Laparoscopic Pyeloplasty in Adults: Stented Versus Stentless

Primary pyeloplasty for uretero-pelvic obstruction in the USA adult population with or without double-J indwelling ureteral stents. Insurance claims data on contemporary time to removal trends, perioperative complications, health care costs, and re-intervention rates

BACKGROUND

Using a large population-based dataset, we primarily sought to compare postoperative complications, health-care expenditures, and re-intervention rates between patients diagnosed with ureteropelvic junction obstruction (UPJO) undergoing stented vs. non-stented pyeloplasty. The secondary objective was to investigate factors that influence the timing of DJ stent removal.

METHODS

Patients ≥18 years old with UPJO treated with primary open or minimally-invasive pyeloplasty were identified using the Merative™ Marketscan® Databases between 2007-2021. Multivariable modeling was implemented to investigate the association between Double-J (DJ) stent placement and post-pyeloplasty complications, hospital costs, and re-intervention rates and the role of the perioperative predictors on time to DJ stent removal. Subgroup analyses stratified by ureteral stenting duration were additionally performed.

RESULTS

Out of 4872 patients who underwent primary pyeloplasty, 4154 (85.3%) had DJ placement. Postoperative complications were rare (N.=218, 4.47%) and not associated with ureteral stenting (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.55-1.12). The median cost for in-hospital charges was $21,775, with DJ stent placement independently increasing the median aggregate amount (OR: 1.29, 95% CI: 1.09-1.53). Overall, re-interventions were performed in 21.18% of patients, with DJ stenting found to be protective (OR: 0.79, 95% CI: 0.66-0.96). Higher Charlson Comorbidity Index, longer hospital stay, and open surgical approach were independent predictors for prolonged DJ stenting time to removal.

CONCLUSIONS

Our study suggests that patients undergoing stent-less pyeloplasty did have a higher rate of secondary procedures, but not higher complications when compared to those undergoing stented procedures. Concurrently, the non-stented approach is associated with decreased health-care expenditures, despite the increased rates of secondary procedures.

[Update on ureteral reconstruction 2024]

Ureteral strictures can occur along the entire course of the ureter and have many different causes. Factors involved in the development include, among other things, congenital anomalies, iatrogenic injuries during endoscopic as well as open or minimally invasive visceral surgical, gynecological, and urological procedures as well as prior radiation therapy. Planning treatment for ureteral strictures requires a detailed assessment of stricture and patient characteristics. Given the various options for ureteral reconstruction, various methods must be considered for each patient. Short-segment proximal strictures and strictures at the pyeloureteral junction are typically surgically managed with Anderson-Hynes pyeloplasty. End-to-end anastomosis can be performed for short-segment proximal and middle ureteral strictures. Distal strictures are treated with ureteroneocystostomy and are often combined with a Boari and/or Psoas Hitch flap. Particularly, the treatment of long-segment strictures in the proximal and middle ureter remain a surgical challenge. The use of bowel interposition is an established treatment option for this, offering good functional results but also potential associated complications. Robot-assisted surgery is increasingly becoming a minimally invasive treatment alternative to reduce hospital stays and optimize postoperative recovery. However, open surgical ureteral reconstruction remains an established procedure, especially after multiple previous abdominal operations.

Failure in Double-J stent inserting in laparoscopic pyeloplasty of ureteropelvic junction obstruction: the clinical features and outcomes

BACKGROUND

Double-J (DJ) stent placement is an important procedure during laparoscopic pyeloplasty (LP). Failing to insert the DJ stent may indicate the patient was also complicated with uretero-vesical junction obstruction (UVJO), and surgeons have to change to another alternative drainage method. In the present study, we analyzed the risk factors of failure of DJ stent placement during the LP and reviewed the clinical outcomes of these challenging pyeloplasties.

METHODS

We retrospectively analyzed the clinical data of patients with ureteropelvic junction obstruction (UPJO) who underwent LP in our department from January 2016 to September 2020. For patients who developed a difficult process of inserting the DJ stent, the externalized uretero-pyelostomy (EUP) stent was indwelled. Patients were finally divided into two groups: DJ group and EUP group. The primary outcomes were recurrent UPJO, postoperative uretero-vesical junction obstruction (UVJO) and complications.

RESULTS

A total of 535 patients were included in the study, of which 37 patients (6.9%) failed to insert the DJ stent. Age was younger, and weight was lower (P < 0.05) in the EUP group. Within follow-up, recurrent UPJO occurred in ten (1.87%) patients, nine in the DJ group and one in the EUP group (P > 0.05). The incidence of postoperative UVJO in the EUP group was significantly higher than in the DJ group (10.8% vs. 0.2%, P < 0.01). 74 patients (13.8%) developed complications after surgery, 12 patients (32.4%) in the EUP group, significantly higher than that in the DJ group (32.4% vs. 12.4%, P < 0.01). Compared with the DJ group, the larger APD were observed in the EUP group at three months postoperatively (3.50 [3.02;4.58] vs. 2.20 [1.50;2.88], P < 0.05), but the difference vanished in further follow-up.

CONCLUSION

The failure of DJ stent placement tends to occur in patients with younger age, lower weight, and larger preoperative APD. Failure may not increase the recurrent UPJO rate, but may indicate a higher probability of postoperative UVJO and may develop more postoperative complications and slower recovery.

Experimental Assessment of New Generation of Ureteral Stents: Biodegradable and Antireflux Properties

Objective: The aim was to assess a new biodegradable and antireflux intraureteral stent (BraidStent^®) design in a swine model after ureteral laparoscopic operation. Materials and Methods: A total of 24 female pigs underwent initial endoscopic, nephrosonographic, and contrast fluoroscopy assessment of the urinary tract. Afterward, unilateral ureteropelvic junction obstruction was performed by laparoscopic approach. Six weeks later, the animals underwent laparoscopic Anderson-Hynes pyeloplasty, and were randomly assigned to Group-I, in which a double-pigtail ureteral stent was inserted for 6 weeks, or Group-II, in which a BraidStent^®, a biodegradable intraureteral stent design, was placed. Follow-up assessments were performed at 3 and 6 weeks and 5 months. Results: In terms of therapeutic success, complete resolution was observed in 91.6% of Group-I animals and 88.8% in Group-II. No evidence of vesicoureteral reflux (VUR) was observed in Group-II animals and statistical significance in VUR and ureteral orifice damage were observed between groups. BraidStent^® degradation occurred in a controlled manner between 3 and 6 weeks, without obstructive fragments. Distal ureteral peristalsis was maintained in 66.6% and 83.3% in Group-II at 3 and 6 weeks of follow-up, respectively. In Group-II, the positive bacteriuria rate was 41.6% and the migration rate 25%. Pathological assessment showed a significant improvement in ureteral healing in Group-II vs Group-I. Conclusions: The results of this comparative study in a porcine model indicate that the intraureteral BraidStent performed similarly to conventional ureteral stents. It avoids complete ureteral length intubation, the adverse effects associated with conventional ureteral stents, and maintains a high level of distal ureteral peristalsis. Moreover, the BraidStent^® exhibited a predictable and controlled degradation rate and did not cause any obstructive fragments. However, further studies are needed to improve the anchoring system and reduce the risk of bacterial colonization.

Use of double-J ureteric stents post-laparoscopic pyeloplasty to treat ureteropelvic junction obstruction in hydronephrosis for pediatric patients: a single-center experience

OBJECTIVES

We aimed to investigate the safety concerns associated with placing double-J ureteric stents post-laparoscopic pyeloplasty surgery for congenital ureteropelvic junction obstruction (UPJO) and hydronephrosis.

METHODS

A total of 1349 patients with postoperative double-J stent placement at our center were included. Clinical variables for enrolled patients were collected by two independent authors. We compared clinical variables and the efficacy of stenting post-laparoscopic pyeloplasty.

RESULTS

The mean age of the patients was 4.23 ± 2.39 years. A total of 58.49% of patients were diagnosed with left UPJO with hydronephrosis and 33.95% were diagnosed with right UPJO. Furthermore, 7.56% of patients had bilateral UPJO. In all cases, 96.96% of indwelling double-J stents were successfully removed 4 weeks post-surgery. A total of 3.04% of the patients still required further management, including stent migration to the renal pelvis (0.37%), stent migration to the bladder (0.30%), prolapse of the stent through the ureter (0.15%), blockage of stents (1.85%), and fouling of stents (0.37%).

CONCLUSIONS

Double-J ureteric stents used after laparoscopic pyeloplasty for treating UPJO in hydronephrosis for pediatric patients is a safe, feasible, and beneficial method, which can be recommended for routine procedures. However, caution should be practiced for follow-up and removal using this method.

Comparison of Safety, Efficacy and Outcomes of Robot Assisted Laparoscopic Pyeloplasty vs Conventional Laparoscopy

Pyeloplasty is considered the gold standard for the management of ureteropelvic junction obstruction in cases of flank pain, recurrent stone formation or infection, and deteriorating renal function. Over the last two decades, minimally invasive techniques such as robotic (RALP) and laparoscopic pyeloplasty (LP) have become increasingly popular and have been moderately replacing the open approach. This paper aims to provide a comprehensive up-to-date review on safety, efficacy and outcomes regarding robotic repair of UPJO compared to the conventional laparoscopic procedure. RALP represents a viable and innovative alternative to conventional LP with a comparable success and complication rate both in adult and in paediatric fields. The robotic approach seems to add further technical advantages when compared to conventional LP but sustains a higher costs. Currently, the choice to adopt one of the different minimally invasive approaches depends on the surgeon's preference or experience, and on institutional availability.

Fibrin glue as a sealant in stentless laparoscopic pyeloplasty: A randomised controlled trial

Objective: To evaluate the value of adding fibrin glue, as a sealant material, to the anastomotic line during stentless laparoscopic pyeloplasty (LPP).

Patients and methods: In all, 92 patients with pelvi-ureteric junction obstruction (PUJO), scheduled for LPP, were randomised into two groups (46 in each group). Group A, underwent transperitoneal stentless LLP sealed with fibrin glue, whilst Group B underwent the same procedure without fibrin glue.

Results: Both groups were similar for patient demographics and presentation. Despite that, we found a significant statistical difference between the groups for operative time and blood loss. The total number of patients that had a urinary leak was 10 and 24 patients, in groups A and B respectively (P = 0.002). A prolonged leak lasting for >5 days, which stopped spontaneously occurred in three patients (7.14%) in Group A and six (14.3%) in Group B (P = 0.265). A persistent 14-day leak that needed intervention developed in two patients (4.3%) in Group A and five (10.9%) in Group B (P = 0.434). One patient in Group B developed urinoma 1 week after discharge, and another patient in the same group developed deep venous thrombosis. There was no significant difference between the groups for postoperative complications in the early 3-month period. The success rate was 39 (92.86%) and 36 patients (85.7%), in groups A and B respectively (P = 0.265).

Conclusion: Adding fibrin glue to seal the anastomosis decreased urinary leakage but did not have a significant impact on outcomes.

Abbreviations: CONSORT: Consolidated Standards of Reporting Trials; DTPA: diethylene-triamine-penta-acetic acid; LPP: laparoscopic pyeloplasty; PUJO: PUJ obstruction; T½: clearance halftime (renogram)

Recent advances in urologic surgical techniques for pyeloplasty

Pyeloplasty is one of the most common urological reconstructive interventions. Since the presentation of the first open pyeloplasty by Anderson and Hynes in 1949, the management of ureteropelvic junction obstruction has dramatically developed. The most immense progress was made in the 1990s with the introduction of laparoscopy. A multitude of new minimal surgical techniques have been introduced since then. In the last few years, the innovations were based on refinement of already-existing techniques and technology. With this aim, single-port surgery, three-dimensional vision for laparoscopy, robotic technology, and alternative techniques for creating the anastomosis-like fibrin glue have been introduced. This unsystematic review is timely, and the scientific interest is to present and discuss some of the latest advances in surgical techniques and different approaches for the intra- and post-operative management in pyeloplasty. To the best of our knowledge, this is the only review looking at the recent advances in urological surgical techniques for pyeloplasty during the last few years with a focus on new technology and surgical techniques.

Laparoscopic pyeloplasty practice patterns in Canada

INTRODUCTION

Ureteropelvic junction obstruction (UPJO) is a condition characterized by partial or complete obstruction of urine transport from the renal pelvis to the ureter and can present with intermittent flank pain, recurrent urinary tract infections, renal stones, or renal dysfunction. While historically, open pyeloplasty was the gold standard for surgical management, laparoscopic methods to repair UPJO have largely taken over as the preferred approach for adolescent and adult patients. Despite near universal adoption of laparoscopic pyeloplasty among Canadian urologists, it remains a technically complex procedure and considerable variability exists in the procedural steps performed.

METHODS

An online survey was distributed to all urologists registered with the Canadian Urology Association (CUA). Participants were asked to describe their training background, comfort level with laparoscopic pyeloplasty, positioning preferences, procedural steps, and stenting practices.

RESULTS

A total of 100 board-certified urologists completed our survey, with approximately half from a community setting and half with academic affiliations (56% and 43%, respectively). The vast majority (98%) reported preferring the Anderson-Hynes (dismembered) pyeloplasty technique. Other technical steps of the procedure were variable among respondents, with no discernable pattern. Those who felt most comfortable with the procedure tended to perform a larger volume of laparoscopic pyeloplasties annually or work at higher-volume institutions.

CONCLUSIONS

Laparoscopic pyeloplasty remains a technically challenging procedure that many Canadian urologists are uncomfortable performing. With this publication, we hope to create discussion among urologists and to reveal procedural tips that may improve comfort in tackling these complex cases.

Robot-Assisted Laparoscopic Excision of Ureteral and Ureteropelvic Junction Fibroepithelial Polyps in Children

INTRODUCTION

Fibroepithelial polyps of the ureter are a rare cause of asymptomatic and symptomatic upper urinary tract obstruction in children. While these lesions can often be managed endoscopically, large or multifocal polyps may preclude such an approach.

OBJECTIVE

We aim to describe our institutional experience with robot-assisted laparoscopic treatment of ureteral polyps and show that a robotic approach is an effective alternative for large or multifocal polyps.

MATERIALS AND METHODS

Four children were identified with ureteral polyps over a 5-year period and underwent transperitoneal robot-assisted laparoscopic excision. Patients presented with flank pain and/or worsening hydronephrosis. All patients were evaluated preoperatively with ultrasound and Tc99m-mercaptoacetyltriglycine (MAG3) diuretic renogram or MR urogram. Retrograde pyelography corroborated the diagnosis of ureteral polyps. We reviewed the charts of these patients and compared the specific robotic approach for each patient, length of hospitalization, surgical complications, need for additional procedures, and resolution of symptoms and hydronephrosis.

RESULTS

In one patient, more than 20 polyps were identified over a long ureteral segment and all were excised; for the remaining three patients, 1 to 2 polyps were found. Mean postoperative length of stay was 1.5 days. One patient developed a ureteral stricture requiring repeat ureteroureterostomy, and another patient required repeat retrograde pyelography for gross hematuria that occurred several months after surgery. No polyps or obstruction was observed on retrograde pyelography in these patients. Mean duration of follow-up was 29 months (9-62 months). Symptoms and degree of hydronephrosis have improved in the three patients who have been followed for at least 12 months.

CONCLUSIONS

Robot-assisted laparoscopy is a safe and feasible alternative to endoscopic treatment of fibroepithelial ureteral polyps. The robotic platform may be preferred in cases of multifocal or large ureteral polyps, or in cases in which a concomitant ureteropelvic junction narrowing may be present.

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.

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.

Stentless laparoscopic pyeloplasty: A single center experience

AIM

To assess the effectiveness of laparoscopic stentless pyeloplasty for congenital ureteropelvic junction obstruction.

MATERIALS AND METHODS

This was a prospective comparative study conducted over a period of 5 years. The study included 35 cases of primary ureteropelvic junction obstruction (UPJO) with mean age of 29.5 years, divided in two groups- Group A (stent-less, 18 patients) and Group B (stented, 17 patients). Follow up ranged from one to 4years (mean 2 years). Transperitoneal laparoscopic Anderson- Hyene's pyeloplasty was standard for both the groups. Perioperative and postoperative complications were prospectively collected and analyzed by Statistical Package for Social Sciences (SPSS) 17 version using Pearson chi square test.

RESULTS

Both the groups were comparable with respect to preoperative differential renal function (DRF) and time required for maximum activity in minutes (tmax.min). Average post operative DRF was significantly higher than preoperative DRF in both the groups. Average tmax was significantly lower after pyeloplasty than pre operative tmax. Mean operative time, mean duration of urethral catheter, and mean duration of drain removal were comparable in both the groups. However bothersome irritative lower urinary tract symptoms (LUTS) and hematuria were significantly more in group B patients (P < 0.0001 and <0.013 respectively).

CONCLUSION

In experienced hands, laparoscopic stentless pyeloplasty is as effective method for treating UPJO as its stented counterpart. It is cost effective, avoids stent-related morbidity, and could be performed without compromising the success rate. However, more randomized studies are needed to evaluate the safety of stentless pyeloplasty.

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.