Abstract
Background and Purpose:
Laparoscopic dismembered pyeloplasty (LDP) is a minimally invasive approach that is becoming standard management of ureteropelvic junction obstruction (UPJO). It provides similar results when compared with open surgery. The main goal of LDP is to meet the standard of open dismembered pyeloplasty with reduced trauma for the patients. The purpose of the study was to evaluate the postoperative and functional results of LDP.
Patients and Methods:
We retrospectively reviewed and analyzed 142 cases of LDP performed at our center over a period of 7 years (January 2003 to December 2009) for UPJO with dilatation of the renal pelvis. Patients' profiles and perioperative, intraoperative, and postoperative parameters, such as time of surgery, blood loss, complications, duration of hospital stay, and outcomes of the procedure, were all evaluated and analyzed.
Results:
The mean operative time for LDP was 145 minutes (range 110–180 min), and the mean estimated blood loss was negligible in all patients. The mean hospital stay was 3.5 days (3–6 d). Two conversions to open surgery occurred because of difficulty to complete the anastomosis. In one patient, shock caused by bleeding from inferior epigastric vessels near the port site developed and had to be explored. The success rate was 96.8%.
Conclusion:
When performed by expert surgeons, LDP can safely achieve success rates that are comparable to those of open surgery described in the literature, with fewer complications and less morbidity to the patients. The few important difficulties with their management that we encountered are discussed.
Introduction
We present our technique and results of LDP for UPJO in 142 patients.
Patients and Methods
From January 2003 to December 2009, 142 LDP were performed by the same surgeon (NKA). All patients had primary UPJO with a dilated renal pelvis (secondary UPJO excluded). The diagnosis was made and confirmed by ultrasonography (US), intravenous urography (IVU), and renal scintigraphy in all aptients. Patients' profiles (age, sex) and perioperative, intraoperative, and postoperative parameters, such as time of surgery, blood loss, complications, duration of hospital stay, and outcomes of the procedure were all evaluated and analyzed. Patients with previous abdominal surgeries were not included.
Surgical technique
To start, we used to perform cystoscopy and ureteral catheterization with a 6F ureteral catheter (UC), followed by retrograde pyelography, and leave the UC in situ in every patient (first 37 cases). The UC was tied to a Foley catheter that was inserted in the bladder to avoid displacement. Then the patients were placed in a 45-degree flank position. We used the transperitoneal approach in all cases.
First, a 12-mm port was placed by open technique at the level of the umbilicus and about two fingers toward the side to be operated. The peritoneal cavity was inspected by a 30-degree telescope, followed by placement of two other ports: A 12-mm port in the ipsilateral midclavicular line in the iliac fossa, and a 5-mm port between the xyphoid and the umbilicus.
Bowel was reflected by giving an incision along the line of toldt. The ureter was identified in the retroperitoneum. The proximal ureter, ureteropelvic junction (UPJ) and the renal pelvis were completely freed. The renal pelvis was either dismembered completely and the redundant portion excised or the dismembering incision was extended to the lateral aspect of the ureter to spatulate it before complete dismembering. The cephalad aspect of the pelvis was closed vertically from above-downward with interrupted/continuous polyglactin 4-0 sutures, leaving about a 1.5–2 cm portion unclosed in the dependent part. After excising the stenotic portion, the ureter was spatulated medial to lateral (above-downward) according to the left-open portion of the pelvis.
The anastomosis was started by taking full-thickness bites (polyglactin 4-0) from the lowermost point of the spatulated ureter to the lowermost point of the pelvis. With interrupted/continuous suturing technique, the posterior layer was completed so that the uppermost point of the ureter was approximated watertight to the uppermost point of the left-open pelvis. In case crossing vessels were the cause, the ureter and the renal pelvis were transposed anteriorly before the anastomosis.
Just before the anastomosis was completed, a guidewire was passed through the UC (already left in) and the UC removed. A 6F Double-J stent was passed over the guidewire and placed in the pelvis and the ureter across the anastomosis. The anastomosis was then completed.
An additional fourth 5-mm port was necessary in the anterior axillary line at the level of the umbilicus to facilitate the dissection and anastomosis in 39 cases.
After the initial 37 cases, our surgeon tried antegrade stent placement laparoscopically by introducing a UC loaded over a guidewire through a 5-mm port. The guidewire was passed into the bladder through the partially completed ureteropelvic anastomosis, the UC removed, and the Double-J stent inserted. In the rest of the cases (105), we did antegrade stent placement laparoscopically.
A 14F closed suction drain was placed through the 5 mm port in the operative area away from the anastomosis. The port sites were closed with interrupted absorbable sutures. The Foley catheter was removed on the morning of postoperative day 2.
Follow-up
The Double-J stent was removed after 4 weeks. The mean follow-up was 30 months (range 4–56 mos). Our protocol was to obtain an IVU at 3 months and a diuretic renal scan in all cases at 6 months of follow-up. The outcome was considered successful if there was complete resolution of flank pain (clinical), adequate renal excretion of contrast on IVU (radiographic), and preserved or improved renal function on the renal scan.
Results
The mean age of patients who underwent LDP was 39 years (18–60). Of these, 78 were men and 64 were women. Crossing vessels with an anterior course to the UPJ were found in 60.5% (86/142) cases. Two patients with retrocaval ureter also underwent LDP without excision of the retrocaval portion. The mean operative time was 145 min (110–180 min), and the mean estimated blood loss was minimal (<20 mL) (Table 1). Two conversions to open surgery occurred because of difficulty to complete the anastomosis. Injury to the crossing vessels did not occur in any case. The mean hospital stay was 3.5 days (3–6).
We started the operation with a standard three-port technique in all cases. In 39 (27.5%) patients, a fourth port was needed to facilitate either the mobilization of the renal pelvis or the ureteropelvic anastomosis. A fourth port was needed for LDP in both patients with retrocaval ureter.
Retrograde stent placement (preopertive) was performed in the first 37 cases and antegrade stent placement in 104. One patient needed postoperative retrograde stent placement, because the stent could not be passed down beyond the vesicoureteral junction. We found antegrade stent placement simpler, easier, and quicker than use of the retrograde technique. The mean operative time of cases in which retrograde (37) and antegrade (104) stent placement was performed was 162 minutes and 124 minutes (P = 0.002), respectively.
Prolonged postoperative ileus was noted in five (3.5%) patients. We removed the drain few hours after catheter removal. Three patients (2.1%) needed recatheterization for another 2 days because of increased urinary drainage from the drain after catheter removal. Postoperative hematoma developed in three patients, all of whom also had prolonged ileus. None of them needed an intervention. Urinoma developed in seven patients (4.9%), and a percutaneous pigtail catheter was placed under US guidance. Insix patients, the urinoma resolved, while one patient needed laparoscopic resuturing of a rent in the anastomosis.
Shock occurred in one patient 8 hours after uneventful LDP, and the patient needed emergency exploration. Severed inferior epigastic vessels near the port site were the cause of bleeding and were ligated. Another problem was accidental loss of the suture needle in two cases; the needle was recovered using fluoroscopy.
The mean follow-up was 30 months (range 4–56 mos). Eleven patients were lost to follow-up after Double-J stent removal. During follow-up, all patients underwent IVU at 3 months. A total of 128 patients underwent a diuretic renal scan at 6 months, and 1 patient at 5 months (11 patients lost in follow-up). The renal scan could not be performed in two patients who did not come for further follow-up after initial evaluation with IVU. If these two are also excluded, the overall success rate is 96.8% (125/129). Four (3%) came with recurrence after 6, 8, 11, and 12 months of operation. All four underwent balloon dilatation, but two patients ultimately needed open surgery.
Discussion
LDP, developed in the early 1990s, is rapidly becoming the standard of care for the management of UPJO. This minimally invasive approach has led to equivalent results compared with open surgery, with decreased convalescence and analgesic requirements. 15,16 The other minimally invasive management options for UPJO include percutaneous and ureteroscopic endopyelotomy and cutting transvesical balloon dilatation. 17 The main goal of these minimally invasive procedures, including LDP, is to meet the standard of open dismembered pyeloplasty with reduced morbidity for the patients. 1
LDP has been shown to provide high success rates similar to those achieved with open pyeloplasty, with similar or lesser overall complication rates, when performed by experts in centers with high laparoscopic expertise. 2 –4,17 The reported success rate of LDP is 73% to 100%. 1 –14,17 LDP provides better visualization of anatomy and more workspace to perform anastomosis in addition to a good track record of performed cases. 11 Our surgeon also reported that improved visualization resulted in better dissection in the UPJ area. Furthermore, Eden 11 in 2007 reviewed the results of minimally invasive treatment of UPJO and concluded that patients undergoing LDP rarely needed transfusion while the transfusion rate with endourologic UPJO incision was 3% to 11%.
Recently, Wagner and associates 17 published the results of LDP in 105 patients. The mean operative time was 150 minutes, and they reported no conversion to open surgery, minimal blood loss, and a success rate of 96.2% with very few complications. In the present series, the mean operative time was 145 minutes, which is on the lower side of the range reported in the literature. 1 –14,17 The mean estimated blood loss was minimal in all patients, and no conversion to open surgery occurred. Our surgeon attributed the zero incidence of injury to the crossing vessels to better visualization of the normal and anomalous anatomy in LDP.
In the study by Wagner and colleagues, 17 the surgeons performing LDP had already performed at least 40 LDPs each before the beginning of the study. They used a four-port technique and occasionally used a fifth port. Our surgeon had completed 25 LDPs before inclusion of his case records into the present study. We used the standard three ports and needed a fourth port in little more than one quarter (39/142) of the cases. Among these, the first 13 fourth-port insertions were needed in the first 26 cases, while the last 13 were in the last 69 cases. According to our team's experience, the learning curve for LDP tapers at about 45 cases.
In our initial cases, we experienced a problem in spatulating the ureter, because it became difficult to handle after complete dismembering. In comparison, extending the dismembering incision on to the lateral aspect of the ureter to spatulate it before complete dismembering really proved helpful by providing traction and stabilization. 18
Also, initially we used to perform anastomosis using an interrupted suturing technique, but with increasing experience, we now prefer a continuous suturing technique because it avoids hindrance caused by multiple intracorporeal knots. Thus, it is time saving. 19
Last, we found antegrade stent placement really simple and quicker than using the retrograde method. Moreover, the surgical area remains free of any hindrance caused by UC/Double-J stent placement in a retrograde manner. This actually makes spatulation of the ureter and subsequent anastomosis easier. Also, it avoids one more procedure and need to change the position of the patient, and obviously reduces the operative time. 20
Conclusion
Although LDP requires great expertise, with increasing experience in laparoscopy, it should be the procedure of choice for primary UPJO in terms of high success rates, fewer complication rates, and decreased surgical morbidity for the patients. Laparoscopic antegrade stent placement, spatulating the ureter before complete renal pelvic dismemberance, and using a continuous suturing technique for anastomosis are a few tips that may prove helpful to increase efficiency and reduce the learning curve.
Footnotes
Disclosure Statement
No competing financial interests exist.