Laparoscopic Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction: Experience with 142 Cases in a High-Volume Center

Comparison of 30-day postoperative outcomes of open and minimally invasive pyeloplasty utilizing the prospective National Surgical Quality Improvement Program-Pediatric database

INTRODUCTION

Open pyeloplasty (OP) has traditionally been the standard for the operative management of ureteropelvic junction obstruction in children. With advances in minimally invasive pyeloplasty (MIP) techniques, it is quickly becoming a popular alternative in both adult and pediatric population.

OBJECTIVE

To evaluate the differences in outcomes between MIP and OP for the surgical correction of ureteropelvic junction obstruction in children.

STUDY DESIGN

Data were obtained from the pediatric National Surgical Quality Improvement Program 2012-2017. We identified 1280 patients who underwent MIP and 1190 patients who underwent OP between 2012 and 2017. Propensity score matching was utilized to adjust for baseline differences. Univariate and multivariable regression were performed to assess odds of complications and procedure-related readmission.

RESULTS

Patients who underwent OP had a significantly decreased operative time (192.42 vs 142.00 min, p < 0.001) compared to MIP. There was no significant difference in the rates of overall peri-operative complications (3.7% [MIP] vs 2.4% [OP] p = 0.397). On multivariable analysis, patients undergoing OP had a lower risk of procedure-related readmission (odds ratio [OR] 0.404, 95% confidence interval [CI] 0.157-0.951, p = 0.046) than MIP. In a multivariable linear regression model, the risk of having any postoperative complication, regardless of surgical approach, decreased with increasing patient age (OR 0.945, 95% CI 0.893-0.996, p = 0.037).

DISCUSSION

Although recent small, retrospective institutional studies have found decreased hospitalization time of MIP as compared to OP, in our large prospective database, we found no such association. While some studies suggest a higher rate of wound complications in the OP group, this was not reproduced in our study as well. MIP was, in fact, associated with higher rate of readmissions as compared to the OP group, which may act as a surrogate of long-term complications in these patients.

CONCLUSION

MIP offers an alternative to OP in the pediatric population with similar rates of peri-operative complications. However, our study shows decreased odds of procedure-related readmission in OP, which may serve as a surrogate for less postoperative complications in these patients.

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.

Current Concepts in Pediatric Robotic Assisted Pyeloplasty

Robotic surgery in pediatric urology has been gaining popularity since its introduction almost two decades ago. Robotic assisted pyeloplasty is the most common robotic procedure performed in pediatric urology. Advances in robotic technology, instrumentation, patient care and surgical expertise have allowed the correction of ureteropelvic junction (UPJ) obstruction in most patients using this minimally invasive technique. The excellent experience with robotic assisted pyeloplasty has challenged other approaches as a new standard for the treatment of UPJ obstruction. In this review, we will describe the technique as it relates to the different robotic platforms, review the surgical experience and compare its results to other surgical approaches. Also, we will discuss patient and parent satisfaction, cost and financial considerations, along with evaluating the future of robotic surgery in the treatment of UPJ obstruction.

Is confirmation of ureteric stent placement in laparoscopic pyeloplasty necessary?

PURPOSE

Placement of an antegrade double-J (JJ) ureteric stent is an important component of pyeloplasty. Correct siting of distal end of the stent in the bladder is essential for ease of removal. To date, no studies have compared methods for confirming stent position. This study aims to address that void in the literature.

METHODS

Eligible patients underwent laparoscopic pyeloplasty with antegrade stent placement at our institution from 2007 to 2015 inclusive. Methods to verify distal stent position of rigid cystoscopy, artificial bladder filling or no confirmation were compared. Effectiveness was determined by the proportion of malpositioned stents detected intra-operatively compared to the total found malpositioned, both intra-operatively and during follow-up.

RESULTS

A total of 75 patients underwent laparoscopic pyeloplasty. Forty-six (61.3%) patients had distal stent position assessed intra-operatively, comprising 27 by cystoscopy and 19 by artificial bladder filling, while for 29 (38.7%) patients no verification method was used. Cystoscopy, artificial bladder filling and no confirmation detected intra-operatively 2, 1 and 0 malpositioned stents, from malpositioned stent totals of 2, 2 and 1, respectively.

CONCLUSION

Malposition of JJ ureteric stent is uncommon, and omitting intra-operative position verification appears reasonable in select cases. Artificial bladder filling can help detect malpositioned JJ stents without repositioning the patient for cystoscopy. However, our results suggest both may be unreliable. If stent malposition is suspected, certainty is desired or extended operative duration is less critical, then the surgeon should proceed with cystoscopy.

Use of fibrin glue as a sealant at the anastomotic line in laparoscopic pyeloplasty: A randomised controlled trial

Objective

To assess the effectiveness of fibrin glue as a sealant at the anastomotic line of a stentless laparoscopic pyeloplasty (LPP) repair instead of JJ stent insertion.

Patients and methods

In all, 46 patients with pelvi-ureteric junction obstruction scheduled for LPP were randomised into two groups each containing 23 patients. Group A underwent stented repair, while group B had a stentless repair together with sealing of the anastomotic line with fibrin glue.

Results

There was no statistically significant difference between the groups for the postoperative improvement in the renal scan and intravenous urography. However, there was a statistically significant decrease in early postoperative adverse events in group B. In group A, all the patients had irritative lower urinary tract symptoms (LUTS) and 16 (72.7%) had postoperative urinary tract infections (UTIs). In group B, no patient had a UTI or irritative LUTS. In all, 21 patients (95.4%) in group A had minimal terminal painful haematuria; while in group B, only one patient (4.3%) had minimal total painless haematuria. Also, patients in group B were spared the need for a second anaesthesia exposure for stent removal.

Conclusion

The use of fibrin glue is a valid alternative to stenting in LPP with the same excellent outcome but with markedly lower short-term postoperative adverse events.

Comparison of Retrograde Balloon Dilatation and Laparoscopic Pyeloplasty for Treatment of Ureteropelvic Junction Obstruction: Results of a 2-Year Follow-Up

Objective

To evaluate the efficacy of laparoscopic pyeloplasty relative to retrograde balloon dilatation for the treatment of ureteropelvic junction obstruction (UPJO).

Methods

This retrospective study enrolled UPJO patients with stricture length < 2 cm who had been treated with laparoscopic pyeloplasty (LP; 44 cases) or balloon dilatation (BD; 38 cases) from Jan 2010 to Jan 2012, according to patients’ preference after consultation. Demographics and clinical parameters were collected. Patients were followed-up at 3, 6, 12, and 24 months. Ultrasonography, intravenous urography, and diuretic renography were applied to evaluate the remission of hydronephrosis.

Results

Both groups were comparable with respect to age, UPJO location, gender, and other baseline parameters. Compared to the LP group, patients receiving BD experienced significantly shorter operative time, analgesia time, hospital stay, and urethral catheter indwelling time, and less cost (P<0.001). Three and 6 months after their respective procedures, the success rates of the LP (97.7%, both) and BD (94.7% and 86.8%) groups were similar, and at 12 and 24 months the long-term success rate of LP (95.5%, both) was better than that of BD (78.9% and 71.0%).

Conclusions

LP showed better long-term success rate than did BD in the management of UPJO with length of stricture < 2 cm. Considering that BD is more minimally invasive, simpler and easier to perform, and costs less, we recommend it for some selective UPJO patients as the first-line therapy.

Functional Results of Laparoscopic Pyeloplasty in Children: Single Institute Experience in Long Term

OBJECTIVE

The aim of this study was to evaluate the long-term functional outcomes of laparoscopic pyeloplasty (LP) in children for consecutive cases of single institute.

MATERIALS AND METHODS

Our laparoscopy database was investigated for children in terms of LP between June 2008 and April 2015. All the patients had ureteropelvic junction obstruction (UPJO) and LP was performed. Demographic data including age, gender, side of UPJO, operation time, estimated blood loss (EBL), hospital stay and complications according to Clavien classifications were recorded. Renal ultrasonography and diethylenetriamine penta-acetate (DTPA) scintigraphies were respectively performed 3, 12 and 24 months after surgery. Statistical analyses were performed and p value was accepted as significant at <0.05.

RESULT

Mean follow-up was 34 ± 4.7 months. The mean age was 13 (6-72) months. A total of 153 (110 boys and 43 girls) LP patients enrolled. Of that, 93 (60.78%) LP were in left side and 60 (39.21%) were in right side. Three cases needed open conversation according to difficulties in anastomosis. Aberrant crossing vessel was observed in 12 (7.84%) patients. The mean operation time was 155 ± 21 min and the mean EBL was 22 ± 11.1 ml. The mean hospital stay was 3.4 days. Anastomotic leakage was the common complication (in 13 patients) that was successfully managed conservatively (Clavien 1). Eight patients experienced unsuccessful LP and underwent open pyeloplasty (Clavien 3b). The mean split renal function significantly increased in DTPA scintigraphy in follow-up. The overall success was 91%.

CONCLUSIONS

The LP procedure can be an effective and safe surgical method for childhood UPJO, specifically in the experienced hands of pioneer centers.

An up-to-date overview of minimally invasive treatment methods in ureteropelvic junction obstruction

Introduction

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction have been developed and are bcoming more popular. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, for both the transperitoneal and retroperitoneal approaches. In this review, we aimed to analyze the current status of minimally invasive therapy of ureteropelvic junction obstruction.

Material and methods

A PubMed database search was conducted to examine minimally invasive treatments of ureteropelvic junction obstruction.

Results

A large number of cases have been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric populations. A clear advantage, in terms of hospital stay, of minimally invasive over open pyeloplasty was observed only in the adult population.

Conclusions

Studies have shown that minimally invasive pyeloplasty techniques are a safe, effective, and feasible in adult and pediatric populations.

Intraoperative and postoperative complications of laparoscopic pyeloplasty: a single surgical team experience with 236 cases

PURPOSE

To describe and analyze a single surgical team's experience with intraoperative and postoperative complications arising from the Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) procedure in the treatment of patients with ureteropelvic junction obstruction (UPJO).

PATIENTS AND METHODS

There were 236 consecutive patients who underwent transperitoneal LP over a period of 8 years (2004-2012). These patients' records were retrospectively analyzed for intraoperative and postoperative complications. Of the 236 patients, 111 (47.0%) were males and 125 (53%) were females. In 226 patients, surgical indication was primary UPJO, and in 10 patients, recurrent obstruction. Two hundred and eleven patients (89.4%) were symptomatic.

RESULTS

Mean operative time was 96.5 minutes (range 45-360 min). The mean blood loss was 20 mL (range 5-500 mL), and no blood transfusions were necessary. The overall success rate was 97% (229 patients) with a mean follow-up of 38 months (range 6-84 mos). In 86 of the 94 patients who presented with a crossing vessel (91.5%), the anomalous crossing vessel was transposed to the ureteropelvic junction (UPJ) dorsally because of evident obstruction. The mean postoperative hospital stay was 4.2 days (range 3-14 days). All 211 preoperative symptomatic patients reported a complete resolution of symptoms after the procedure. Intraoperative incidents occurred in nine (3.8%) patients, while postoperative complications occurred in 32 (13.5%) patients.

CONCLUSIONS

Our retrospective analysis confirms that LP is an efficacious and safe procedure resulting in a reported success rate of 97% and a concomitant low level of intraoperative (3.8%) and postoperative complications (13.6%). Major complications necessitating active management occur in a low percentage of cases (5.9% of patients). The most frequent and severe intraoperative complications are related to the Double-J stent insertion. The most common postoperative complication is urine leakage.

Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis

CONTEXT

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized.

OBJECTIVE

To critically analyze the current status of laparoscopic and robotic repair of UPJO.

EVIDENCE ACQUISITION

A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria.

EVIDENCE SYNTHESIS

Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population.

CONCLUSIONS

Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.

Laparoendoscopic single-site pyeloplasty: outcomes of an international multi-institutional study of 140 patients

OBJECTIVE

To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes.

MATERIALS AND METHODS

LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed.

RESULTS

The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m(2); 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan.

CONCLUSION

This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

Conservative management of pelvi-ureteric junction obstruction (PUJO): is it appropriate and if so what duration of follow-up is needed?

OBJECTIVE

• To establish whether it is safe to manage minimally symptomatic and asymptomatic pelvi-ureteric junction obstruction (PUJO) conservatively.

PATIENTS AND METHODS

• In all, 50 patients with PUJO diagnosed with dynamic renography, and monitored with at least two renograms.

RESULTS

• In all, 19 patients were totally asymptomatic, while 31 patients had minimal symptoms at time of diagnosis. • The mean follow-up was 53 months. • During the course of follow-up 10 of the 50 patients deteriorated. • All patients who had asymptomatic renographic deterioration, deteriorated within 2 years of diagnosis. • Eight of the 10 patients that deteriorated needed pyeloplasty and two nephrectomy.

CONCLUSIONS

• Conservative management of patients with minimally symptomatic and asymptomatic PUJO is safe. • Discharging patients could be considered at 2 years from diagnosis, if they remain renographically stable and asymptomatic or minimally symptomatic.