A modified suture technique for transperitoneal laparoscopic dismembered pyeloplasty of pelviureteric junction obstruction

Treatment of ureteropelvic junction obstruction in patients with renal calculi via laparoscopic pyeloplasty and flexible vacuum-assisted ureteral access sheath ureteroscopy: a multicenter retrospective observational study

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is a common obstructive disease of the urinary tract. UPJO patients commonly exhibit coexistent renal calculi. The main aim of therapy is to relieve the obstruction and remove the stones at the same time.

METHODS

This retrospective study included 110 patients diagnosed with UPJO coexisting with multiple renal calculi at Shanxi Bethune Hospital and the First Hospital of Shanxi Medical University between March 2016 and January 2022. Patients were divided according to the methods used for dealing with UPJO and renal calculi. In Group A, patients underwent traditional open pyeloplasty and pyelolithotomy. In Group B, patients underwent percutaneous nephrolithotomy first and then laparoscopic pyeloplasty. In Group C, patients underwent flexible cystoscopy to remove stones and then laparoscopic pyeloplasty. In Group D, patients underwent flexible vacuum-assisted ureteral access sheath (FV-UAS)assisted flexible ureteroscopy (f-URS) and underwent laparoscopic pyeloplasty. The stones were broken up using a holmium laser. The pyeloplasty success rate, stone clearance rate, operation time, bleeding amount, complication occurrence rate, postsurgical pain, length of stay, and hospitalization cost were compared between the groups. The follow-up period was at least 2 years.

RESULTS

The use of f-URS and the FV-UAS, significantly increased the renal stone clearance rate and significantly reduced the complication incidence and operation time in UPJO patients with multiple coexisting renal calculi.

CONCLUSIONS

Laparoscopic pyeloplasty combined with f-URS and FV-UAS is safe and effective for treating UPJO in patients complicated by renal caliceal stones.

TRIAL REGISTRATION

Retrospectively registered.

A Pilot Study to Determine the Role of Spatulating the Ureter During Pyeloplasty in Children for Ureteropelvic Junction Obstruction in the Robotic Era

Purpose: Spatulation during ureteropelvic junction obstruction repair was evaluated in children treated by robot-assisted retroperitoneal pyeloplasty anastomosis (RRPA). Methods: Intraoperative video recordings (IVRs) of RRPA (n = 22 ureters) performed at a single institute between 2018 and 2022 were reviewed blindly by 5 independent surgeons for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and spatulation ranking as superior (+1), inferior (-1), or unnecessary (0). The retroperitoneal space was accessed in the lateral decubitus position using a closed technique under direct vision to avoid air leakage and subcutaneous emphysema. All subjects had a Double-J stent (4.7F) placed. Results: Subjects had similar demographics and preoperative ureter diameters. IVRs were RRPA with spatulation of the ureter on the lateral side (RRPA +SP) (n = 13) and RRPA without spatulation of the ureter (RRPA -SP) (n = 9). Overall DOS scores and coefficients of variation for time taken to place one suture were similar. Total anastomotic time was significantly shorter for RRPA -SP; 67.9 ± 8.4 minutes versus 57.9 ± 9.2 minutes, P = .01. Overall spatulation ranking was 0. Postoperative scanning showed improved drainage in 12 of 13 (92%) in RRPA +SP and 8 of 9 (88%) in RRPA -SP; differences were not significant. One anastomotic stricture in RRPA -SP required open repair. Conclusions: RRPA was quicker and more precise without spatulation. Outcomes of scanning 1 year after RRPA were similar for RRPA -SP and RRPA +SP.

Robotic versus laparoscopic ureteroplasty with a lingual mucosa graft for complex ureteral stricture

PURPOSE

Ureteroplasty with a lingual mucosa graft (LMG) for complex ureteral stricture was reported promising. We aimed to compare outcomes of robotic versus laparoscopic ureteroplasty using a LMG (RU-LMG vs. LU-LMG, respectively).

METHODS

From October 2018 to January 2021, 32 ureteroplasties using LMGs were performed by one experienced surgeon, including 16 robotic and laparoscopic procedures each. Patient demographics and peri-operative, post-operative, and follow-up data were prospectively collected and compared.

RESULTS

The robotic group had a higher rate of previous reconstruction than the laparoscopic group (62.50% vs. 18.75%; p = 0.012). The stricture length was significantly longer in the robotic group (4.8 ± 1.2 cm) than the laparoscopic group (3.7 ± 1.2 cm; p = 0.013). All procedures were completed successfully without open conversion. The operative time was shorter in the robotic group (192 ± 54 min) than the laparoscopic group (254 ± 46 min; p = 0.001). The robotic group had a shorter length of post-operative stay (6.1 ± 2.4 d vs. 8.9 ± 4.3 d; p = 0.033) but a higher hospital cost (76,801 ± 17,974 vs. 42,214 ± 15,757 RMB; p < 0.001) than the laparoscopic group. The mean follow-up time was 21 ± 7 months for the robotic group and 29 ± 9 months for the laparoscopic group respectively (p = 0.014). No difference was detected in the success rate (93.75% and 100%, respectively; p = 0.309) and complication rate (18.75% and 31.25%, respectively; p = 0.414) between the robotic and laparoscopic groups.

CONCLUSION

Both RU-LMG and LU-LMG are feasible, effective, and safe for repair of complex ureteral strictures. RU-LMG had a shorter operative time and a shorter length of post-operative stay but a higher hospital cost.

Clinical Application of the Computed-Tomography-Based Three-Dimensional Models in the Surgical Planning and Intraoperative Navigation of Ureteropelvic Junction Obstruction Complicated with Renal Calculi

Background and Objectives: To clinically validate the computed tomography (CT)-based three-dimension (3D) model for treatment planning and intraoperative navigation of ureteropelvic junction obstruction (UPJO) complicated with renal calculi. Materials and Methods: We retrospectively collected the data of 26 patients with UPJO and renal calculi who were surgically treated in our institution from January 2019 to December 2021. Before surgery, 3D models based on preoperative CT scans were constructed in all patients. Additionally, the patients were divided into three groups according to the results of 3D models, distinguished by different treatment of renal calculi, that is, left untreated (1), pyelolithotomy (2), and endoscopic lithotomy (3). The quantitative analysis of renal calculi parameters, and perioperative and follow-up data were compared. Results: The mean number of involved renal calyces (p = 0.041), and the mean maximum cross-sectional area (p = 0.036) of renal stones were statistically different among the three groups. There were no significant differences among the three groups in the mean operative time, mean estimated blood loss, mean pararenal draining time, and mean hospital stay. The intraoperative stone clearance rates were 100% (11/11) and 77.8% (7/9) in group 2 and group 3, respectively. The trends of increased estimated glomerular filtration rate and decreased creatinine on the average levels after surgery were observed, although these changes were not statistically significant. At a mean follow-up of 19.4 ± 6.4 months, the overall surgical success rate of the UPJO was 96.2% (25/26), and the overall success rate of renal calculi removal was 80.8% (21/26). Renal stones in 66.7% (4/6) of patients in group 1 spontaneously passed out. Conclusions: Preoperative 3D CT models have exact clinical value in the surgical planning and intraoperative navigation of UPJO patients complicated with renal calculi.

[Laparoscopic pyeloplasty combined with ultrasonic lithotripsy via nephroscope for treatment of ureteropelvic junction obstruction with renal calculi]

OBJECTIVE

To investigate the efficacy and safety of laparoscopic pyeloplasty combined with ultrasonic lithotripsy via nephroscope in the treatment of ureteropelvic junction obstruction (UPJO) with renal calculi.

METHODS

From June 2016 to January 2022, eight patients including five males and three females underwent laparoscopic pyeloplasty combined with ultrasonic lithotripsy via 19.5F(1F≈0.33 mm) nephroscope in Peking University People' s Hospital. The age ranged from 23-51 years (mean: 40.5 years) and the body mass index (BMI) ranged from 18.8-32.4 kg/m² (mean 27.0 kg/m²). The lesion located on the left side in all of the eight patients. Two patients had solitary kidney and one patient had horseshoe kidney. Solitary stone was seen in one patient and the other seven patients suffered multiple stones, with two patients had staghorn stones. The largest diameter of stones ranged from 0.6-2.5 cm (mean: 1.5 cm). CT or ultrasound showed that moderate nephrosis was seen in five patients and severe nephrosis was seen in three patients. During surgery, after exposure of renal pelvis and proximal ureter, a small incision of 1.5 cm was performed in the anterior wall of the renal pelvis, and a 19.5F nephroscope was introduced into renal pelvis through laparoscopic trocar and renal pelvis incision. Stones were fragmented and sucked out by 3.3 mm ultrasonic probe placed through nephroscope. After stones were removed, modified laparoscopic pyeloplasty was performed.

RESULTS

Surgery was successfully completed in all of the eight patients without conversion to open surgery. The operation time ranged from 160-254 min (mean 213 min) and the time of nephroscopic management time was 25-40 min (mean: 33 min). The hemoglobin was decreased by 3-21 g/L (mean: 10.3 g/L). The stone-free rate was 75% (6/8 cases), stones were incompletely removed in two patients due to abnormal intrarenal structure. The modified Clavien classification system (MCCS) grade ⅢA complication occurred in one patient postoperatively, which was nephrosis due to intrarenal bleeding, and nephrostomy was performed. With the mean follow-up of 30 months (ranged from 2-68 months), there was no evidence of obstruction in all the patients, and one patient underwent percutaneous nephrolithotomy to treat residual calculi.

CONCLUSION

Laparoscopic pyeloplasty combined with ultrasonic lithotripsy via 19.5F nephroscope is feasible and safe, and could be a complementary method to treat UPJO and renal calculi.

Initial experiences with preoperative three-dimensional image reconstruction technology in laparoscopic pyeloplasty for ureteropelvic junction obstruction

Background

To explore the clinical value of three-dimensional image reconstruction technology (3DIT) on preoperative surgical planning and perioperative outcomes in laparoscopic pyeloplasty (LP).

Methods

Data of 25 patients with ureteropelvic junction obstruction (UPJO) admitted to our hospital from January 2018 to January 2019 was analyzed retrospectively. All patients underwent preoperative enhanced computed tomography (CT) scanning. In the 12 cases in the 3DIT group, preoperative planning involved the use of virtual operation and morphometry based on reconstruction of the CT data into three-dimensional (3D) images. Surgery in the other 13 cases was performed with traditional CT examination. Demographic, surgical outcome, and postoperative parameters were compared between these two groups.

Results

Reconstructed 3D images clearly showed the spatial structural relationships between the UPJO and surrounding blood vessels. In all 25 cases surgery was completed with no conversion to open surgery. Preoperative 3DIT analyses resulted in significant improvements to mean operation time (107.76 vs. 141.58 min, P=0.024), mean time of dissociating ureteropelvic junction (UPJ) (11.26 vs. 19.40 min, P=0.020), and mean estimated blood loss volume (23.84 vs. 49.16 mL, P=0.028). There were no statistically significant differences in perioperative complications, postoperative hospital stays or postoperative drainage time.

Conclusions

3DIT based on enhanced CT scans is of clinical value in the treatment of UPJO, as it can provide accurate anatomical information and reliable guidance for preoperative operation planning, and it facilitates image-guided LP.

A comparative study on the Efficacy of Retroperitoneoscopic Pyeloplasty and Open Surgery for Ureteropelvic Junction Obstruction in Children

Objectives:

To compare the therapeutic effect of retroperitoneoscopic dismembered pyeloplasty and open ureteropelvic junction plasty on the ureteropelvic junction obstruction (UPJO) in children.

Methods:

After the retrospective analysis of clinical data, 78 children with ureteropelvic junction stenosis treated from January, 2012 to June, 2018 were divided into two groups: OP (open pyeloplasty) group (38 cases) and LP (laparoscopic dismembered pyeloplasty) group (40 cases) according to the surgical methods. The operation time, intraoperative bleeding volume, postoperative length of stay (LOS), postoperative complication rate, postoperative hydronephrosis improvement and other indicators were compared between the two groups.

Results:

All patients underwent surgery successfully, without conversion to open surgery in LP group. The incidence of postoperative urine leakage and the recovery of hydronephrosis between LP group and OP group 12 months after operation showed no statistically significant difference (P>0.05). The intraoperative bleeding volume, the incidence of postoperative retroperitoneal hematoma, and the postoperative LOS in LP group were lower than those in OP group, while the operation time was longer than that in the OP group, with statistically significant difference (P<0.05).

Conclusion:

Retroperitoneoscopic dismembered pyeloplasty had similar effect with open dismembered pyeloplasty, but faster recovery and fewer complications, so it has become the preferred treatment method for UPJO in children.

Initial Experience with the Comprehensive Modified Laparoscopic Pyeloplasty Technique Based on Membrane Anatomy for Treating Ureteropelvic Junction Obstruction

OBJECTIVE

The aim of the objective was to present our initial experience and evaluate the feasibility of the novel comprehensive modified laparoscopic pyeloplasty (CMLP) technique based on membrane anatomy.

MATERIALS AND METHODS

Forty-eight patients underwent CMLP from February 2016 to October 2020. CMLP involves the following: dissection of the ureter was based on the fascia or fusion fascia formed by embryonic development. The ureter was separated from the ureteral sheath, and the pelvis and ureter were incised with incomplete amputation. The first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis to ensure correct orientation of the anastomosis; anastomosis of the renal pelvis and ureter was performed using the touchless technique.

RESULTS

All CMLPs were completed successfully without conversion. The mean overall operating time was 230.96 min. The median estimated blood loss was 50.00 (interquartile range 20.00-57.50) mL. The average postoperative hospital stay was 9.31 days. The average follow-up time was 24.73 months. No major complications occurred. In 1 case, revision laparoscopic pyeloplasty was performed, but the obstruction persisted after double J stent removal, so ultimately, the double J stent required regular replacement. Another asymptomatic patient with hydronephrosis experienced failed treatment and is still under follow-up. The overall success rate was 95.83% (46/48). The success rate in patients with recurrent ureteropelvic junction obstruction (UPJO) was 87.5% (7/8).

CONCLUSIONS

CMLP is a practical and effective treatment option for UPJO with a high success rate. An advantage of CMLP is the clear surgical field.

A ureteral stricture disease score and classification system: correlation with upper urinary tract reconstructive surgery complexity

Background

To develop an original and standardized ureteral stricture disease (USD) score and classification system for quantifying ureter stricture characteristics, assessing complexity of the minimally invasive upper urinary tract reconstructive (UUTR) surgical procedure, formulating preoperative plans, and offering objective comparisons of surgical techniques between different institutions and surgeons.

Methods

We retrospectively reviewed a test set of 64 patients and a validation set of 170 patients who underwent minimally invasive UUTR surgery from January 2018 to January 2021. Three factors were selected to be included in the USD score and classification system: (I) stricture etiology (E, 1–2 points); (II) stricture segment (S, 0–3 points); and (III) length of stricture (L, 1–5 points). The UUTR surgery involves low-complex surgeries (cystoscopy with ureteral dilation and stent placement, ureteropyeloplasty, end to end repair, ureteral reimplantation) and high-complex surgeries (onlay repair (buccal mucosae, lingual mucosae, appendix mucosae), Boari flap repair and ileal ureter replacement). Estimated blood loss and operative time were used as surrogate indicators of surgical complexity.

Results

The interrater reliability of the USD score and classification system was 0.908. A linear relationship between the USD score and estimated blood loss was observed (rs =0.676, P<0.001). The USD score was also correlated with operative time (rs =0.638, P<0.001). A significant difference in USD scores was found between the high and low complexity surgery groups (4 vs. 7, P<0.001). Variability of UUTR surgery is based on USD classification system, but with regularity to conform to.

Conclusions

The USD score and classification system is a concise, easily applicable, and validated scale to delineate the clinically significant features of ureter stricture that correlate with the complexity of the UUTR surgical procedure. The use of this score and classification system can facilitate preoperative plan and comparison of USD treatments in clinical practice and urological literature. Research with large sample is needed to further examine and modify the use of the system.

Modified Laparoscopic and Robotic Flap Pyeloplasty for Recurrent Ureteropelvic Junction Obstruction with a Long Proximal Ureteral Stricture: The "Wishbone" Anastomosis and the "Ureteral Plate" Technique

OBJECTIVES

The aim of the study was to present our modified flap pyeloplasty techniques for recurrent ureteropelvic junction obstruction (UPJO) with a long proximal ureteral stricture and compare outcomes of laparoscopic and robotic procedures.

MATERIALS AND METHODS

Between March 2018 and January 2020, 21 patients underwent modified laparoscopic or robotic flap pyeloplasty for recurrent UPJO with a long proximal ureteral stricture. Our surgical modifications included the "wishbone" anastomosis and "ureteral plate" technique. Demographic, perioperative, and follow-up data were recorded and compared retrospectively between the groups. Success was defined as subjective pain alleviation and hydronephrosis improvement.

RESULTS

Thirteen modified laparoscopic flap pyeloplasty (mLFP) and 8 modified robotic flap pyeloplasty (mRFP) were performed successfully without conversion. mRFP tended to have shorter overall operative time (142.4 vs. 179.1 min, p = 0.122) and anastomosis time (43.1 vs. 61.0 min, p = 0.093) than mLFP. No difference was found in estimated blood loss (p = 0.723) and pararenal draining time (p = 0.175) between the groups. The mean postoperative hospital stay of mRFP was significantly shorter than that of mLFP (5.0 vs. 8.2 days, p = 0.015). No major complications occurred. During the mean follow-up of 17.9 months, the overall success rate was 90.5%, and there was no significant difference between 2 groups.

CONCLUSIONS

The modified flap pyeloplasty could be considered a practical and effective treatment option with a high success rate for recurrent UPJO with a long proximal ureteral stricture, and the robotic procedures showed advantages of higher efficiency and faster recovery.

Real-time navigation by three-dimensional virtual reconstruction models in robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction: our initial experience

Background

The aim of this study was to evaluate the effectiveness and safety of real-time surgical navigation by three-dimensional (3D) virtual reconstruction models in robot-assisted laparoscopic pyeloplasty (RALP).

Methods

Between November 2018 and January 2020, 38 patients with ureteropelvic junction obstruction (UPJO) who underwent RALP were retrospectively enrolled. The operations were assisted in real time by 3D models in 16 patients, while 22 patients underwent surgery without navigation. Based on whether patients had a prior intervention history, crossing vessels or congenital deformities, we further divided them into the “complicated UPJO” cohort and the “regular UPJO” cohort for subgroup analysis. The demographic characteristics, intraoperative parameters, perioperative data and follow-up data were recorded and compared between the groups.

Results

All of the procedures were successfully performed without open or laparoscopic conversion. The mean dissection time to the UPJ was shorter in the navigation group than in the non-navigation group, both in the whole cohort (15.3 vs. 24.8 min, P=0.011) and in the complicated cohort (15.4 vs. 27.5 min, P=0.004), while there was no significant difference in the regular cohort. The overall operative time and estimated blood loss in the navigation group tended to be less, although the difference was not statistically significant. No difference in anastomosis time, postoperative hospital stay or complications was noted between the two groups in either cohort. At a mean follow-up of 11.2 months, the overall success rate was 94.7% (36/38), and there was no significant difference between the two groups.

Conclusions

Real-time navigation by 3D virtual reconstruction models might be helpful to improve surgical efficiency and safety of RALP by facilitating the dissection around the UPJ, especially for cases of complicated UPJO. However, the prospective study with larger sample size is further needed to confirm the results.

Concomitant Treatment of Ureteropelvic Junction Obstruction Complicated by Renal Calculi with Laparoscopic Pyeloplasty and Pyelolithotomy via 19.5F Rigid Nephroscope: A Report of 12 Cases

OBJECTIVE

To introduce our experience of concomitant laparoscopic pyeloplasty (LP) and pyelolithotomy via 19.5 F rigid nephroscope to treat ureteropelvic junction obstruction (UPJO) complicated with renal calculi.

METHODS

The data of 42 patients with UPJO who underwent LP from June 2016 to August 2019 were retrospectively reviewed. Twelve patients with ipsilateral renal calculi underwent LP and concomitant pyelolithotomy via 19.5 F rigid nephroscope. Perioperative data of this group were compared with other 12 matched patients without calculi who underwent LP only.

RESULTS

Of 12 patients with renal calculi, only 4 patients had simple stone and the other 8 patients suffered complex stones. Anatomical solitary kidney was found in 2 patients. The mean diameter of the largest stone was 1.1 cm (ranged from 0.6 to 1.7). The mean operative time was 171 min, the mean time of nephroscopic management was 17.2 min, 7 patients received pyelolithotomy by forceps, 3 patients received pyelolithotomy and ultrasonic lithotripsy, 1 patient received ultrasonic lithotripsy, the mean number of stones retrieved was 8.9 (ranged from 0-53), in one case the calculus was inaccessible because it was located in a narrow neck caliceal diverticulum. Overall stone-free rate was 91.7% (11/12). No difference in operative time, postoperative hemoglobin drop, postoperative hospital stay and incidence of complications was observed between the 2 groups. At the mean follow-up of 17.9 months, no patients had obstruction or recurrent stones.

CONCLUSION

LP and concomitant pyelolithotomy via 19.5 F rigid nephroscope is a safe and feasible option to treat UPJO with renal calculi, with acceptable success rate and stone-free rate.

Laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures: our experience and strategy

PURPOSE

To present our experience of laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures and summarize our treatment strategies for these challenging scenarios.

METHODS

From March 2018 to January 2020, 53 patients with long proximal/middle ureteral strictures (2-6 cm) who underwent laparoscopic or robotic onlay flap/graft ureteroplasty were retrospectively enrolled. Different reconstruction techniques were chosen based on our management strategy: pelvic flap (PF) was the first choice for proximal stricture if pelvic tissue was sufficient for repair, while appendiceal flap (AF) was preferred over oral mucosa graft for both proximal and middle strictures.

RESULTS

A total of 28 PFs, 9 AFs and 16 lingual mucosa grafts (LMGs) onlay ureteroplasty were performed successfully, with 33 laparoscopic procedures and 20 robotic procedures being undertaken. No intraoperative complications or conversion occurred. The median stricture length was 4 cm (range 2-6 cm). Compared with laparoscopic procedures, robotic procedures showed significantly shorter operative time (P = 0.008), shorter postoperative hospital stay (P = 0.011) but higher hospital cost (P < 0.001). At a mean follow-up of 12.8 months, the overall success rate was 94.3%. There was no difference in postoperative complications or the success rate between the approaches.

CONCLUSION

Laparoscopic and robotic onlay flap/graft ureteroplasty can be safe and feasible to repair long proximal/middle ureteral strictures while robotic procedures showed higher efficiency, faster recovery but higher cost. Our algorithmic strategies may provide beneficial references for their standardization and dissemination into clinical care.

Laparoscopic Disconnected Pyeloplasty to Treat Ureteropelvic Junction Obstruction (UPJO) in Children

Background

The aim of this study was to assess the safety and clinical effectiveness of laparoscopic disconnected pyeloplasty in treating ureteropelvic junction obstruction (UPJO) in children.

Material/Methods

We retrospectively analyzed the clinical data of 122 young children with UPJO treated from February 2015 to February 2018 at our hospital. According to the surgery type, the patients were divided into 2 groups: a laparoscopic surgery group (group A, n=69) and a traditional open surgery group (group B, n=53).

Results

The success rate of laparoscopic disconnected pyeloplasty was 100%, and none of the patients were converted to open surgery. The mean duration of use of painkillers was 27.6±11.3 h in group A and 58.2±18.2 h in group B (p=0.012), the postoperative hospital stay was 7.8±1.5 days in group A and 11.5±2.6 days in group B (p=0.041), and the length of the incision was 1.5±0.4 cm in group A and 5.2±1.1 cm in group B (p=0.007). The incidence rate of poor surgical wound healing was 0% in group A and 7.5% in group B (p=0.020). The incidence rate of ureteral stricture was 4.3% in group A and 3.8% in group B (p=0.874) during follow-up. The 1-year follow-up showed that both the anterior and posterior diameters and glomerular filtration rate were significantly improved from the preoperation period.

Conclusions

Laparoscopic disconnected pyeloplasty to treat UPJO in young children has the same early clinical effectiveness and safety as open surgery, and this procedure has the advantages of minimal trauma, quick recovery, and good cosmetic effect.

[Advances in surgical repair of ureteral injury]

Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.

[Review of upper urinary modified minimal invasive surgical technology]

Upper urinary surgery is an important area of urology surgery. Open surgery used to be the gold standard of upper urinary surgery. With the development of medical techniques, minimal invasive surgeries including laparoscopic and robot assisted-laparoscopic surgery have gradually replaced the open surgery. Because of the complexity and diversity of upper urinary diseases, surgeries sometimes are difficult, and minimal invasive surgeries require higher surgical abilities of urologists than open surgeries. In recent years, depending on our surgical experience and international reports, our team from three Chinese medical centers summarizes techniques of upper urinary minimal invasive surgeries. For malignant diseases, such as renal and ureteral carcinomas, it's important to totally remove the tumor first, and then to avoid the surgical injuries. We summarize surgical experience of retroperitoneal laparoscopic partial nephrectomy for moderately complex renal hilar tumors. Our team modified minimal invasive techniques for some complex tumors, including ring suture technique for renal hilar tumors, internal suspension technique for renal ventral tumors, and combination retroperitoneal laparoscopic surgery with mini-flank incision for complex renal tumors. While for begin diseases, urologists should focus on the resections and surgical injuries at the same time. We have reported the novel technique of laparoscopic aspiration for central renal angiomyolipoma, making the surgery simple and available. For reconstruction surgeries, operations should be based on several principals. We generalize it as "4TB principals", which include "tension-free", "water-tight", "thin suture", "no touch of the key area" and "protecting the blood supply". Depending on the localization, length, and etiology of the strictures, different techniques are required. Our team summarize the pyeloplasty, ureteral reimplantation and ileal ureter replacement based on our surgical experience. For infant upper urinary surgeries, our team has made invasive surgeries that can be used in complex diseases, such as duplex kidney. Based on years of surgical techniques, our modified surgeries achieve a better subjective cosmetic result than the traditional surgeries. In the future, the standardized, practical, simple and individual minimal invasive surgical technique will become the main direction in the future researches.

A New Touchless Technique for Suturing in Transperitoneal Laparoscopic Pyeloplasty

BACKGROUND

The most difficult, time-consuming, and critical steps of laparoscopic pyeloplasty (LPP) are ureteral spatulation, apical ureteral stitch placement, and ureteropelvic anastomosis. To simplify these critical steps, avoid the risk of ureteral shortening, and also minimize ureteral manipulation, we present a modified dismembered technique for suturing with the outcome of patients who underwent LPP using this technique.

MATERIALS AND METHODS

This study included 23 patients who were candidates for transperitoneal dismembered Anderson-Hynes LPP. The ureter was partially cut just below the ureteropelvic junction. The ureter was spatulated at its lateral aspect to cross the obstruction site and reach the normal ureter. The renal pelvis was obliquely cut equal to the size of ureteral spatulation. The ureter and pelvis were still connected partially. At this point, the first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis. Anastomosis was performed by running sutures.

RESULTS

No cases of internal organ injury and no cases of open surgery conversion were encountered. The radiologic success rate was 96%. After operation, in 1 patient, obstruction still existed and the patient underwent nephrectomy due to a nonfunctional obstructive kidney.

CONCLUSIONS

This modification preserves total ureteral length and facilitates spatulation and suturing in transperitoneal laparoscopic dismembered pyeloplasty. The results showed that it is a useful method, especially for less-experienced surgeons.

Laparoscopic In Situ Dismembered Pyeloplasty Can Facilitate Laparoscopic Ureteropelvic Junction Obstruction Repair: A Prospective Cohort Trial

PURPOSE

To describe the technique of laparoscopic in situ dismembered pyeloplasty as a modified technique during which the alignment of ureter and renal pelvis remains intact during ureteropelvic junction (UPJ) anastomosis. We also assessed intraoperative and postoperative outcomes of this modification in comparison to standard laparoscopic dismembered pyeloplasty.

PATIENTS AND METHODS

Patients with significant primary UPJ obstruction without any history of abdominal surgery, high ureter insertion, or renal anomalies were considered. The patients were consecutively enrolled one after another into one of two study groups: classic laparoscopic dismembered pyeloplasty (Group I) or laparoscopic in situ dismembered pyeloplasty (Group II), however, those with aberrant vessels crossing the UPJ were allocated specifically to Group I because UPJ anastomosis should be done anterior to the aberrant vessels. Demographic data, intraoperative timings, and postoperative and follow-up outcomes were compared in the two groups.

RESULTS

Patients in Group I (n = 23) and Group II (n = 14) had similar demographic characteristics. Mean operative time was significantly longer in Group I (103.8 ± 19.95 minutes vs 89.5 ± 18.90 minutes, p = 0.038). Total duration of UPJ repair and anastomosis was also significantly longer in Group I (92.7 ± 15.82 minutes vs 78.4 ± 14.76 minutes, p = 0.021). The method of pyeloplasty significantly affected the time required to prepare ureter and renal pelvis (p = 0.017) and the duration of UPJ anastomosis (p = 0.014). Both were shorter in Group II. Mean follow-up period was 14.4 ± 7.42 months in Group I and 14.05 ± 7.93 months in Group II (p = 0.88). Success rate was 95.6% in Group I and 100% in Group II (p = 0.42).

CONCLUSION

Laparoscopic in situ pyeloplasty is a safe and effective approach that can help simplify laparoscopic pyeloplasty, especially at teaching centers where surgeons with variable levels of experience perform laparoscopic procedures.

A modified technique of paraumbilical three-port laparoscopic dismembered pyeloplasty for infants and children

BACKGROUND

Common causes of complications of laparoscopic pyeloplasty in children include anastomotic stricture, poor drainage due to high ureteropelvic anastomosis, and torsion of ureter. Herewith, we described our modified technique of paraumbilical three-port laparoscopic dismembered pyeloplasty (PTLDP) to minimize these complications.

PATIENTS AND METHODS

Data from 62 patients (age: 1-180 months, median: 12 months) with ureteropelvic junction obstruction (UPJO) who underwent pyeloplasty using our modified technique of PTLDP between February 2014 and September 2014 at our institution were reviewed. The key steps of our modified method involve identifying the lowest point of the renal pelvis and the lateral aspect of the ureter to guarantee a low pelviureteric and correct orientation anastomosis, and using a 4-0 silk for assistant suturing to avoid crushing of the anastomotic tissue.

RESULTS

All surgeries were successfully completed without conversion. Three patients required an accessory port for the anastomosis. All the patients achieved complete clinical or radiologic resolution after the operation. The mean operative time was 103.4 min, and mean estimated blood loss was 14.4 mL. Mean postoperative differential function of affected kidney was 43.0 ± 16.3 % (range 24-100 %), increased from 39.7 ± 18.0 % (range 18-100 %), preoperatively (p < 0.001). The success rate was 100 % at a mean follow-up of 18.3 ± 2.9 (range 13-25) months.

CONCLUSIONS

Our modified technique of PTLDP is safe and feasible and to allow high success rate for the treatment of pelviureteric junction obstruction in children.