Laparoscopic treatment of retroperitoneal fibrosis: report of two cases and review of the literature

Management of idiopathic retroperitoneal fibrosis from the urologist's perspective

INTRODUCTION

Idiopathic retroperitoneal fibrosis (IRF) is a rare disease characterized by a fibrotic reaction that affects retroperitoneal organs, especially the urinary tract. In this review we analyze the current imaging techniques, morphological characteristics, clinical aspects and therapeutic aspects of idiopathic retroperitoneal disease.

METHODS

A PubMed search was conducted in December 2013 to find original articles, bibliographic reviews and series reports published in the past 15 years on idiopathic retroperitoneal fibrosis, its management and outcomes by combining terms like retroperitoneal fibrosis, periaortitis, treatment and autoimmune. A total of 89 articles were included in this review that referred strictly to IRF. We analyzed the imaging tools used for diagnostic and the decision making protocol used by physicians in the management of IRF.

RESULTS

A computerized tomography (CT) scan represents the most commonly used imaging technique for diagnosis. Magnetic resonance imaging (MRI) is unable to differentiate more accurately between benign and malignant retroperitoneal fibrosis (RF) than a CT scan. Biopsy remains the most reliable diagnostic tool for IRF. However, the histological characteristics of IRF are not yet well-defined and the protocol for biopsy is not standardized in terms of template, number of biopsies and the immunohistochemical panel needed for positive diagnosis. The most common treatment reported is corticosteroid therapy alone or in combination with other immunosuppressants, whereas surgical treatment is reserved for severe cases. Indwelling ureteric stents represent the most common procedure for renal drainage, but their efficacy is questionable. Open ureterolysis remains the gold standard for surgical treatment, but its purpose is only to resolve the ureteric obstruction, not to treat the retroperitoneal fibrosis. Laparoscopic and robotic approaches have been reported to be feasible, but no prospective, comparative trials have been performed due to the rarity of the disease. Surgical technique is not standardized and the outcome of the treatment only evaluates the recovery of the renal function.

CONCLUSIONS

The imaging procedures available today are unable to accurately differentiate between idiopathic and malignant RF. A biopsy is mandatory to confirm the diagnosis, but there is no consensus regarding the template, timing and number of biopsies needed to exclude malignancy. Open ureterolysis represents the main surgical treatment for cases with severe IRF, and laparoscopic or robotic approach may be an option in selected cases. The recovery of the renal function is a surrogate for evaluating the success of the treatment. More clinical studies are needed in order standardize the protocol for diagnostic, treatment and follow up after medical or surgical management.

Laparoscopic ureterolysis and omental wrapping in patients with retroperitoneal fibrosis and obstructive uropathy: a single-center experience

OBJECTIVES

To analyze the outcomes with mid- to long-term follow-up of laparoscopic ureterolysis (LU) and omental wrapping in retroperitoneal fibrosis (RPF) with obstructive uropathy.

PATIENTS AND METHODS

Records of 9 patients with RPF who had obstructive uropathy at presentation and had undergone LU and omental wrapping at our center during January 2004 to June 2012 were collected and analyzed.

RESULTS

Six females and three males underwent LU for RPF. Underlying causes of RPF could not be found in 8 (89%) cases. Two patients underwent bilateral LU. Mean operative time and estimated blood loss were 213 minutes (range, 180-280 minutes) and 119 mL (range, 70-200 mL), respectively. No case required conversion to open surgery. The only significant intraoperative complication (1/9 [11%]) was ureteral injury, which was easily repaired intraoperatively. The postoperative complication rate was 44% (4/9). Most complications (75% [3/4]) were minor and did not need specific treatment. The mean follow-up period was 46 months (range, 4-72 months). The success rate at last follow-up was 89%.

CONCLUSIONS

Treatment of RPF is still controversial. Any future prospective randomized comparative trials seem unlikely in view of the low incidence of RPF. LU and omental wrapping in the setting of obstructive uropathy are safe and an effective alternative with a high success rate at mid- to long-term follow-up.

Transmesocolic ureteral intraperitonealization: a new approach for laparoscopic treatment of retroperitoneal fibrosis

INTRODUCTION

Retroperitoneal fibrosis (RPF) is characterized by the presence of an inflammatory fibrotic process in the retroperitoneum causing compression of the retroperitoneal structures including the ureters. The ureterolysis is the liberation of the incarcerated portion of the ureter, from its proximal healthy portion to the distal portion, generally free of fibrosis, below the iliac vessels. We report the transmesocolic ureteral intraperitonealization as a new approach for laparoscopic treatment of RPF.

PATIENT AND METHODS

A 52-year-old female patient diagnosed with idiopathic RPF was submitted to laparoscopic transmesocolic ureteral intraperitonealization after medical management failure. An open access using a Hasson trocar was placed through the umbilicus and two additional trocars were placed-10  mm in the midline at 6  cm below the umbilicus and a 5  mm in the midline at 6  cm above the umbilicus. The left mesocolon was incised 3  cm lateral to aortic pulsation and the left ureter was identified and dissected off the retroperitoneal mass. Lateral incised mesocolon was mobilized and wrapped posterior to the left ureter using a running suture.

RESULTS

Operative time was 2 hours. The mean blood loss was less than 100  mL. The patient was discharged painless on the second postoperative day. No complications were observed. Pathology showed fibrous tissue. An intravenous pyelography was performed at 6 months after the surgery and showed no ureteral obstruction. Serum creatinine level stabilized at 0.9  mg/dL.

CONCLUSION

The transmesocolic ureteral intraperitonealization for laparoscopic treatment of RPF is feasible and can be considered a potential alternative for traditional laparoscopic intraperitonealization.

Laparoscopic ureterolysis with omental wrap for idiopathic retroperitoneal fibrosis

OBJECTIVE

To describe various approaches for ureterolysis with an omental wrap using minimally invasive techniques, as surgery for idiopathic retroperitoneal fibrosis includes tissue biopsy, ureterolysis, and intraperitonealization or omental wrap.

PATIENTS AND METHODS

Since 2006 we have performed ureterolysis in four patients diagnosed with retroperitoneal fibrosis in two institutions. The ureterolysis in two cases was bilateral, using a standard laparoscopic approach for one case and a hand-assisted technique for the other. Unilateral ureterolysis was completed using a standard laparoscopic approach in one case and was converted to a hand-assisted technique in the other due to difficulty with ureteric identification. An omental wrap was used after ureterolysis for all renal units.

RESULTS

A minimally invasive technique was used for all ureterolysis procedures and none required open conversion. There was fascial dehiscence after surgery at the hand-port site in one patient, and required re-operation for wound closure. The median (range) hospital stay for all patients was 2.5 (2-10) days and the median blood loss was 100 (50-550) mL. No patient required a blood transfusion. At a median 16.5 (12-32) months of follow-up, there was symptomatic and radiographic success in all patients.

CONCLUSIONS

Ureterolysis can be a challenging operation depending on the extent of the retroperitoneal mass. An understanding of various laparoscopic techniques can provide the flexibility for successful completion of nearly all of these procedures using a minimally invasive approach.

Robot-assisted laparoscopic ureterolysis: case report and literature review of the minimally invasive surgical approach

Results of this study suggest that robotic-assisted laparoscopic ureterolysis is a safe and effective procedure for patients with idiopathic retroperitoneal fibrosis.

Objectives:

To evaluate our case of robot-assisted ureterolysis (RU), describe our surgical technique, and review the literature on minimally invasive ureterolysis.

Methods:

One patient managed with robot-assisted ureterolysis for idiopathic retroperitoneal fibrosis was identified. The chart was analyzed for demographics, operative parameters, and immediate postoperative outcome. The surgical technique was assessed and modified. Lastly, a review of the published literature on ureterolysis managed with minimally invasive surgery was performed.

Results:

One patient underwent robot-assisted ureterolysis at our institution in 2 separate settings. Operative time (OR) decreased from 279 minutes to 191 minutes. Estimated blood loss (EBL) was less than 50mL. The patient has been free of symptoms and both renal units are unobstructed. According to the published literature, 302 renal units underwent successful laparoscopic ureterolysis (LU), and 6 renal units underwent RU. There were 9 open conversions (all in LU). Mean OR in LU was 248 minutes for unilateral and 386 minutes for bilateral cases. In RU, mean OR was 220 minutes for unilateral and 390 minutes for bilateral cases. EBL averaged 200mL in LU and 30 mL in RU.

Conclusions:

Our data reveal that robot-assisted ureterolysis is safe and feasible. Published data demonstrate the advantages of minimally invasive surgery.

[Complications of laparoscopic urological procedures]

Laparoscopic urology has evolved considerably during last decade as well as number and spectrum of surgical related complications. Experiences reported by laparoscopic trained groups allow preventing, promptly recognizing, and safe and efficient management of the laparoscopic related complications. We present our complications in all patients undergoing urological laparoscopic procedures from November 1992 to June 2005. A literature search was conduced to evaluate complications of every laparoscopic procedure.

Hand-assisted laparoscopic ureterolysis to treat ureteral obstruction secondary to idiopathic retroperitoneal fibrosis: Assessment of a novel technique and initial series

OBJECTIVES

To describe a novel technique and assess an initial series of hand-assisted laparoscopic ureterolysis for the treatment of retroperitoneal fibrosis.

METHODS

Five patients (3 women and 2 men, mean age 56.4 years) with ureteral obstruction secondary to retroperitoneal fibrosis underwent bilateral hand-assisted laparoscopic ureterolysis with biopsy. These patients had undergone an imaging evaluation with excretory urography, computed tomography, furosemide washout nucleotide scan, and/or magnetic resonance imaging. All had ureteral stents placed before or at surgery. A periumbilical hand port, bilateral 10-mm perirectal camera ports, and bilateral 5-mm or 10-mm working ports were placed. The ureters were completely mobilized and placed intraperitoneally. The patient demographic, operative, and early and late postoperative data were collected.

RESULTS

The average operating room time was 259 minutes (range 215 to 300), and the estimated blood loss was 80 mL (range 50 to 200). The mean hospital stay was 4.20 days (range 3 to 5). One minor intraoperative ureteral injury and no postoperative complications occurred. The mean analgesic requirement was 45.6 mg morphine sulfate (range 20 to 88). Three patients also received 120 mg of parenteral ketorolac. All indwelling ureteral stents were removed by 2 to 4 weeks postoperatively. At 22.4 months (range 12 to 29) postoperatively, 90% of the renal units were unobstructed.

CONCLUSIONS

Hand-assisted laparoscopic ureterolysis is an effective minimally invasive technique with less morbidity than open ureterolysis. It offers a shorter operative time and is less technically challenging than conventional laparoscopy. It is our preferred surgical approach for obstructive retroperitoneal fibrosis.

Laparoscopic Ureterolysis for Benign and Malignant Conditions

Ureteral obstruction secondary to extrinsic compression is uncommon. Extrinsic compression results from both benign and malignant conditions of the retroperitoneum. In certain patients, laparoscopic ureterolysis is a minimally invasive alternative to the open approach. To date, the largest numbers of patients have undergone this procedure for idiopathic retroperitoneal fibrosis. Select patients with ureteral obstruction following cancer chemotherapy or radiotherapy may also be candidates for laparoscopic ureterolysis, although experience is limited. This article reviews the current indications, technique, and results of laparoscopic ureterolysis for both benign and malignant conditions. Further long-term studies are required to define its role.