Laparoscopic pyeloplasty. Indications, technique, and long-term outcome

Techniques in minimally invasive transperitoneal pyeloplasty: A compilation

Context

Minimally invasive management (laparoscopic/robot assisted) is currently the standard of care for managing pelvi ureteric junction obstruction (PUJO). Open techniques of management of PUJO are well described in literature. However, there appears to be relative lack of description of minimally invasive techniques in the literature.

Objective

This article is aimed at describing in detail, with images, the various techniques and modifications in laparoscopic or robot-assisted management of PUJO.

Evidence Acquisition

A review of literature on PubMed was performed and all articles which detailed any technique of minimally invasive pyeloplasty were included.

Evidence Synthesis

The various techniques of minimally invasive pyeloplasty as well as the authors' techniques are compiled and described in detail with intraoperative images.

Conclusions

Operative techniques of minimally invasive pyeloplasty are not well described in literature. We have attempted to present a comprehensive resource of different techniques of minimally invasive pyeloplasty and the clinical scenarios in which they may be appropriate. This should prove to be a useful reference to the practicing urologist.

Patient Summary

In this paper, we have compiled the various surgical techniques of treating obstruction at the PUJ of the kidney along with intraoperative photograph.

Robotic-assisted surgery in the pediatric surgeons' world: Current situation and future prospectives

Robotic-assisted surgery has been fully embraced by surgeons for the adult population; however, its acceptance is too slow in the world of pediatric surgeons. It is largely due to the technical limitations and the inherent high cost associated with it. In the past two decades, indeed, there has been considerable advancement in pediatric robotic surgery. A large number of surgical procedures were performed on children with the assistance of robots, even with comparative success rates to standard laparoscopy. As a newly developing field, it still has many challenges and obstacles. This work is centered on the current status and progression of pediatric robotic surgery as well as the future perspectives in the field of pediatric surgery.

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.

Surgical outcomes are equivalent after pure laparoscopic and robotic-assisted pyeloplasty for ureteropelvic junction obstruction

INTRODUCTION

Minimally invasive (robotic and pure laparoscopic) pyeloplasty has been increasingly used for treatment of ureteropelvic junction obstruction (UPJO). However, few large-scale studies have compared these two modalities directly.

METHODS

We performed a retrospective single-center review of all patients who underwent pure laparoscopic (LP) or robotic pyeloplasty (RALP) between 2007 and 2018. Patients were excluded if the initial surgery at our institution was a redo pyeloplasty or if they lacked follow-up information. Outcomes of interest included operative time, length of stay, and complication rates, including rates of secondary procedures. We compared these outcomes between groups using Student's t test for continuous variables and a Chi-square for categorical variables.

RESULTS

A total of 282 patients were identified. Forty-eight were excluded based on study criteria; therefore, our total study cohort was 234 patients: 119 RALP and 115 LP cases. Overall mean postoperative follow-up time was 20.8 months, with no significant differences between groups. Mean operative time was shorter in the LP group when compared the RALP group (3 h 7 min vs. 3 h 41 min, p < 0.001). There were no significant differences between groups in length of stay (1.22 days vs 1.50 days, p = 0.095). Complications occurred in 52 patients (22.2% of overall cohort) with no difference in incidence between groups. Twenty-five patients (14 in the RALP group and 11 in the LP group) underwent unplanned secondary procedures; 19 of these patients (9 in the RALP group and 10 in the LP group) needed a procedure to address secondary obstruction.

CONCLUSION

We demonstrated no significant differences between RALP and LP in regards to complication rates. Surgeons performing RALP and LP have the potential to offer the same level of care for the surgical management of UPJO, especially in countries where robotic technology may not be readily available.

The Future of Robotic Surgery in Pediatric Urology: Upcoming Technology and Evolution Within the Field

Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.

Prospective randomized comparison between transperitoneal laparoscopic pyeloplasty and retroperitoneoscopic pyeloplasty for primary ureteropelvic junction obstruction

Background and Objectives:

To compare laparoscopic transperitoneal versus retroperitoneoscopic pyeloplasty for primary ureteropelvic junction obstruction in a prospective randomized manner and assess overall results with long-term follow-up.

Methods:

In this prospective study, from 2008 to 2012, 112 cases of primary ureteropelvic junction obstruction were randomized in a 1:1 ratio into 2 groups. Group I included patients who underwent transperitoneal laparoscopic pyeloplasty, and group II consisted of patients who underwent retroperitoneoscopic laparoscopic pyeloplasty. Demographic and clinical characteristics and postoperative and operative data were collected and analyzed. The statistical analysis was performed with the Fisher exact test, χ² test, and Mann-Whitney U test for independent groups, and P < .05 was considered statistically significant.

Results:

The total operative time and intracorporeal suturing time were significantly higher in group II than in group I (P < .001). The visual analog scale score for pain on postoperative day 1 and the requirement for tramadol were significantly higher in group I than in group II (P = .004). The hospital stay and the rate of temporary ileus were significantly greater (P < .036 and P < .02, respectively) in group I than in group II. The success rate of transperitoneal laparoscopic pyeloplasty versus retroperitoneoscopic laparoscopic pyeloplasty was 96.4% versus 96.6% with a mean follow-up period of 30.75 ± 4.85 months versus 30.99 ± 5.59 months (P < .88).

Conclusion:

Transperitoneal laparoscopic pyeloplasty is associated with significantly greater postoperative pain, a higher tramadol dose, a higher rate of ileus, and a longer hospital stay in comparison with retroperitoneoscopic laparoscopic pyeloplasty. Although the operative time for retroperitoneoscopic laparoscopic pyeloplasty is significantly longer, the success rate remains the same for both procedures.

Role of laparoscopy in ureteropelvic junction obstruction with concomitant pathology: a case series study

Introduction

Laparoscopic pyeloplasty is considered a standard treatment for ureteropelvic junction obstruction (UPJO). However, the presence of another pathology makes it a more challenging operation and guides the surgeon towards open conversion. In this study, we present our experience in difficult pyeloplasty cases managed by laparoscopy.

Material and methods

Six patients (4 females and 2 males) with an average age of 44 and a range of 27 to 60 years old, were diagnosed for UPJO. Three were on the left side and 3 on the right side. In addition to UPJO, 2 patients had renal stones, one patient had both renal ptosis and an umbilical hernia, 3 patients had a para-pelvic cyst, hepatomegaly and malrotated kidney, respectively. All patients had a preoperative ultrasound, CT or IVU, and a renal isotope scan. Laparoscopic pyeloplasty was performed according to the dismembered Anderson-Hynes technique with auxiliary maneuver, according to the pathology.

Results

All patients were treated successfully for UPJO and the concomitant pathologies, except hepatomegaly and malrotation. Mean operative time was 125 minutes and estimated blood loss was <50 ml.

Conclusions

Laparoscopic pyeloplasty can be performed in difficult situations provided that the surgeon has enough experience with laparoscopy.

Pediatric ureteropelvic junction obstruction: can magnetic resonance urography identify crossing vessels?

BACKGROUND

MR Urography (MRU) is an increasingly used imaging modality for the evaluation of pediatric genitourinary obstruction.

OBJECTIVE

To determine whether pediatric MR urography (MRU) reliably detects crossing vessels in the setting of suspected ureteropelvic junction (UPJ) obstruction. The clinical significance of these vessels was also evaluated.

MATERIALS AND METHODS

We identified pediatric patients diagnosed with UPJ obstruction by MRU between May 2009 and June 2014. MRU studies were evaluated by two pediatric radiologists for the presence or absence of crossing vessels. Ancillary imaging findings such as laterality, parenchymal thinning/scarring, trapped fluid in the proximal ureter, and presence of renal parenchymal edema were also evaluated. Imaging findings were compared to surgical findings. We used the Mann-Whitney U test to compare continuous data and the Fisher exact test to compare proportions.

RESULTS

Twenty-four of 25 (96%) UPJ obstructions identified by MRU were surgically confirmed. MRU identified crossing vessels in 10 of these cases, with 9 cases confirmed intraoperatively (κ = 0.92 [95% CI: 0.75, 1.0]). Crossing vessels were determined to be the primary cause of UPJ obstruction in 7/9 children intraoperatively, while in two children the vessels were deemed incidental and noncontributory to the urinary tract obstruction. There was no significant difference in age or the proportions of ancillary findings when comparing children without and with obstructing vessels.

CONCLUSION

MRU allows detection of crossing vessels in pediatric UPJ obstruction. Although these vessels are the primary cause of obstruction in some children, they are incidental and non-contributory in others. Our study failed to convincingly identify any significant predictors (e.g., age or presence of renal parenchymal edema) that indicate when a crossing vessel is the primary cause of obstruction.

Robotic pyeloplasty: Initial experience of a single UK centre

Objective:

We present our experience and outcomes at a single UK robotic centre of robotic-assisted laparoscopic dismembered pyeloplasty for the treatment of pelvo-ureteric junction obstruction (PUJO).

Materials and methods:

Between July 2009 and July 2013, 20 robotic-assisted transperitoneal laparoscopic pyeloplasties were performed by four surgeons. Data were obtained from patient case notes, patient charts, and radiographic reports.

Results:

A total of 20 robot-assisted laparoscopic dismembered pyeloplasties were performed in 11 men and nine women. Mean age at treatment was 37 years (range 16–75) with an average follow-up of 14 months (five to 24). The average console time was two hours: 8 minutes (1:30–3:30), mean drop in haemoglobin 0.67 g/dl (−3.5 to +1.3), mean change in serum creatinine −0.5 (−22 to +18). The average time to post-operative catheter removal was 1.64 days (one to two), to post-operative drain removal 2.43 days (two to three), and to discharge 2.8 days (two to four). The average time to stent removal was 6.1 weeks (six to eight). At the mean follow-up of 14 months no major perioperative complications had occurred and no patients were re-admitted within 30 days of operation. The success rate was 95%; one patient required a second procedure in the form of an open redo-pyeloplasty because of continued pain and radiographic evidence of continued obstruction.

Conclusions:

These results suggest that robotic-assisted laparoscopic pyeloplasty is a feasible treatment for PUJO in a UK centre. Low rates of morbidity, short post-operative stay and high success rates at our centre are comparable with other series. Longer follow-up of this cohort is needed to demonstrate durable and effective outcomes.

Novel prototype sewing device, EndoSew®, for minimally invasive surgery: an extracorporeal ileal conduit construction pilot study in 10 patients

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The EndoSew(®) prototype was first tested in a porcine model several years ago. The investigators found it both simple to master and reliable, its greatest advantage being a 2.4-fold time saving compared with straight laparoscopic suturing. In addition to that publication, there is a single case report describing the performance of an open EndoSew(®) suture to close parts (16 cm) of an ileal neobladder. The time for suturing the 16 cm ileum was 25 min, which is in line with our experience. The knowledge on this subject is limited to these two publications. We report on the first consecutive series of ileal conduits performed in humans using the novel prototype sewing device EndoSew(®). The study shows that the beginning and the end of the suture process represent the critical procedural steps. It also shows that, overall, the prototype sewing machine has the potential to facilitate the intracorporeal suturing required in reconstructive urology for construction of urinary diversions.

OBJECTIVE

To evaluate the feasibility and safety of the novel prototype sewing device EndoSew(®) in placing an extracorporeal resorbable running suture for ileal conduits.

PATIENTS AND METHODS

We conducted a prospective single-centre pilot study of 10 consecutive patients undergoing ileal conduit, in whom the proximal end of the ileal conduit was closed extracorporeally using an EndoSew(®) running suture. The primary endpoint was the safety of the device and the feasibility of the sewing procedure which was defined as a complete watertight running suture line accomplished by EndoSew(®) only. Watertightness was assessed using methylene blue intraoperatively and by loopography on postoperative days 7 and 14. Secondary endpoints were the time requirements and complications ≤30 days after surgery.

RESULTS

A complete EndoSew(®) running suture was feasible in nine patients; the suture had to be abandoned in one patient because of mechanical failure. In three patients, two additional single freehand stitches were needed to anchor the thread and to seal tiny leaks. Consequently, all suture lines in 6/10 patients were watertight with EndoSew(®) suturing alone and in 10/10 patients after additional freehand stitches. The median (range) sewing time was 5.5 (3-10) min and the median (range) suture length was 4.5 (2-5.5) cm. There were no suture-related complications.

CONCLUSIONS

The EndoSew(®) procedure is both feasible and safe. After additional freehand stitches in four patients all sutures were watertight. With further technical refinements, EndoSew(®) has the potential to facilitate the intracorporeal construction of urinary diversions.

Advances in the surgical pediatric urologic armamentarium

The surgical armamentarium of the pediatric urologist has changed greatly in the past 2 decades on account of new technology and careful adaptation of minimally invasive techniques in children. Conventional laparoscopy, robotic-assisted laparoscopy, laparoendoscopic single-site surgery, and endourologic surgery have, to varying degrees, provided new approaches to urologic surgery in the pediatric population. This article reviews the technology and adaptations behind these recent advances as well as their current applications in management of urologic disease in children.

Perioperative comparison of robotic assisted laparoendoscopic single-site (LESS) pyeloplasty versus conventional LESS pyeloplasty

BACKGROUND

Conventional laparoendoscopic single-site (C-LESS) pyeloplasty is technically challenging due to instrument clashing, loss of triangulation, and difficulty sewing. Application of the da Vinci S or Si robotic platforms could potentially overcome these challenges.

OBJECTIVE

Compare our initial experience with robotic assisted laparoendoscopic single-site (R-LESS) pyeloplasty to our latter experience with C-LESS pyeloplasty (ie, after the initial 15 patients).

DESIGN, SETTING, AND PARTICIPANTS

This single-institution retrospective observational cohort study involved consecutive patients who presented with symptomatic ureteropelvic junction obstruction and who were deemed suitable for single-incision pyeloplasty by the treating surgeon.

MEASUREMENTS

Demographic, clinical, perioperative, and early postoperative comparative outcomes.

RESULTS AND LIMITATIONS

Ten patients each underwent R-LESS or C-LESS pyeloplasty by a single surgeon between March 2009 and July 2011. For R-LESS and C-LESS groups, age, gender distribution, body mass index, proportion of patients with prior abdominal surgery, estimated blood loss, and hospital length of stay were statistically similar. Mean operative time was significantly longer for R-LESS (226 vs 188 min; p=0.007). C-LESS pyeloplasty alone required an accessory port for the anastomosis in 10 of 10 cases. Two conversions to standard laparoscopy and two postoperative complications occurred in 3 of 10 patients in the C-LESS group, compared with no conversions and one postoperative complication in the R-LESS group (p=0.26). Study limitations are a retrospective design, a modest number of patients, and a lack of quantification of subjective outcomes such as instrument clashing and maneuverability.

CONCLUSIONS

Adaptation of the da Vinci Si robotic surgical platform to laparoendoscopic single-site pyeloplasty appears to reduce the physical learning curve for this complex procedure. Future prospective, comprehensive evaluation of additional outcomes including subjective parameters, cosmesis, and longer term functional outcomes will help better define its role in minimally invasive dismembered pyeloplasty and better estimate its associated learning curve.

Laparoscopic reconstructive urology

Objective:

Laparoscopic reconstructive urology is undergoing rapid change. We review the current status of laparoscopic reconstructive urology, with particular respect to pyeloplasty and reconstructive ureteric surgery.

Methods:

An extensive Medline search of reconstructive laparoscopic procedures was undertaken. The initial reports and large series reports of a range of procedures was examined and summarised. The most commonly practised procedure within this remit is laparoscopic pyeloplasty. Several series of over 100 patients have been published. Success rates average over 90% for laparoscopic pyeloplasty with a low complication rate. Much less common laparoscopic reconstructive urological procedures include ureteric re-implantation, Boari flap, urinary diversion and transuretero-ureterostomy. The results of these are encouraging.

Conclusions:

Laparoscopic pyeloplasty may be safely performed by either the transperitoneal or retroperitoneal routes with excellent results. It should be considered the “gold standard” for the management of UPJ obstruction, especially in those patients with significant hydronephrosis, renal impairment or a crossing vessel. Laparoscopic ureteric reimplantation, Boari flap, urinary diversion and transuretero-ureterostomy have been performed by experienced laparoscopic urologists with encouraging results.

Miniature pyeloplasty as a minimally invasive surgery with less than 1 day admission in infants

PURPOSE

Open dismembered pyeloplasty is usually performed through flank, anterior subcostal or posterior lumbotomy incisions. These incisions are cosmetically less acceptable and may produce significant postoperative pain. We present the smallest incision for open pyeloplasty, called a 'miniature pyeloplasty'. The aim of this study was to reduce hospital stay and postoperative pain, along with enhanced cosmetic results.

PATIENTS AND METHOD

373 infants (mean age 4 months) with hugely dilated pelvises underwent the miniature pyeloplasty. The exact site of incision was determined by intraoperative renal ultrasonography and palpation. A muscle-splitting incision was made in the most dependent part of the lower quadrant. After meticulous dissection of the ureteropelvic junction component, the affected section was pulled out and underwent classic dismembered pyeloplasty without renal pelvis reduction. All children had long-duration stented anastomoses. Surgical incision size, operative time, hospital stay, postoperative analgesic use and complication rate were recorded.

RESULTS

The operation was successful in all patients. The mean operative time was 53 min (range 43-75) and patients were discharged after 18 ± 3 (mean ± SD) h. Incision size ranged from 11 to 15 mm (mean 13). No narcotic analgesic was required postoperatively and there were no major complications during follow up.

CONCLUSIONS

Miniature pyeloplasty is a safe and successful technique for ureteropelvic junction obstruction that avoids long operative time with negligible postoperative pain compared to the classic open pyeloplasty in infants. The exact incision site must be reconfirmed intraoperatively by physical examination or renal ultrasonography.

The minimally invasive management of ureteropelvic junction obstruction in horseshoe kidneys

PURPOSE

Data regarding the treatment of ureteropelvic junction obstruction (UPJO) in horseshoe kidneys are limited. We performed a retrospective analysis of our experience with minimally invasive treatment of UPJO in patients with this anomaly.

METHODS

Between March of 1996 and March 2008, 9 patients with horseshoe kidneys were treated for UPJO at our institution. Of these patients, 6 were managed with retrograde endopyelotomy, 2 with laparoscopic pyeloplasty, and one by robotic pyeloplasty. Outcomes of these procedures were retrospectively reviewed.

RESULTS

A total of nine patients were available for analysis. Four of six patients who underwent endopyelotomy had available follow-up, with a mean of 56 months. The success rate for these patients was 75%. Two of three patients (67%) in the laparoscopic/robotic cohort were successfully treated with a mean follow-up of 21 months.

CONCLUSIONS

UPJO in horseshoe kidneys can pose a therapeutic dilemma. The minimally invasive treatment of these patients is feasible with good success rates for both endopyelotomy and laparoscopic/robotic pyeloplasty.

Retroperitoneoscopic Anderson-Hynes dismembered pyeloplasty in infants and children: a 60-case report

PURPOSE

To present a new technique of retroperitoneoscopic Anderson-Hynes dismembered pyeloplasty (AHDP) in infants and children with ureteropelvic junction obstruction (UPJO) based on our clinical experience.

METHODS

From March 2003 to February 2007, retroperitoneoscopic AHDP was performed in 60 (44 boys and 16 girls) UPJO infants and children with a three-port lateral retroperitoneal approach. The retroperitoneal space was entered via a 1-cm longitudinal incision beneath the 12th rib and further developed by a glove balloon. Video-retroperitoneoscopy was undertaken with a 5-mm laparoscope between the mid axillary line and 1 cm away from the superior border of iliac crest. Dismembered pyeloplasty was carried out with the Anderson-Hynes anastomosis where 5-0 or 6-0 vicryl sutures were over a double-J ureteric stent. Anastomosis was completed with freehand intracorporeal suture techniques. Follow-up studies were conducted by intravenous urography and renal ultrasonography.

RESULTS

Among the 60 patients (62 sides) with retroperitoneoscopic AHDP, only the first two cases were converted to open surgery due to difficulties in developing the retroperitoneal space, and the remaining cases succeeded. The average operative time was 70 +/- 12.6 min (ranging from 55 to 130 min), the average estimated blood loss was 10 +/- 2.2 ml (ranging from 5 to 20 ml), and the average postoperative hospital stay was 7 +/- 1.3 days (ranging from 3 to 15 days). Aberrant artery vessel was intraoperatively observed in seven patients. Postoperative urinary leakage occurred in two patients, but spontaneously disappeared on the 6th and 11th days after the surgery, respectively; and one of them underwent open surgery for recurrent UPJO 8 months later. During an average follow-up period of 24 months, we performed radiographic assessment by intravenous urography and found that all the cases showed good results except the patient who underwent open surgery later.

CONCLUSIONS

Our experience with retroperitoneoscopic AHDP demonstrates that this technique is safe, effective and time saving for treating UPJO in infants and children.

Percutaneous ureteral catheterization in laparoscopic surgery: value of nephroscopy needle trocar

OBJECTIVES

To report our experience with use of the nephroscopy needle trocar for percutaneous catheterization. In multiple urologic procedures, surgeons use ureteral catheters to decrease morbidity, increase the success rate, and allow for postoperative radiographic follow-up. The advent of laparoscopic surgery has logically required catheterization to be adapted to our laparoscopic procedures.

METHODS

The expansion of our daily practice to include multiple laparoscopic procedures showed us the difficulties inherent to ureteral catheterization in laparoscopic surgery. During our experience of >1000 laparoscopic procedures, we have used more or less complex catheterization techniques. After developing the use of the nephroscopy needle trocar for laparoscopic urinary diversion and finding that such use simplified the procedure, this technique was extended to all other laparoscopic procedures in which catheterization is required.

RESULTS

We analyzed the use of the nephroscopy needle trocar in 15 ureteropyeloplasty, 21 ileal conduit, and 4 laparoscopic ureteral reimplantation procedures. The mean operating time required for anterograde catheterization in ureteropelvic junction stenosis was 3 minutes, 35 seconds, and the mean operating time for retrograde catheterization was 2 minutes, 20 seconds. Anterograde catheterization was impossible in 1 case. No cases of a false ureteral tract occurred.

CONCLUSIONS

The results of our analysis have shown that the use of the nephroscopy needle trocar for percutaneous catheterization in laparoscopic surgery markedly simplifies the procedure, with the resultant savings in operating time.

Concomitant percutaneous nephrolithotomy and transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction complicated by stones

INTRODUCTION

Ureteropelvic junction (UPJ) obstruction and stones can co exist. Therapeutic controversy exists regarding their ideal management. We present our experience of combining Percutaneous nephrolithotomy (PNL) with laparoscopic pyeloplasty (LP),in patients with UPJ obstruction with multiple secondary, in the same session or staged manner.

PATIENTS AND METHOD

From November 2006 till April 2008 ten patients underwent PNL with LP at our institution. Two of these patients had recurrent obstruction and stones after PNL and endopyelotomy. All patients had multiple calyceal and pelvic calculi (>10) with sizes ranging from 3 to 24 mm. Mean age of patients was 33 years (17-55). PNL was done in standard manner and was followed by laparoscopic pyeloplasty.

RESULT

Complete stone clearance could be achieved in all by PNL. Procedure was staged in 2 due to the presence of infected hydronephrosis. 9 patients underwent dismembered pyeloplasty and in 1 Fengerplasty was done. Reduction of baggy pelvis was required in 3 cases. Mean operative time was 3. 9 hours (3-5). Postoperatively the nephrostomy was kept for an average of 2 days (1-3). Drain was removed after an average of 3. 5 days (3-5). Mean hospital stay was 5. 2 days (5-7). None of the patients required blood transfusion. Stent was removed after 4 weeks. At 6 months patients are stone free on ultrasound and show good drainage on renal scan. One year follow-up is available for 5 patients which shows a stone free status and good drainage across UPJ.

CONCLUSION

Concomitant PNL and laparoscopic pyeloplasty are feasible and safe for patients with UPJ obstruction complicated by multiple calculi. We did not encounter any intraoperative difficulty during pyeloplasty following PNL.

Long-term follow-up for salvage laparoscopic pyeloplasty after failed open pyeloplasty

OBJECTIVES

To report our long-term experience with salvage laparoscopic pyeloplasty after a failed open procedure. Laparoscopic repair of a primary ureteropelvic junction obstruction (UPJO) is associated with very high long-term success. However, there are limited data on patients who have failed previous open pyeloplasty. We have determined that salvage laparoscopic pyeloplasty is an excellent option for these patients.

METHODS

We queried our laparoscopic pyeloplasty database of 367 patients from July 1994 to May 2007 for patients who had undergone prior open pyeloplasty. We analyzed demographic data, perioperative course, complications, and follow-up studies on identified subjects. We assessed clinical status by verbal pain scale and diagnostic studies. Radiologic follow-up consisted of diuretic renal scan, intravenous pyelography, or both.

RESULTS

We identified 9 patients (2.5%) who underwent salvage laparoscopic pyeloplasty for persistent obstruction after open pyeloplasty. The mean age of our cohort was 30.5 years (range, 19-50 years). Mean operative time was 204 minutes (range, 80-264 minutes), estimated blood loss was 105 mL (range, 20-300 mL), and mean length of stay was 2.1 days (range, 2-3 days). No intraoperative or postoperative complications were reported. All patients reported relief of symptoms in the immediate postoperative period. At a median follow-up of 66 months (range, 12-119 months), 8 of 9 patients (89%) had clinical and radiologic resolution of UPJO with stable renal function, pain free status, and a patent ureteropelvic junction. The remaining patient failed laparoscopic repair within the first year with evidence of persistent obstruction, necessitating endopyelotomy.

CONCLUSIONS

Our findings support the use of salvage laparoscopic pyeloplasty as an excellent option for patients who failed previous open pyeloplasty. This approach provides durable long-term outcomes.

Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience

PURPOSE

The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty.

MATERIALS AND METHODS

A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups.

RESULTS

Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts.

CONCLUSIONS

To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney.

Transperitoneal laparoscopic pyeloplasty in children

BACKGROUND AND PURPOSE

Ureteropelvic junction (UPJ) obstruction remains the most common cause of hydronephrosis in newborns and children. Open pyeloplasty has been the gold standard for management of UPJ obstruction in these patients. We report our technique and outcome with laparoscopic transperitoneal dismembered pyeloplasty in children.

PATIENTS AND METHODS

Nineteen patients, ages 2 to 14 years, underwent laparoscopic pyeloplasty at our center between June 2004 and December 2006. Thirteen pyeloplasties were on the left side and six on the right side. A transmesocolic approach was used in five left-sided UPJ obstructions. All operations were performed by the transperitoneal route using either three or four ports.

RESULTS

Sixteen patients underwent dismembered (Anderson-Hynes) pyeloplasty, while three had a nondismembered Foley's Y-V pyeloplasty. Mean operative time was 198 minutes (range 105-300 min). Mean estimated blood loss was 45 mL (range 30-130 mL). Mean length of stay was 4 days (range 3-5 d). Mean followup was 13.8 months (range 2-30 mos). Postoperatively, one child had a urinary tract infection that necessitated hospital admission and administration of intravenous antibiotics. Eighteen of 19 patients demonstrated improved drainage with no evidence of obstruction on diuretic renography and/or excretory urography. One patient is awaiting follow-up. There was no conversion to open surgery.

CONCLUSION

Laparoscopic pyeloplasty in children is a safe, minimally invasive treatment option that duplicates the principles and techniques of definitive open surgical repair. It is technically challenging; with increasing expertise, operative times are reduced significantly.

Laparoscopic pyeloplasty: a prospective randomized comparison between the transperitoneal approach and retroperitoneoscopy

PURPOSE

A prospective randomized study was performed to compare the results of laparoscopic dismembered pyeloplasty using transperitoneal and retroperitoneal approaches.

MATERIALS AND METHODS

A total of 40 patients with primary ureteropelvic junction obstruction were included in the study. The patients were prospectively randomized between transperitoneal (20 patients, group 1) and retroperitoneal (20 patients, group 2) laparoscopic Anderson-Hynes pyeloplasty. All the patients were assessed preoperatively by excretory urography, diuretic isotope renography and computerized tomography angiography. The patients were followed at 3 and 6 months postoperatively, and then every 6 months. Evaluation was performed by excretory urography and diuretic renography. Both approaches were compared regarding operative time, morbidity, hospital stay, convalescence and functional outcome. The preoperative demographic data of the patients and radiological and operative findings were statistically correlated to the operative time.

RESULTS

The preoperative data of both groups were comparable. All the procedures were successfully completed with laparoscopy. Mean operative times were 149 and 189 minutes for the transperitoneal approach and retroperitoneoscopy, respectively (p = 0.02). In groups 1 and 2 there were complications in 3 and 5 patients, respectively. Morbidity, hospital stay, convalescence and success rate had no significant differences between the groups. None of the patient parameters apart from the approach had a significant impact on operative time.

CONCLUSIONS

Laparoscopic dismembered Anderson-Hynes pyeloplasty has a satisfactory functional outcome and low morbidity regardless of the approach. Nevertheless, with early experience retroperitoneoscopy is associated with a longer operative time.

Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results

OBJECTIVES

To analyse the indications and long-term results of endoscopic and minimal access approaches for the treatment of ureteropelvic junction (UPJ) obstruction and to compare them to open surgery.

METHODS

A review of the literature from 1950 to January 2007 was conducted using the Ovid Medline database.

RESULTS

A lack of standardisation of techniques used to diagnose UPJ obstruction and to follow up treated patients introduces a degree of inaccuracy in interpreting the success rates of the various modalities of treatment. However, there is no indication that any one of these techniques is affected by this to a greater or lesser extent than another. Open pyeloplasty achieves very good (90-100% success) results, endopyelotomy and balloon disruption of the UPJ fail to match these results by 15-20%, and minimal access pyeloplasty produces results that are at least as good as those of open surgery but with the advantages of a minimal access approach.

CONCLUSIONS

Minimal access pyeloplasty is likely to gradually replace endopyelotomy and balloon disruption of the UPJ for the treatment of UPJ obstruction. The much higher cost of robotic pyeloplasty and greater availability of laparoscopic expertise in teaching centres are likely to limit the dissemination of robotic pyeloplasty.

Long-Term Outcome of Endopyelotomy for The Treatment of Ureteropelvic Junction Obstruction: How Long Should Patients Be Followed Up?

PURPOSE

To evaluate the long-term success rate of endopyelotomy for the treatment of ureteropelvic junction (UPJ) obstruction.

PATIENTS AND METHODS

Between January 1995 and December 2003, 85 endopyelotomies (10 percutaneous, 75 retrograde) were performed in 77 patients with a mean age of 35.2 +/- 13.9 years. The mean number of procedures per patient was 1.14, with 69 patients undergoing a single procedure. Endopyelotomies were performed using either a cold knife (N = 26), Ho:YAG laser (N = 47), or hook electrode (N = 12). Treatment success was defined as symptomatic relief with radiographic resolution or stabilization of renal function, as judged by an excretory urogram or diuretic renogram. Kaplan-Meier analysis was used to determine the long-term probability of success.

RESULTS

With a median follow-up of 37.3 months (range 3-98 months), the overall success rate was 67.5%, and the median time to failure was 7.7 months (range 1-50 months). Kaplan-Meier estimates of success were 87.8% at 6 months, 76.9% at 12 months, 72.2% at 18 months, 68.7% at 24 months, 64.8% at 36 months, and 61.6% at 60 months. The success rate was not significantly affected by the etiology, surgical approach, or incisional method. Similarly, the degree of preoperative hydronephrosis or renal function did not affect the success rate.

CONCLUSIONS

The success rate of endopyelotomy decreases as the follow-up increases. Although most failures were detected within 1 year of the procedure, it appears that follow-up of at least 36 months is required for patients who have undergone endopyelotomy for UPJ obstruction.

Laparoscopic Transperitoneal Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction

PURPOSE

To review the outcome of transperitoneal laparoscopic dismembered pyeloplasty (LDP) in our institution.

PATIENTS AND METHODS

From April 2001 to April 2005, 36 men and 34 women underwent LDP for symptomatic and radiologically proved ureteropelvic junction (UPJ) obstruction. A successful outcome was defined clinically by improvement in symptoms and objectively by improvement in the diuretic renography study performed at 3 and 12 months after reconstruction.

RESULTS

The mean operative time was 160.5 +/- 45 minutes with a mean blood loss of 77.8 +/- 52.8 mL. There were no conversions to open surgery. Lower-pole vessels were observed in 38 patients (54.3%). In all cases, the ureter was transposed anteriorly. The mean hospital stay was 3.3 +/- 2.1 days. Postoperative complications were recorded in 4 patients (5.7%). One patient developed an anastomotic stricture. A successful outcome was achieved in 68 of the 70 patients (97.1%) at a mean follow-up of 27.6 +/- 13.2 months.

CONCLUSION

Our results further strengthen the evidence that LDP has a reliable medium-term outcome with the added benefit of being minimally invasive.

Minimally Invasive Treatment of Ureteropelvic Junction Obstruction: Optimizing Outcomes with Concomitant Cost Reduction

With the seemingly exponential increase in the use of minimally invasive techniques in urology, cost-benefit comparisons will continue to play a major part in establishing services and in improving those that already exist. The management of ureteropelvic junction obstruction is a focus of significant attention. An effective way of optimizing the economy of management is to understand the implications in terms of the success of each mode of treatment. Subsequently, costing models should be developed and applied in large-scale multicenter studies with the aid of health economists. The long-term benefits can then be assessed by also including patient's perceived quality of life. Economic assessment will not be enough to promote cost-effective practices. The take-up of any techniques will always be influenced not only by patient preference and surgeon expertise but also, perhaps ironically, by the way hospitals and surgeons are remunerated. In addition, the impact of the time taken to train a surgeon to carry out laparoscopic dismembered pyeloplasty competently may play a significant role. Until these issues are resolved, definitive recommendation for the treatment of ureteropelvic junction obstruction will continue to be made on an individual basis.

[Reconstructive procedures in laparoscopic urology]

The introduction of laparoscopic pyeloplasty was the first step towards the development of suturing and knotting techniques. The final breakthrough came with the development of radical prostatectomy since the performance of the urethrovesical anastomosis required highly developed skills in reconstructive surgery. For most laparoscopic surgeons suturing and knot tying became quite familiar henceforth. As a consequence, the interest for other reconstructive procedures has increased tremendously since. Within a very short time pyeloplasty was developed to a surgical standard, and the results compare very favorably with open surgery. A very attractive method is the ureteral reimplantation according to the psoas hitch technique, which, however, does not completely duplicate the open surgical operation. Many patients can potentially be attracted by sacrocolpopexy to treat genital prolapse. The long-term success rate is 92% which is excellent for this indication. Urinary diversion following cystectomy is usually not performed completely intracorporeally, but laparoscopically assisted.

The incidence of crossing vessels in patients with normal ureteropelvic junction examined with endoluminal ultrasound

PURPOSE

We estimated the incidence of a crossing vessel at the normal ureteropelvic junction (UPJ) in patients undergoing ureteroscopy and endoluminal ultrasonography for indications other than UPJ obstruction.

MATERIALS AND METHODS

Endoluminal ultrasonography was performed in 141 patients undergoing upper tract endoscopy for various indications excluding UPJ obstruction. A detailed description of the anatomy of the UPJ as well as the location and size of crossing vessels was included in the operative note. Charts were reviewed to determine the precise anatomy of the UPJ.

RESULTS

The overall incidence of crossing vessels at the unobstructed UPJ was 19.2%. Endoluminal ultrasonography demonstrated a crossing vessel in 13.2% of patients with ureteral narrowing or stricture, 31.3% of those with tumors or filling defects, 10.5% of those with submucosal calculi and 16.7% of patients with ureteral diverticula. In cases where the position of a crossing vessel was ascertained, 41% were anterior to the ureter, 28% anterolateral, 24% anteromedial and 7% posterior. There was a statistically significant difference in the frequency of vessels at the UPJ in patients with and without obstruction examined with endoluminal ultrasound (p <0.0001).

CONCLUSIONS

A crossing vessel at the UPJ is seen with endoluminal ultrasound in 19.2% of patients with a normal UPJ. This incidence is lower than that seen in patients with obstructed UPJ. Many of these vessels are related to the lateral surface of the UPJ and there was no area that was always free of vessels.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction (UPJO): Solving the Technical Difficulties

OBJECTIVES

To evaluate our current practice in retroperitoneoscopic pyeloplasty in patients with ureteropelvic junction obstruction (UPJO). Special interest was paid to technical difficulties associated with the retroperitoneoscopic approach.

METHODS

Our retroperitoneoscopic approach for pyeloplasty is explained step for step including the most technically challenging part: the ureteropelvic anastomosis.

RESULTS

Within 49 months a total of 47 retroperitoneoscopic pyeloplasties we performed at our institution. Before pyeloplasty an endopyelotomy had failed in five patients (11%). We did not necessarily perform a ventral transposition of the anastomosis in cases with a crossing vessel. Two (4%) conversions to open surgery were required because of scarring after previous endopyelotomy and massive obesity resulting in a limited working space. There were no intraoperative complications. A recurrence of UPJO was observed in 2% (n = 1).

CONCLUSION

Functional results after retroperitoneoscopic pyeloplasty are excellent and comparable to those of open surgery. However, special knowledge of retroperitoneoscopy is necessary to provide the patient with a safe and effective minimally invasive alternative to open pyeloplasty.