Laparoscopic versus open pyeloplasty: Comparison of two surgical approaches -- a single centre experience of three years

Laparoscopic strategies in complex upper urinary tract obstruction

OBJECTIVES

We enumerate the various laparoscopic strategies to resolve upper urinary tract (UUT) obstruction in the context of variations in anatomy and report their outcomes.

PATIENTS AND METHODS

Retrospective review of primary laparoscopic UUT reconstructions performed between May 2012 and May 2021. Anomalies included: malrotated kidney (MRK), horseshoe kidney (HSK), duplex kidney (DK), pure intrarenal pelvis (IRP) and mid-ureteric stenosis (MUS). Success was defined by postoperative resolution of symptoms, improvement of anterior-posterior renal pelvic diameter (APD) on US and drainage on Mag3. Complications were categorised by Clavien-Dindo grading. Outcomes compared using the student's t-test with P < 0.05 considered statistically significant.

RESULTS

Of the 214 laparoscopic primary UUT reconstructions, 37 (17.2 %) were: 13-MRK, 12-HSK, 4-DK, 4-IRP and 4-MUS. Median age at surgery was 5-years (range 0.3-15). Dismembered pyeloplasty: 8; pyeloplasty with renal sinus dissection: 8; neo-PUJ anastomosis: 8; primary ureterocalycostomy: 7; pyeloureterostomy: 2; and uretero-ureterostomy: 4. Median follow-up was 43-months (range 8-108) with a success rate of 94.5 % (35/37). Complete resolution of symptoms in 20/21 patients; improvement of hydronephrosis on US in 35/37 patients (median pre-operative APD 27 mm vs. median postoperative APD 8 mm) [P < 0.001]; improvement of drainage on diuretic renogram in 32/34 kidneys and stable/improved DRF in 34/35 kidneys (median preoperative DRF - 45 % vs. median postoperative DRF - 47 %) [P > 0.05]. Postoperative complications managed medically (II Clavien) included urinary tract infections - 2 patients (5 %), stent-related symptoms in 2 (5 %) and umbilical port site collection in 1 patient (3 %). Recurrent pelvi-ureteric junction obstruction PUJO occurred in one patient (3 %) requiring redo surgery (IIIb Clavien), renal stones in 1 (3 %) which resolved with ESWL (IIIb Clavien); in 1 (3 %) patient with a HSK there was complete loss of ipsilateral kidney function but this was managed conservatively up to date (I Clavien).

CONCLUSION

Laparoscopic transperitoneal approach allows the prompt recognition of in-situ anatomical variants. UUT obstruction in such settings calls for a variety of strategies with excellent outcomes.

Comparison between open and minimally invasive pyeloplasty in infants: A systematic review and meta-analysis

INTRODUCTION

Ureteropelvic junction obstruction (UPJO) is the most common cause of congenital hydronephrosis. Techniques such as laparoscopic pyeloplasty (LP) have gained in popularity over recent years. Although some retrospective studies have compared minimally invasive reconstructive techniques with open surgery for treatment of UPJO in infants, results remain controversial due to the small sample size in most of these studies.

OBJECTIVE

To verify whether the benefits of minimally invasive pyeloplasty (MIP) observed in adults and children over 2 years of age also apply to infants.

METHODS

A systematic review of the literature was performed according to PRISMA recommendations. We searched databases of MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials. We excluded studies in which patient cohorts were outside the age range between 1 and 23 months of age (infants). Studies should evaluate at least one of the following outcomes: average hospital stay, operative time, follow-up time, complications, post-surgical catheter use, success rate and reintervention rate. The quality of the evidence was assessed with the ROBINS-I tool.

RESULTS

In total, 13 studies were selected. 3494 patients were included in the meta-analysis, of whom 3054 underwent OP, while the remaining 440 were part of the group undergoing MIP. The mean difference in hospital days was -1.16 lower the MIP group (95 % CI; -1.78, -0.53; p = 0.0003). Also, our analysis showed a significantly shorter surgical time in the group who underwent OP, with a mean operative time of 119.92 min, compared to 137.63 min in the MIP group (95 % CI; -31.76, -6.27; p = 0.003). No statistically significant between-group differences were found respect to follow-up time, complications, post-surgical catheter use, success rate and reintervention rate.

CONCLUSION

This systematic review with meta-analysis has shown that laparoscopic/robotic pyeloplasty in infants is a safe technique with similar success rates to open surgery. Nonetheless, randomized clinical trials with longer follow-up are needed to consolidate these results with more robust scientific evidence.

Single-Port Mini-Pfannenstiel Robotic Pyeloplasty: Establishing a Non-Narcotic Pathway Along with A Same-Day Discharge Protocol

OBJECTIVE

To analyze the feasibility of a same day discharge protocol following SP robotic pyeloplasty.

PATIENTS AND METHODS

From a single institution series, 23 patients (12 multi-port (MP), 11 single-port (SP)) who underwent primary robotic dismembered pyeloplasty between February 2018 and March 2021 were analyzed. The association between baseline and perioperative characteristics with functional outcome was analyzed using, chi-square, Fisher's exact, Mann Whitney U and t-tests.

RESULTS

All SP cases were completed using the mini Pfannenstiel incision without the need for conversion or additional ports. Baseline characteristics were comparable. No intraoperative complications were seen. Only one patient in the SP group had a Clavien II complication. All patients in the MP group had a drain placed, whereas drain was not placed in the SP group. Length of stay was shorter in the SP group (11.4 vs. 42.6 hours, p<0.001). Although visual analog pain score was comparable at discharge (p=0.633), the SP group had lower opioid usage (morphine milligram equivalent) in the hospital (p<0.001) and a lower rate of opioid prescription during discharge (18.2% vs. 91.7% p<0.001). At a median follow-up of 8 months, no patients had flank pain and all patients had good kidney drainage on follow-up images.

CONCLUSIONS

Single-port robotic dismembered pyeloplasty through a mini-Pfannenstiel access allows a same-day discharge protocol with minimal opiate use.

Laparoscopic Versus Open Pyeloplasty for Primary Pelvic Ureteric Junction Obstruction: A Prospective Single Centre Study

Introduction

The aim of the study was to compare the clinical and patient-reported outcomes among open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) patients.

Materials and methods

This was a prospective single centre, case-cohort study conducted in a tertiary care hospital with 62 patients. In both techniques, dismembered Anderson-Hynes pyeloplasty were undertaken. Post-operatively patients underwent visual analogue scale (VAS) assessment for pain, days to ambulation and comparison of the short- and long-term outcomes of the two procedures.

Results

There was no difference in the physical and functional outcomes between the two surgical approaches at 12 months period after surgery. However, patients in the laparoscopic group did report a higher rate of satisfaction at six weeks and six months’ postoperatively.

Likewise, patients in LP experienced less pain during the postoperative period (p-value <0.001), with decreased analgesic requirements. This translated into an early patient ambulation in the laparoscopic group (p-value <0.001), and a shorter hospital stay for the LP group (p-value <0.001). Moreover, follow-up ultrasound showed equal improvement of hydronephrosis among the two groups.

Conclusion

Laparoscopic and open pyeloplasty are equally effective in treating pelvic ureteric junction obstruction (PUJO), with comparable patient-reported outcomes at 12-month follow-up. However, the laparoscopic technique merits over open surgery with faster rehabilitation, a decreased postoperative pain experience and shorter hospital stay.

Surgical approaches for treatment of ureteropelvic junction obstruction - a systematic review and network meta-analysis

Background

Multiple surgical treatment options are available for the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study is to compare the most frequently used technics in a comprehensive network approach.

Methods

A systematic literature search of the EMBASE, MEDLINE and COCHRANE libraries was conducted in January 2018. Publications were included that evaluated at least two of the following surgical techniques: open pyeloplasty (OP), endopyelotomy (EP), laparoscopic (LP) and robot assisted pyeloplasty (RP). Main outcomes were operative success, complications, urinary leakage, re-operation, transfusion rate, operating time, and length of stay. Network meta-analyses with random effects models simultaneously assessed effectiveness of all surgical techniques.

Results

A total of 26 studies including 3143 patients were analyzed. Compared with RP, EP and LP showed lower operative success rates (EP: OR = 0.09, 95%CI:0.05–0.19; p < 0.001; LP: OR = 0.51, 95%CI:0.31–0.84; p = 0.008). Compared with OP, LP and RP had lower risk for complications (LP: OR = 0.62; 95%CI:0.41–0.95; p = 0.027; RP: OR = 0.41; 95%CI:0.22–0.79; p = 0.007). Compared with RP, no significant differences were detected for urinary leakage or re-operation, transfusion rates. Compared with EP, RP yielded longer operating time (mean = 102.87 min, 95%CI:41.79 min–163.95 min, p = < 0.001). Further significant differences in operating times were detected when comparing LP to EP (mean = 115.13 min, 95%CI:65.63 min–164.63 min, p = < 0.001) and OP to EP (mean = 91.96 min, 95%CI:32.33 min–151.58 min, p = 0.003).

Conclusions

Multiple surgical techniques are available for treatment of UPJO. RP has the highest rates of operative success and as well as LP lower complication rates than OP. Although surgical outcomes are worse for EP, its operating time is shorter than OP, RP, and LP. Surgeons should consider these findings when selecting the optimal treatment method for individual patients.

The Comparative Effectiveness of Treatments for Ureteropelvic Junction Obstruction

OBJECTIVE

To examine the effectiveness of the 3 primary treatments for ureteropelvic junction obstruction (ie, open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy) as assessed by failure rates.

MATERIALS AND METHODS

Using MarketScan data, we identified adults (ages 18-64 years) who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was failure (ie, need for a secondary procedure). We fit a Cox proportional hazards model to examine the effects of different patient, regional, and provider characteristics on treatment failure. We then implemented a survival analysis framework to examine the failure-free probability for each treatment.

RESULTS

We identified 1125 minimally invasive pyeloplasties, 775 open pyeloplasties, and 1315 endopyelotomies with failure rates of 7%, 9%, and 15%, respectively. Compared with endopyelotomy, minimally invasive pyeloplasty was associated with a lower risk of treatment failure (adjusted hazards ratio [aHR] 0.52; 95% confidence interval [CI], 0.39-0.69). Minimally invasive and open pyeloplasties had similar failure rates. Compared with open pyeloplasty, endopyelotomy was associated with a higher risk of treatment failure (aHR 1.78; 95% CI, 1.33-2.37). The average length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P <.001).

CONCLUSION

Endopyelotomy has the highest failure rate, yet it remains a common treatment for ureteropelvic junction obstruction. Future research should examine to what extent patients and physicians are driving the use of endopyelotomy.

Cost Analysis of Treatments for Ureteropelvic Junction Obstruction

BACKGROUND AND PURPOSE

Ureteropelvic junction obstruction is a common urologic condition that accounts for approximately $12 million in inpatient spending annually. Few studies have assessed the costs related to treatment. We sought to examine the cost of care for patients treated for ureteropelvic junction obstruction.

PATIENTS AND METHODS

We used the MarketScan^® database to identify adults from 18 to 64 years old treated with minimally invasive pyeloplasty, open pyeloplasty, and endopyelotomy for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was total expenditures related to the surgical episode, defined as the period from 30 days prior until 30 days after the index surgery. We fit a multinomial linear regression model to evaluate cost of the surgical episode, adjusting for age, gender, comorbidity, benefit plan type, and region of residence.

RESULTS

We identified 1251 endopyelotomies, 717 open pyeloplasties, and 1048 minimally invasive pyeloplasties. The adjusted mean costs were $16,379 for endopyelotomy, $22,421 for open pyeloplasty, and $22,843 for minimally invasive pyeloplasty (p < 0.0001, ANCOVA). Both open and minimally invasive pyeloplasties were more costly than endopyelotomy (both p < 0.0001, comparison between groups). However, the cost of open and minimally invasive pyeloplasties was similar (p = 0.57, comparison between groups).

CONCLUSIONS

Among the three treatments, endopyelotomy was the least expensive in the immediate perioperative period. Open and minimally invasive pyeloplasties were similar in cost, but both more expensive than endopyelotomies. The similar cost between the two pyeloplasty approaches provides additional evidence that minimally invasive pyeloplasty should be considered the standard treatment for ureteropelvic junction obstruction.

Variation in the Use of Open Pyeloplasty, Minimally Invasive Pyeloplasty, and Endopyelotomy for the Treatment of Ureteropelvic Junction Obstruction in Adults

BACKGROUND AND PURPOSE

Ureteropelvic junction obstruction is a common condition that can be treated with open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy. While all these treatments are effective, the extent to which they are used is unclear. We sought to examine the dissemination of these treatments.

PATIENTS AND METHODS

Using the MarketScan^® database, we identified adults 18 to 64 years old who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was ureteropelvic junction obstruction treatment (i.e., open pyeloplasty, minimally invasive pyeloplasty, endopyelotomy). We fit a multilevel multinomial logistic regression model accounting for patients nested within providers to examine several factors associated with treatment.

RESULTS

Rates of minimally invasive pyeloplasty increased 10-fold, while rates of open pyeloplasty decreased by over 40%, and rates of endopyelotomy were relatively stable. Factors associated with receiving an open vs a minimally invasive pyeloplasty were largely similar. Compared with endopyelotomy, patients receiving minimally invasive pyeloplasty were less likely to be older (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.95, 0.97) and live in the south (OR 0.52; 95% CI, 0.33, 0.81) and west regions (OR 0.57; 95% CI 0.33, 0.98) compared with the northeast and were more likely to live in metropolitan statistical areas (OR 1.52; 95% CI 1.08, 2.13).

CONCLUSIONS

Over this 9-year period, the landscape of ureteropelvic junction obstruction treatment has changed dramatically. Further research is needed to understand why geographic factors were associated with receiving a minimally invasive pyeloplasty or an endopyelotomy.

Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: long-term results

OBJECTIVE

To evaluate the long-term results of laparoscopic pyeloplasty in patients with secondary ureteropelvic junction obstruction after failed primary interventions.

METHODS

Between August 2000 and October 2012, transperitoneal dismembered laparoscopic pyeloplasty was carried out in 13 patients with a surgical history of failed prior surgical interventions. Perioperative outcomes as well as long-term results were assessed. These outcomes were compared with those of the same procedure carried out for primary ureteropelvic junction obstruction by a single surgeon during the same study period.

RESULTS

Laparoscopic transperitoneal pyeloplasty was completed successfully in all cases without converting to open surgery or requiring blood transfusion. The preoperative symptoms in 12 of 13 patients all disappeared soon after the operation. Asymptomatic severe hydronephrosis found in a 2-year-old boy reduced in size postoperatively. When comparing the primary with the secondary laparoscopic pyeloplasty carried out by the same surgeon, the mean operative time was longer (183 vs 241 min, P = 0.002), estimated blood loss was larger (33 vs 66 mL, P = 0.03) and the complication rate was higher (8.8% vs 22.2%, P = 0.01) in the secondary group. Success rates were 97.9% and 100% (P = 0.41) at a mean follow up of 25.9 and 40.0 months (P = 0.14) for the primary and secondary groups, respectively.

CONCLUSIONS

Laparoscopic pyeloplasty is an excellent option for patients who failed previous surgical management. This approach provides durable long-term outcomes comparable with those of primary treatment for ureteropelvic junction obstruction.

Trends in the treatment of adults with ureteropelvic junction obstruction

BACKGROUND AND PURPOSE

Minimally invasive pyeloplasty is an effective treatment for patients with ureteropelvic junction obstruction that offers quicker convalescence than open pyeloplasty. Technical challenges, however, may have limited its dissemination. We examined population trends and determinants of surgical options for ureteropelvic junction obstruction.

PATIENTS AND METHODS

Using the State Inpatient and Ambulatory Surgery Databases for Florida, we identified adults who underwent ureteropelvic junction obstruction repair between 2001 and 2009. After determining the surgical approach (minimally invasive pyeloplasty, open pyeloplasty, or endopyelotomy), we estimated annual utilization rates and the effects of patient, surgeon, and hospital predictors on surgery type, using multilevel multinomial logistic regression.

RESULTS

Rates of minimally invasive pyeloplasty increased 360% (P for monotonic trend < 0.01), while rates of open pyeloplasty decreased 56% (P<0.01). Rates of endopyelotomy were substantially higher and remained relatively stable (P=0.27). Compared with open pyeloplasty, minimally invasive pyeloplasty was used more commonly among patients with private insurance (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.2-2.3), those treated at teaching hospitals (OR 1.6; CI 1.0-2.6), and those treated by high-volume surgeons (OR 2.9; CI 2.0-4.2). Its use was less frequent among patients with multiple comorbidities (OR 0.53; CI 0.37-0.76). Similar associations were observed when comparing receipt of minimally invasive pyeloplasty with endopyelotomy; however, patients who underwent endopyelotomy were older.

CONCLUSIONS

The use of minimally invasive pyeloplasty has dramatically increased, largely replacing open pyeloplasty, while the use of endopyelotomy, albeit significantly more common than the other approaches, has remained stable. The surgical approach is influenced by several patient, surgeon, and hospital factors.

Minimal invasive pyeloplasty technique with vertical surgical approach: an alternative to laparoscopic pyeloplasty

This retrospective clinical study presents pyeloplasty results following a muscle-splitting dissection, with mini-flank incision, using instruments held in a vertical position. Between 2004 and 2010, dismembered pyeloplasty (Anderson-Hynes) was performed in 37 cases (32 males and 5 females) with an average age of 26 years (range, 20-56 years). The technique was carried out through a window opened by separating the lateral abdominal muscles. Operation duration, length of incision, postoperative pain, complications, and radiological and clinical results were discussed. The operation duration was between 50 and 90 minutes (average=65 minutes), the incisional length 5 and 7 cm (average=5.2 cm), and visual pain scale was 4.1 ± 3.1 and 3.3 ± 3.4 at 4 and 24 hours after the operation, respectively. The duration of hospitalization was between 30 and 120 hours (average=42 hours). In a retrospective analysis of our study, one case was reoperated on, following recurrence with obstruction, there were 9 cases with prolonged dilation in response to diuretics and 29 cases with complete recovery. Pyeloplasty operations, with a vertical surgical approach through smaller incisions and muscle separation, offered shorter periods of hospitalization, less postoperative pain, acceptable cosmetic results and higher rates of functional recovery.

Determination of patient concerns in choosing surgery and preference for laparoendoscopic single-site surgery and assessment of satisfaction with postoperative cosmesis

background and purpose: Laparoendoscopic single-site (LESS) surgery offers potential improvements in cosmesis and recovery over standard laparoscopy (SL). We report the factors with which patients are most concerned in choosing surgery and how these affect preference for LESS. In addition, we rate the satisfaction of scars after laparoscopy.

PATIENTS AND METHODS

Patients followed after a laparoscopic procedure completed two surveys. First, patients rated, on a 5-point Likert scale, the importance of pain, recovery time, cost, treatment success, scars, and complications in choosing surgery. In addition, they were asked their preference for LESS. In the second survey, the impact of scars on body image and cosmesis was assessed.

RESULTS

Seventy-nine patients (median age 54.8 years, 65% male and 35% female) were treated for malignancy (53), donation (15), and benign indications (9). Treatment success (4.71 ± 0.81) and complications (4.22 ± 1.16) were most important, followed by pain (3.43 ± 1.21) and convalescence (3.65 ± 1.11), P<0.05. Cost was rated 2.68 ± 1.38, and cosmesis was 2.22 ± 1.13 (P<0.005). Cosmesis score increased in females (2.59 ± 1.08 vs 2.02 ± 1.12), patients <50 years (2.59 ± 1.09 vs 2.02 ± 1.12), and benign surgical indication (3.33 ± 1.12 vs 2.07 ± 1.06), P<0.05. LESS was preferred in 30.4%, SL in 39.2%. Concern for cosmesis was associated with LESS preference (48.5% vs 17.8%, P=0.004). Sex, age, and surgical indication also influenced this. On the body image scale, patients scored a mean 18.8 ± 1.5 of 20. Patients rated scar appearance 8.31 ± 1.80 of 10.

CONCLUSION

Patients who were treated with laparoscopy were most concerned with success and complication. Preference for LESS was influenced by concerns for cosmesis, sex, age, and surgical indication.

[Comparison of the operation time and complications between conventional and robotic-assisted laparoscopic pyeloplasty]

OBJECTIVE

To compare the different times into which the convention and robotic-assisted laparoscopic pyeloplasty can be divided. To compare the rate of complications between both procedures.

MATERIAL AND METHODS

A retrospective study was performed of the patients diagnosed of pyeloureteral junction stenosis and treated with convention and robotic laparoscopic pyeloplasty with more than one year of follow-up. All of the interventions were recorded and visualized. The different times in which the pyeloplasty can be divided were measured. All of the peri- and post-operative complications that occurred by the patients were collected. The non-parametric tests of Kolmogorov-Smirnov and Mann-Whitney U-Test for independent samples were applied using a significance level of 0.05.

RESULTS

A total of 50 patients were validated. Thirty three were treated with convention laparoscopy and 17 with robotic laparoscopy. The suture time, total intervention time and time of hospital stay were lower with a statistically significant difference in the robotic-assisted pyeloplasty. The robotic pyeloplasty had a lower percentage of complications (76.5% vs 48.5%). The most frequent complications were urinary infections, in relationship to the double J. Two restenoses occurred in the conventional laparoscopy and one in the robotic-assisted. Success rate was 93.9% for the conventional laparoscopy and 94.1% for the robotic-assisted one.

CONCLUSIONS

Although the success rate is similar in both procedures, the robotic pyeloplasty is a very fast procedure and has lower rates of complications than the conventional laparoscopy.