A New Touchless Technique for Suturing in Transperitoneal Laparoscopic Pyeloplasty

Introduction

Since the first report of laparoscopic pyeloplasty (LPP) for ureteropelvic junction obstruction (UPJO) in 1993, ¹ developments in surgical instruments and techniques have improved the safety and efficacy of this surgery. The success rate of LPP has been reported as 87%–100%. ² This high success rate is comparable with that of open pyeloplasty. The minimally invasive nature of LPP and its high success rate have resulted in the wide acceptance of this technique globally. ³ During the last decade, LPP has become the gold standard treatment for UPJO. ⁴

LPP is a technically challenging laparoscopic surgery. The most difficult, time-consuming, and critical steps of this operation are ureteral spatulation, apical ureteral stitch placement, and ureteropelvic anastomosis. ⁵ To simplify these critical steps of the procedure, various techniques have been developed.^5,6 In our practice, we modified the challenging steps of LPP to facilitate ureteral spatulation, avoid the risk of ureteral shortening, minimize the ureteral manipulation, and decrease the operation time. In this study, we present our technique along with the outcome of patients who underwent LPP by this technique.

Materials and Methods

This study included 23 patients with UPJO (11 women, 12 men; mean age 27.1 years, range: 1–51), who were candidates for transperitoneal dismembered Anderson–Hynes LPP. The diagnosis of UPJO was made on the basis of intravenous pyelography (IVP), intravenous contrast computed tomography (CT), or diuretic renogram diethylene-triamine-penta-acetic acid (DTPA) scan. The inclusion criteria for this study were significant flank pain, renal stone, infection, or decreased renal function. All patients with previous renal surgery, pyonephrosis, and bleeding tendency were excluded. All procedures were performed in Labbafinejad Hospital, affiliated to Shahid Beheshti University of Medical Sciences. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences. The studied patients underwent standard LPP with the transperitoneal approach.

The patients were initially placed in a lateral position for transperitoneal laparoscopic access. After induction of pneumoperitoneum, the colon was mobilized medially by identifying and incising the line of Toldt. After kocherization of the colon and identification of the gonadal vessel and psoas, the proximal ureter was identified. By enough vascular preservation, the ureter was dissected up to the renal pelvis to complete the mobilization of the ureteropelvic junction (UPJ).

The ureter was partially cut just below the UPJ transversely. The ureter was spatulated at its lateral aspect to cross the obstruction site and reach the normal ureter. No part of the ureter was removed at this time and the remaining ureteral attachment was used as a handle for suturing and anastomosis. The renal pelvis was obliquely cut equal to the size of ureteral spatulation. The ureter and pelvis were still connected partially (Fig. 1). At this point, the first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis. The remaining attachment of the UPJ was cut after first stitch placement (Fig. 1). The posterior side of the anastomosis was performed by running sutures with 4-0 Vicryl. Then, the Double-J stent was passed antegradely into the ureter and the anterior wall of anastomosis was done. During the anastomosis, the ureter was not grasped or touched with instruments. Preserving total length of ureter allowed for using the upper most part of spatulated ureter as a handle during suturing. This small part of ureter is a portion of the obstructed ureter and removed after completion of anastomosis. A drain was placed into the surgical bed that was removed if the drainage was ≤30 mL per day. The Double-J stent was removed after 6 weeks.

OPEN IN VIEWER

FIG. 1.

(a) UPJ obstruction. (b, c) The ureter was partially cut just below the UPJ transversely. The ureter was spatulated at its lateral aspect to cross the obstruction site and reach the normal ureter. The renal pelvis was obliquely cut. (d) The first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis. (e) The remaining attachment of UPJ was cut after first stitch placement. (f) The anastomosis was performed by running sutures. UPJ, ureteropelvic junction. Artwork by Zahra Shahmoradi.

Perioperative and postoperative data including duration of operation, blood transfusion, complications, and radiologic assessment were analyzed. Radiologic assessment was carried out in all patients. Radiologic success was defined as resolution of obstruction in the IVP or CT scan or DTPA scan 3 months after Double-J stent removal.

Results

Twenty-two LPP procedures were conducted in our institute on 23 patients (12 men and 11 women) during the study period. The affected side was right in 13 and left in 10 patients. The patients' mean age was 27.1 years (range: 1–51 years), and the mean body mass index was 24.5 ± 3.9 kg/m². The majority indication of surgery was pain (Table 1).

The mean overall operation time was 155 ± 27 minutes, the operation time in the left and right side was not statistically different (P = .3). No cases of internal organ injury and no cases of open surgery conversion were encountered. The mean hemoglobin was 12.6 ± 1.7 before operation and 12 ± 1.7 after surgery. One patient needed blood transfusion based on hemoglobin drop.

The mean follow-up period was 10.8 months (range: 6–21 months). The radiologic success rate based on follow-up IVP or DTPA renal scans was 96%. Postoperative urinary tract infection occurred in 1 patient. Infection was improved by intravenous antibiotics.

In 1 patient, IVP showed that the obstruction still exists. A Double-J stent was inserted for this patient again but after Double-J stent removal, the patient did not return to our clinic for follow-up. She returned back after 1 year and underwent nephrectomy due to a nonfunctional obstructive kidney.

Discussion

Previous literature has shown that LPP in comparison with open surgery is associated with less bleeding, more detailed anatomy, shorter hospital stay, and higher or equal success rates.^7,8 Based on these advantages, LPP is recommended as a choice technique for patients with UPJO in many urology centers in the world. During LPP, ureteropelvic anastomosis is the most important and critical step that significantly affects the outcomes. Several techniques have been described for ureteropelvic suturing in the literature.^5–7 Although previous studies have showed the feasibility and efficacy of these methods, there is no consensus regarding the best anastomosis technique. A suitable technique has certain criteria. First, water-tight, funnel–shaped, and dependent anastomosis eventuate better long-term results. Second, elimination of ureteral grasping with any instrument can cause minimal ureteral injury in the time of suturing. Third, surgeon comfort is an important point in laparoscopic surgeries. Previous literature reported some techniques with respect to these critical points.^5–7 Yang et al. ⁷ reported a modified suture technique for transperitoneal laparoscopic dismembered pyeloplasty. With their technique, surgeons can better reach to these critical technical points. Our technique is more similar to Yang's technique. In both techniques, the ureter is not freed from the UPJ during ureteral spatulation. Our technique allows easy spatulation and suturing. In addition, ureteral grasping and manipulation are minimized and the grasping segment of the ureter is removed after suturing. Therefore, reduced clamping of the ureter can lead to better surgical outcomes. Compared with the traditional pyeloplasty technique, another advantage of our technique is prevention of ureteral torsion and preservation of correct orientation of the ureter for spatulation. These points are very important for surgeons with little experience in performing LPP. The mentioned advantages are possessed in common in both ours and Yang et al.'s techniques. The difference between our technique and Yang et al.'s method is in the site of spatulation and pelvic excision. In Yang et al.'s technique, the ureter was cut partly below the level of the stenosis, but in our method the ureter was cut just below the UPJ at the site of stenosis and only enough ureter for grasping with a device is left above the incision site. Therefore, we used the stenotic part of the ureter in ureteropelvic anastomosis. In addition, Yang et al. excised some part of pelvis, but in our technique, we omitted a little part of the ureter without pelvic excision, which has two main advantages: first, we faced no problem in the connection of the ureter and pelvis in long stenosis. Second, if the surgery fails, there is still enough ureter and pelvic tissue left for redo pyeloplasty.

Nevertheless, this study suffers from some limitations: the main weakness of our research was not being a comparative study; in addition, the study had a small sample size. Therefore, confirmation of the efficacy and safety of our technique require further larger multicenter studies.

In conclusion, the new preserving stenotic ureteral technique for spatulation and suturing in transperitoneal laparoscopic dismembered pyeloplasty can be considered as a useful method, especially for less-experienced surgeons.