation and contact with the intraperitoneal organs.3 The first prospective randomized study that compared the transperitoneal and retroperitoneal approaches was published in 2007 and was able to demonstrate conclusive data.10

Before this publication, available data in the medical literature was conflicting and mainly based on retrospective studies in which more than one surgeon performed different procedures.11,12 The publication by Shoma and associates10 concluded that, with early experience, both the transperitoneal and retroperitoneal LP techniques had comparable and satisfactory functional outcomes with minimal morbidity, with the exception that a longer operative time was needed for the retroperitoneal approach. At our institution, we have opted for the retroperitoneal procedure based on our extensive experience over the past few years gained by performing more than 1000 laparoscopic retroperitoneal procedures that have allowed us to obtain reasonable operative times and technical manipulation for LP.

We believe that the choice of performing a retroperitoneal or transperitoneal approach should be based mainly on the personal preference and experience of the individual surgeon. The use of a needle introductor to perform the antegrade Double-J insertion allowed us to significantly reduce the duration of this surgical step. A benefit of this approach is that the surgeon can simultaneously work through both operative 5-mm trocars facilitating a quick introduction, while the assistant guarantees an adequate site exposure with a laparoscopic retractor inserted in a 10-mm trocar.

The authors would like to emphasize an important technical point of the personal technique, consisting of a simple approaching stitch between the proximal ureter and renal pelvis. This surgical trick has ensured excellent results in terms of the quality of the pelvis-ureter anastomosis and the reduction in operative time.

As described previously, the stitch is intended to precisely gather the normal tracts of the ureter and renal pelvis that will subsequently be joined with sutures, and simultaneously expose the obstructed segment of the UPJ that can then be easily resected and removed. Furthermore, it strongly limits irritating movements of the anatomic structures during the division of the renal pelvis, spatulation of the proximal ureter, and in carrying out the posterior suture. This is particularly useful in cases of limited operative space, such as during the retroperitoneal procedure and in the presence of a less skilled surgeon.

According to previously published studies, the minimum follow-up period for confirming the endurance of positive results is 12 months, bearing in mind that other studies with a longer follow-up period showed that UPJO recurrence after 1 year was extremely rare.11,13,14 In our experience, the minimum follow-up period was 18 months and was based on both a clinical and radiologic evaluation that confirmed a high success rate after the first postoperative 6 months (96.6%). In fact, our only three (3.4%) patients with partial persistence of postoperative UPJO were definitively treated by conservative management in two cases, and by a successful open dismembered pyeloplasty in one case.

Finally, associated procedures, such as pyelolithotomy and renal fixation, were successfully completed laparoscopically, without influencing the total operative time and led to a definitive solution of the concomitant stone disease or renal ptosis.

Conclusions

Our experience with retroperitoneal laparoscopic dismembered pyeloplasty has demonstrated that this technique represents an excellent minimally invasive treatment option for UPJO in expert hands, with a success rate of 96,6% and very low incidence of early postoperative complications. The reduced patient morbidity and length of hospital stays offer considerable advantages over open procedures.

1. O'Reilly PH, Brooman PJ, Mak S, et al. The long-term results of Anderson–Hynes pyeloplasty. BJU Int 2001;87:287–289.

2. Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM. Laparoscopic dismembered pyeloplasty. J Urol 1993;150:1795–1799.

3. Chuanyu S, Guowei X, Ke X, et al. Retroperitoneal laparoscopic dismembered Anderson-Hynes pyeloplasty in treatment of ureteropelvic junction obstruction (report of 150 cases). Urology 2009;74 1036–1040.

4. Baldwin DD, Dunbar JA, Wells N, McDougall EM. Single-center comparison of laparoscopic pyeloplasty, Acucise endopyelotomy, and open pyeloplasty. J Endourol 2003;17:155–60.

5. Dong J, Wong J, Al-Enezi A, et al. Laparoscopic pyeloplasty: The updated McMaster University experience. Can Urol Assoc J 2008;2:388–391.

6. Shalhav AL, Giusti G, Elbahnasy AM, et al. Adult endopyelotomy: Impact of etiology and antegrade versus retrograde approach on outcome. J Urol 1998;160:685–689.

7. Ponsky LE, Streem SB. Retrograde endopyelotomy: A comparative study of hot-wire balloon and ureteroscopic laser. J Endourol 2006;20:823–826.

8. Bauer JJ, Bishoff JT, Moore RG, et al. Laparoscopic versus open pyeloplasty: Assessment of objective and subjective outcome. J Urol 1999;162:692–695.

9. Klingler HC, Remzi M, Janetschek G. Comparison of open versus laparoscopic pyeloplasty techniques in treatment of uretero-pelvic junction obstruction. Eur Urol 2003;44:340–345.

10. Shoma AM, El Nahas AR, Bazeed MA. Laparoscopic pyeloplasty: A prospective randomized comparison between the transperitoneal approach and retroperitoneoscopy. J Urol 2007;178:2020–2024.

11. Davenport K, Minervini A, Timoney AG, Keeley FX Jr. Our experience with retroperitoneal and transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction obstruction. Eur Urol 2005;48:973–977.

12. Hemal AK, Goel R, Goel A. Cost effective laparoscopic pyeloplasty: Single center experience. Int J Urol 2003;10:563–568.

13. Moore RG, Averch TD, Schulam PG, et al. Laparoscopic pyeloplasty: Experience with the initial 30 cases. J Urol 1997;157:459–462.

14. Jarrett TW, Chan DY, Charambura TC, et al. Laparoscopic pyeloplasty: The first 100 cases. J Urol 2002;167:1253–1256.

CT-computed tomography

IVU-intravenous urography

LP-laparoscopic pyeloplasty

UPJ-ureteropelvic junction

UPJO-ureteropelvic junction obstruction

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