Laparoscopic Transperitoneal Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction

Efficacy and late complications of laparoscopic pyeloplasty: experience involving 125 consecutive ureters

INTRODUCTION

Laparoscopic pyeloplasty is now widely recognized as a minimally invasive alternative for the surgical management of ureteropelvic junction obstruction. However, there have been insufficient reports describing the long-term outcomes and the stability of the results. In addition, late complications have not been thoroughly discussed.

METHODS

Between October 1999 and December 2010, we performed laparoscopic pyeloplasty on 125 consecutive ureters in 119 patients with an obstruction of the ureteropelvic junction. We performed dismembered Anderson-Hynes pyeloplasty, Fenger plasty and Y-V flap in 108 (86.4%), 15 (12.0%), and 2 ureters (1.6%), respectively.

RESULTS

All procedures were completed successfully. Median operative time was 200 min (range, 80-775 min) and median estimated blood loss was 20 mL (range, 20-250 mL). Intraoperative and postoperative complications categorized as Clavien grade II and III occurred in 11 (8.9%) procedures. Among them, three were observed after 12 months postoperative and all involved renal stones in the collapsed pelvis. In 120 (96%) ureters, hydronephrosis improved and/or obstructive pattern on diuretic renography disappeared during a median follow-up period of 45 months (range, 5-146 months). The degree of hydronephrosis steadily improved for more than 2 years, and re-obstruction was never observed after 1 year postoperative.

CONCLUSION

The efficacy of laparoscopic pyeloplasty seems to be durable over 2 years postoperatively. Because obstruction recurrence was not observed after 12 months postoperative, patients with complete disappearance of hydronephrosis may unnecessarily be followed longer than 2 years. However, cases with persisting hydronephrosis should be regularly monitored because of the remaining possibility of stone formation.

Transperitoneal laparoscopic pyeloplasty: Brazilian initial experience with 55 cases

PURPOSE

To evaluate prospectively the results obtained in 55 patients undergoing laparoscopic pyeloplasty through transperitoneal access.

MATERIALS AND METHODS

From January 2005 to July 2009, fifty-five patients between 13 and 64 years old, were treated for ureteropelvic junction (UPJ) stenosis via a transperitoneal laparoscopy. All patients had clinical symptoms of high urinary obstruction and hydronephrosis confirmed by imaging methods. Anderson-Hynes dismembered pyeloplasty was performed in 51 patients and Fenger technique in the other 4 cases. Patients were clinically and imaging evaluated in the postoperative period at 3 and 6 months and then followed-up annually.

RESULTS

The operative time ranged from 95 to 270 min. The mean hospital stay was 2 days. The average blood loss was 170 mL. The time to return to normal activities ranged from 10 to 28 days. Anomalous vessels were identified in 27 patients, intrinsic stenosis in 23 patients and 5 patients had high implantation of the ureter. Laparoscopic pyelolithotomy was successfully performed in 6 patients with associated renal stones. That series monitoring ranged from 1 to 55 months. One patient had longer urinary fistula (11 days), 3 patients had portal infection and 6 patients had prolonged ileus. There was one conversion due to technical difficulties. From the later postoperative complications, 2 patients had re-stenosis, one determined by Anderson-Hynes technique and the other by Fenger technique. The success rate was 95.65%.

CONCLUSIONS

Laparoscopic pyeloplasty has functional results comparable to conventional open technique. It offers less morbidity, with aesthetic and post-operative convalescence benefits and lower complication rates.

Ureteropelvic junction obstruction: which is the best treatment today?

The aim of this review is to critically compare the different procedures performed for the treatment of ureteropelvic junction obstruction (UPJO) in order to identify, currently, the best treatment that a urologist should propose to patients with this condition. Three different types of procedures were assessed: open pyeloplasty (OP), endopyelotomy, and laparoscopic pyeloplasty (LP). Regarding efficacy, success rates of 94.1, 62-83, and 95.9-97.2% were reported for OP, endopyelotomy, and LP, respectively. Concerning operative time and length of hospital stay, no extensive data are available in the literature, although endopyelotomy seems to provide shorter times with respect to those reported after OP and LP. Regarding the complication rate, it was very similar after the different techniques and due to the respective approaches. Overall, our data support the conclusion that LP provided a balance between the highly successful technique reported by OP and the quick postoperative recovery provided by the endoscopic approach. Anyway, in spite of these clear advantages, the reproducibility of LP is still strongly limited by the challenge of the learning curve. The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA), providing an extraordinary vision and precision of surgical movement, appears to be changing this scenario, allowing naïve surgeons to achieve very good results after few procedures. In this setting, robot-assisted pyeloplasty seems to be emerging as the new standard of care in the patients with UPJO, which will further take place over the other techniques once its costs decrease.

Robot-assisted laparoscopic pyeloplasty: outcomes reported by a centre with no previous laparoscopic experience

Laparoscopic pyeloplasty (LP) has proved to be an effective minimally invasive treatment for ureteropelvic junction obstruction (UPJO). However, its application is still limited by the challenge of the laparoscopic learning curve, which seems to be overcome by the recent introduction of robot assistance. The aim of this manuscript is to show our outcomes after the first robot-assisted laparoscopic pyeloplasties (RP) and critically evaluate the feasibility of this technique when performed by a surgical team without any previous laparoscopic experience. Between March 2005 and July 2008, 16 patients with UPJO underwent transperitoneal RPs. Before and after surgery patients were evaluated by ultrasonography, intravenous urography or retrograde pyelography, computed tomography (CT) scan, and/or diuretic renography. Mean follow-up was 16.8 months. The assessed outcomes were mean operative time (OT), mean estimated blood loss (EBL), mean length of hospital stay (LOS), success (SR), and complication rates (CR). OT, EBL, LOS, and SR were 202 min, 60 ml, 5.2 days, and 94%, respectively. Among the minor complications, two patients (12%) reported moderate abdominal pain while, concerning major complications, one patient (6%) developed ileus. Robot assistance was confirmed as a special tool for laparoscopic treatment of UPJO with excellent outcomes after a shorter learning curve. As shown by our results, the feasibility of RP may also be extended to naïve surgeons who can approach this technique even in the absence of previous laparoscopic training, rapidly attaining results similar to those reported by both laparoscopically experienced and expert robotic surgeons.

Updates in endourology

Rapid urologic innovations in minimally invasive treatment are creating exciting new horizons in endourology. However, these new concepts are blurring the traditional boundary between endourology and oncology. Organ-sparing surgery, laparoscopy, robotics systems, and image-guided ablation techniques enable surgeons to develop specifically tailored treatments for patients. We examine recent developments and future prospects for how new technology will continue to advance the field of endourology.