Hand-assisted laparoscopic ureterolysis to treat ureteral obstruction secondary to idiopathic retroperitoneal fibrosis: Assessment of a novel technique and initial series

Our experience in laparoscopic ureterolysis and omental wrapping as a definitive surgical management of ureteric obstruction related to retroperitoneal fibrosis

Introduction and Objectives:

Retroperitoneal fibrosis (RPF) is a rare fibro-inflammatory disease and a cause of ureteric obstruction that leads to obstructive uropathy. Although the mainstay of RPF treatment is medical, ureterolysis becomes a necessity if medical treatment fails or if patients are unable to tolerate side effects of conservative/medical management, including those of ureteric stents. We aimed to investigate our experience of laparoscopic ureterolysis (LU) and omental wrapping as a definitive surgical treatment for RPF.

Patients and methods:

We conducted a retrospective analysis of 17 patients who underwent LU between September 2009 and October 2018 in a single institution. Mode of presentation, investigation and interventions were reviewed. Outcome measures were stent or nephrostomy-free rates, post-ureterolysis change in estimated glomerular filtration rate (eGFR), operative time, estimated blood loss, length of hospital stay, complications and need for additional procedures. MAG3 renography was performed to assess ureteral patency.

Results:

Among 17 patients, a total of 23 LU procedures were performed in 20 operative sessions. Median (IQR) length of hospital stay was 4 (2–6) days. Median length of follow-up was 23.5 months (range 4–92 months), where 14 patients completed at least 15 months of follow-up. All patients were either stent ( n=9) or nephrostomy ( n=8) dependent before ureterolysis. Some 82.4% patients ( n=14) remain stent/nephrostomy free after LU. Renal function remains stable after ureterolysis with a median (IQR) change in eGFR at latest follow-up of: +7.5 (−8 to +23), ( P=0.74).

Conclusions:

LU is safe and effective at halting decline in renal dysfunction secondary to RPF. It has reliably avoided internal or external ureteric drainage in most patients. Consideration should be given to early referral to a specialised centre for ureterolysis in the context of multi-disciplinary management of benign RPF, to preservation of renal function and to render patients stent or nephrostomy free.

Level of Evidence:

4 (case series).

Outcomes of ureterolysis for primary retroperitoneal fibrosis: A single-center experience

OBJECTIVE

To report our experience with ureterolysis for the management of retroperitoneal fibrosis.

METHODS

The data of 25 patients who underwent ureterolysis due to primary retroperitoneal fibrosis between 2002 and 2017 were reviewed retrospectively. Initial symptoms, laterality, renal function status (initial/final), operation complications and serum creatinine levels (diagnosis/preoperative/6 months, 12 months postoperatively) were recorded. After surgery, patients were followed up by ultrasonography and serum creatinine levels. Patients with impaired results underwent furosemide renogram and/or late phase of computed tomography. Factors affecting final serum creatinine levels were evaluated. The χ² -test was used for nominal data among groups. The level of statistical significance was set as P < 0.05.

RESULTS

A total of 19 patients (76%) were operated bilaterally. The mean follow-up period was 46.2 ± 9.2 months. Among 44 operated renal units, non-functioning kidney developed in seven (15.9%). A total of 34 renal units (77.3%) did not require any additional surgical intervention, and two underwent balloon dilatation (4.5%), one (2.25%) followed with double J stent changes. Two patients developed end-stage renal disease secondary to bilateral unresolved obstruction. High final serum creatinine levels developed in eight (32%) patients without dialysis. Eight patients (32%) were treated with immunosuppressive therapy for systemic recurrence. There was a significant relationship between preoperative serum creatinine levels with final serum creatinine levels (P = 0.005). There was no statistically significant relationship between diagnosis serum creatinine levels with final serum creatinine levels and postoperative dialysis requirement (P = 0.79 and P = 0.817, respectively).

CONCLUSIONS

Ureterolysis provides acceptable success with low complication rates in patients with retroperitoneal fibrosis. Preoperative high-serum creatinine levels can be considered as a risk factor for long-term renal impairment and these patients should be followed closely.

Management of idiopathic retroperitoneal fibrosis from the urologist's perspective

INTRODUCTION

Idiopathic retroperitoneal fibrosis (IRF) is a rare disease characterized by a fibrotic reaction that affects retroperitoneal organs, especially the urinary tract. In this review we analyze the current imaging techniques, morphological characteristics, clinical aspects and therapeutic aspects of idiopathic retroperitoneal disease.

METHODS

A PubMed search was conducted in December 2013 to find original articles, bibliographic reviews and series reports published in the past 15 years on idiopathic retroperitoneal fibrosis, its management and outcomes by combining terms like retroperitoneal fibrosis, periaortitis, treatment and autoimmune. A total of 89 articles were included in this review that referred strictly to IRF. We analyzed the imaging tools used for diagnostic and the decision making protocol used by physicians in the management of IRF.

RESULTS

A computerized tomography (CT) scan represents the most commonly used imaging technique for diagnosis. Magnetic resonance imaging (MRI) is unable to differentiate more accurately between benign and malignant retroperitoneal fibrosis (RF) than a CT scan. Biopsy remains the most reliable diagnostic tool for IRF. However, the histological characteristics of IRF are not yet well-defined and the protocol for biopsy is not standardized in terms of template, number of biopsies and the immunohistochemical panel needed for positive diagnosis. The most common treatment reported is corticosteroid therapy alone or in combination with other immunosuppressants, whereas surgical treatment is reserved for severe cases. Indwelling ureteric stents represent the most common procedure for renal drainage, but their efficacy is questionable. Open ureterolysis remains the gold standard for surgical treatment, but its purpose is only to resolve the ureteric obstruction, not to treat the retroperitoneal fibrosis. Laparoscopic and robotic approaches have been reported to be feasible, but no prospective, comparative trials have been performed due to the rarity of the disease. Surgical technique is not standardized and the outcome of the treatment only evaluates the recovery of the renal function.

CONCLUSIONS

The imaging procedures available today are unable to accurately differentiate between idiopathic and malignant RF. A biopsy is mandatory to confirm the diagnosis, but there is no consensus regarding the template, timing and number of biopsies needed to exclude malignancy. Open ureterolysis represents the main surgical treatment for cases with severe IRF, and laparoscopic or robotic approach may be an option in selected cases. The recovery of the renal function is a surrogate for evaluating the success of the treatment. More clinical studies are needed in order standardize the protocol for diagnostic, treatment and follow up after medical or surgical management.

Bilateral hand-assisted laparoscopic renal surgery in the supine position: the spleen at risk

OBJECTIVE

We evaluated the safety of simultaneous bilateral renal procedures performed using hand-assisted laparoscopy (HAL) with the patient in the supine position.

MATERIALS AND METHODS

After securely strapping the patient to the table, a hand-port device is placed via a 7-cm supraumbilical or peri-umbilical incision with two to four 5-mm to 12-mm trocars placed bilaterally. During a 3-year period, 8 bilateral HAL renal operations were initiated (upper pole partial nephrectomies, 3 nephroureterectomies, 3 bilateral nephrectomies, and right nephrectomy with left adrenalectomy).

RESULTS

Mean patient age was 41 years. One patient with ADPKD required conversion to open due to failure to progress secondary to excessive perirenal fat and 22-cm kidneys. The other 7 were completed successfully with a mean operative time of 417 minutes and mean EBL of 336cc. Two patients received transfusions. Two small splenic lacerations, managed conservatively, were the only complications.

CONCLUSIONS

Bilateral hand-assisted laparoscopic renal surgery with the patient in the supine position (rolling the table side to side) is feasible in the majority of patients. However, very large kidneys (eg, ADPKD) may be better approached with the patient in the lateral decubitus position or via an open subcostal incision. Importantly, the spleen appears to be at increased risk for capsular injury due to apparent increased difficulty of left colon mobilization in the "rolled" or "airplaned" supine position.

Transmesocolic ureteral intraperitonealization: a new approach for laparoscopic treatment of retroperitoneal fibrosis

INTRODUCTION

Retroperitoneal fibrosis (RPF) is characterized by the presence of an inflammatory fibrotic process in the retroperitoneum causing compression of the retroperitoneal structures including the ureters. The ureterolysis is the liberation of the incarcerated portion of the ureter, from its proximal healthy portion to the distal portion, generally free of fibrosis, below the iliac vessels. We report the transmesocolic ureteral intraperitonealization as a new approach for laparoscopic treatment of RPF.

PATIENT AND METHODS

A 52-year-old female patient diagnosed with idiopathic RPF was submitted to laparoscopic transmesocolic ureteral intraperitonealization after medical management failure. An open access using a Hasson trocar was placed through the umbilicus and two additional trocars were placed-10  mm in the midline at 6  cm below the umbilicus and a 5  mm in the midline at 6  cm above the umbilicus. The left mesocolon was incised 3  cm lateral to aortic pulsation and the left ureter was identified and dissected off the retroperitoneal mass. Lateral incised mesocolon was mobilized and wrapped posterior to the left ureter using a running suture.

RESULTS

Operative time was 2 hours. The mean blood loss was less than 100  mL. The patient was discharged painless on the second postoperative day. No complications were observed. Pathology showed fibrous tissue. An intravenous pyelography was performed at 6 months after the surgery and showed no ureteral obstruction. Serum creatinine level stabilized at 0.9  mg/dL.

CONCLUSION

The transmesocolic ureteral intraperitonealization for laparoscopic treatment of RPF is feasible and can be considered a potential alternative for traditional laparoscopic intraperitonealization.

Laparoscopic ureterolysis with omental wrap for idiopathic retroperitoneal fibrosis

OBJECTIVE

To describe various approaches for ureterolysis with an omental wrap using minimally invasive techniques, as surgery for idiopathic retroperitoneal fibrosis includes tissue biopsy, ureterolysis, and intraperitonealization or omental wrap.

PATIENTS AND METHODS

Since 2006 we have performed ureterolysis in four patients diagnosed with retroperitoneal fibrosis in two institutions. The ureterolysis in two cases was bilateral, using a standard laparoscopic approach for one case and a hand-assisted technique for the other. Unilateral ureterolysis was completed using a standard laparoscopic approach in one case and was converted to a hand-assisted technique in the other due to difficulty with ureteric identification. An omental wrap was used after ureterolysis for all renal units.

RESULTS

A minimally invasive technique was used for all ureterolysis procedures and none required open conversion. There was fascial dehiscence after surgery at the hand-port site in one patient, and required re-operation for wound closure. The median (range) hospital stay for all patients was 2.5 (2-10) days and the median blood loss was 100 (50-550) mL. No patient required a blood transfusion. At a median 16.5 (12-32) months of follow-up, there was symptomatic and radiographic success in all patients.

CONCLUSIONS

Ureterolysis can be a challenging operation depending on the extent of the retroperitoneal mass. An understanding of various laparoscopic techniques can provide the flexibility for successful completion of nearly all of these procedures using a minimally invasive approach.

Robot-assisted laparoscopic ureterolysis: case report and literature review of the minimally invasive surgical approach

Results of this study suggest that robotic-assisted laparoscopic ureterolysis is a safe and effective procedure for patients with idiopathic retroperitoneal fibrosis.

Objectives:

To evaluate our case of robot-assisted ureterolysis (RU), describe our surgical technique, and review the literature on minimally invasive ureterolysis.

Methods:

One patient managed with robot-assisted ureterolysis for idiopathic retroperitoneal fibrosis was identified. The chart was analyzed for demographics, operative parameters, and immediate postoperative outcome. The surgical technique was assessed and modified. Lastly, a review of the published literature on ureterolysis managed with minimally invasive surgery was performed.

Results:

One patient underwent robot-assisted ureterolysis at our institution in 2 separate settings. Operative time (OR) decreased from 279 minutes to 191 minutes. Estimated blood loss (EBL) was less than 50mL. The patient has been free of symptoms and both renal units are unobstructed. According to the published literature, 302 renal units underwent successful laparoscopic ureterolysis (LU), and 6 renal units underwent RU. There were 9 open conversions (all in LU). Mean OR in LU was 248 minutes for unilateral and 386 minutes for bilateral cases. In RU, mean OR was 220 minutes for unilateral and 390 minutes for bilateral cases. EBL averaged 200mL in LU and 30 mL in RU.

Conclusions:

Our data reveal that robot-assisted ureterolysis is safe and feasible. Published data demonstrate the advantages of minimally invasive surgery.

University of Michigan surgical experience with ureterolysis for retroperitoneal fibrosis: a comparison of laparoscopic and open surgical approaches

OBJECTIVES

To compare our experience with open surgical ureterolysis (OU) and laparoscopic ureterolysis (LU) to determine any differences in success and convalescence. OU for extrinsic compression of the ureters secondary to retroperitoneal fibrosis effectively releases the ureters from the fibrotic environment in most cases. Reports have suggested that LU provides similar benefits, with a decreased intensity and duration of convalescence.

METHODS

We retrospectively reviewed the data from 22 patients who had undergone 25 ureterolysis procedures for retroperitoneal fibrosis from 1997 to 2006 at our institution.

RESULTS

LU was performed in 13 cases (10 patients) and a total of 16 ureters. No conversion to open surgery was required. OU was performed in 12 cases (12 patients) and a total of 16 ureters. LU was associated with a significantly shorter hospital stay than OU (mean 2.1 versus 5.9 days, P = .004). Laparoscopic intraperitonealization of the ureters was performed in 97.5% of all affected ureters compared with 50% with OU (P = .02). No difference was seen between the 2 groups in the performance of an omental wrap, postoperative creatinine level, complication rate, operating time, or transfusion requirement. With a mean follow-up of 30 months for the OU group and 24 months for the LU group, the success rate was 87.5% after OU and 93.8% after LU (P = 1.0).

CONCLUSIONS

The results of our study have shown that LU is a safe and effective surgical procedure for retroperitoneal fibrosis. LU offers similar results and a shorter hospital stay compared with OU and should be considered the technique of choice, when available.

Minimally invasive management of retroperitoneal fibrosis

OBJECTIVES

Ureteral obstruction is a common finding in retroperitoneal fibrosis (RPF). The management of ureteral obstruction in patients with RPF is challenging and controversial. To our knowledge we are the first to report on laparoscopic ureterolysis (LU) and robotic ureterolysis (RU) for the management of RPF to determine feasibility and success.

METHODS

We reviewed the charts of all patients who have undergone laparoscopic ureterolysis with or without robotic assistance at our institution.

RESULTS

Between 2001 and 2006, one surgical team performed laparoscopic ureterolysis with or without robotic assistance on 15 renal units in 10 patients. Mean age was 50.9 years (range, 28 to 71 years). Eight patients presented with back pain and all 15 renal units had radiographic evidence of obstruction. Five patients underwent LU, and 5 underwent RU. Mean operative times for bilateral and unilateral LU were 509.0 and 110 minutes, and the mean estimated blood loss was 362.5 and 50 mL. Mean operative times for bilateral and unilateral RU were 390 and 220.5 minutes, and the mean estimated blood loss was 25 and 35.5 mL. With a mean follow-up of 15.6 months, 90% of all patients were asymptomatic and 86.7% renal units had no signs of obstruction on imaging.

CONCLUSIONS

Laparoscopic ureterolysis with or without robotics may be performed with minimal perioperative morbidity and provides excellent success rates for relief of symptoms and obstruction in RPF. RU appears to have better short-term outcomes and is now our technique of choice.