Laparoscopic Pyeloplasty Outcomes of Elderly Patients

Critical analysis of pyeloplasty role in adults with late diagnosis of ureteropelvic junction obstruction-a comparative study

PURPOSE

Due to the data paucity about the functional outcomes post pyeloplasty for patients diagnosed with ureteropelvic junction obstruction (UPJO) with a preoperative age above the age of 45 years and according to the elderly definition (age ≥ 65 years), we conducted this study to clarify the different outcomes in adults presented with late hydronephrosis.

METHODS

We included patients who were managed by pyeloplasty with a preoperative age ≥ 45 years. We further subdivided those patients into; group (A) patient's age ≥ 65 years and group (B) patient's age ≥ 45 and < 65 years. Split renal function (SRF) difference was evaluated by the changes between the last follow-up and the baseline renogram, where 5% change was considered a significant change. Functional outcomes and factors predicting the functional recoverability post pyeloplasty were evaluated.

RESULTS

A total of 119 patients were included. The mean age was 62.3 ± 16.4 years. Group (A) and group (B) included 47 and 72 patients, respectively. After 24 months, GFR and SRF were increased at the last follow-up (P = 0.32 and 0.57, respectively). No significant functional changes were noted between both groups. Sixty two, 7 and 13 patients showed static, decreased and improved renal function. Lower preoperative SRF was the only predictor for poor functional recoverability in patients with age ≥ 45 years who were managed by pyeloplasty.

CONCLUSION

Elderly patients should not be excluded from the corrective surgery for UPJO. Lower preoperative SRF was the only predictor for renal function deterioration post pyeloplasty.

Pelvic ureteric junction obstruction: Natural history, nephrological considerations and current evidence base for surgical management in poorer functioning kidneys

Pelvic ureteric junction obstruction (PUJO) can pose a management challenge to urologists. The natural history of the disease, particularly in adults is poorly understood and management decisions are largely based on historical, poor quality data. Additionally, many older patients may already have a degree of renal impairment secondary to systemic disease, further compounding the situation. The purpose of this paper is to detail the pathophysiology and natural history of PUJO, discuss the implications of chronic kidney disease in this population detailing the current evidence base for poorer functioning kidneys and describe the nephrological advantages of accurate renal function testing. There exists accurate methods to assess both glomerular filtration rate (GFR) and split function which could potentially provide both the urologist and patient with more relevant data on which to base their decisions when contemplating surgical intervention. The existing, low patient number case series currently published fail to address the relevance of overall GFR on the outcomes after pyeloplasty, no studies use single unit GFR and there is no clear consensus on what constitutes surgical success. PUJO is an area of benign upper tract disease that is in need of high-quality scientific studies to identify when intervention is necessary, long-term success of both surgery and conservative management in poorer functioning kidneys and clear guidelines for urologists.

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.

[Pyeloplasty: pro laparoscopic]

With increasing experience and availability of the da Vinci® robotic surgery system there has been an extension of the indications from initially exclusively ablative interventions, such as nephrectomy and radical prostatectomy to reconstructive interventions, such as pyeloplasty, bladder augmentation and urinary diversion. Laparocopic pyeloplasty has been established for both adults and children, with results comparable to the open procedure. In comparison the conventional laparoscopic procedure is little cost-intensive and therefore widely used. The available literature has to be analysed to find advantages for the cost-intensive, robot-assisted laparoscopic pyeloplasty from which patients can profit.