Commentary on “Laparoscopic Retroperitoneal Dismembered Pyeloplasty: Single-Center Experience in China”

Hao et al. ¹ describe their series of 117 consecutive patients who underwent retroperitoneal laparoscopic dismembered pyeloplasty over an 8-year period. The series is notable for a success rate (94%) over a mean 43-month period that is in line with other reported laparoscopic/robotic pyeloplasty success rates (greater than 95%).^2,3 Only 2 patients had postoperative complications, and 7 patients developed ureteral strictures over the follow-up period. The authors conclude that the reconstruction is more difficult with the retroperitoneal approach but that this approach may become the new standard of care for ureteropelvic junction (UPJ) obstruction.

Another modern series that focused on the retroperitoneal approach for UPJ repair is from the Cleveland Clinic, where they noted similar success and low complications in 10 patients. ⁴ The data for transperitoneal laparoscopic/robotic pyeloplasty demonstrate excellent durable success rates with low complication rates.^2,3,5 The transperitoneal approach offers the advantages of familiar anatomy and a large working space. The theoretical disadvantage of the transperitoneal approach is exposure of the abdominal contents (bowel, liver, spleen, etc.) to injury. However, bowel injury in retroperitoneal laparoscopic kidney surgery is not unheard of. The retroperitoneal approach to renal reconstruction may be difficult because of unfamiliar access and anatomy. Retroperitoneal renal surgery also offers limited space, which can be very problematic for robotic repairs. The biggest concern with retroperitoneal UPJ repair is identification and management of reconstruction in the face of crossing vessels. The authors of the current article ¹ and the Cleveland Clinic article ⁴ both note the technical difficulty of retroperitoneal UPJ reconstruction in the face of crossing vasculature.

Notwithstanding the success of the retroperitoneal laparoscopic approach in the current article ¹ and the Cleveland Clinic series, ⁴ it should be noted that both are authored by extremely high-volume institutions and surgeons. My belief is that the unfamiliarity of the anatomy and of the retroperitoneal access would make this approach extremely difficult and possibly unsafe in the regular urologist's hands. The only benefit I see to retroperitoneal laparoscopic/robotic pyeloplasty is in patients with multiple abdominal surgeries, but this is not common in the UPJ obstruction patient population (usually younger and healthier patients). In closing, I do think the series from Hao et al. ¹ confirms that retroperitoneal UPJ repair is feasible and does carry an equivalent success rate to the transperitoneal approach. Although this is important information in cases where one is forced to perform this approach, my advice is for those unfamiliar with the access to proceed with caution. Given the success and widespread adoption of the transperitoneal approach, it is doubtful the retroperitoneal laparoscopic UPJ repair will ever become standard of care.