Laparoscopic surgical correction ofcircuivicaval ureter

CASE REPORT I

LAPAROSCOPIC SURGICAL CORRECTION OF CIRCUMCAVAL URETER SHIRO BABA,M.D. MOTOTSUGU OYA, M.D. MAKOTO MIYAHARA,M.D. NOBUHIRO DEGUCHI, M.D. HIROSHI TAZAKI, M.D. From the Department of Urology, Keio University, School of Medicine, Shinjuku-ku, Tokyo, Japan

ABSTRACT--Laparoscopic transposition and reanastomosis of a circumcaval ureter were performed in a 52-year-old man with right flank pain. A preoperative perfusion pressure study revealed abnormally high intrapelvic pressure. Under laparoscopy, the renal pelvis was divided above the ureteropelvic junction and the ureter was relocated from behind the vena cava. A 5 cm segment of redundant ureter containing the postcaval segment was resected and the ureteral end and renal pelvis were reapproximated with interrupted sutures by intracorporeal knot tying. The postoperative convalescence was uneventful, not necessitating the administration of analgesics. The patient resumed full activities 3 weeks later. The intravenous urogram and renogram obtained 2 months after the operation revealed remarkable improvement in the ureteral obstruction.

A retrocaval ureter is a congenital anomaly in which the ureter passes behind the vena cava. In the majority of patients, symptoms are due to ureteral obstruction and resulting hydronephrosis. The most common form of anomaly is so-called circumcaval ureter, which courses from a dorsolateral position above to a ventromedial position below around the inferior vena cava} A retrograde ureteropyelogram will demonstrate the typical fishhook-shaped curve of the upper ureter and deviation of the middle ureter toward the midline. Either an infusion pyelogram or a retrograde ureterogram in combination with an inferior venacavogram confirms the presence of a circumcaval ureter. 2,3 In patients with minimal caliectasis and no subjective symptoms, surgical correction is not indicated, but observation should be maintained. 3 Division of the dilated renal pelvis with transposition and reanastomosis was initially described by Harrill 4 and has been the most popular form of treatment in patients with symptomatic hydronephrosis. Both flank and transabdominal apSubmitted: November 10, 1993, accepted (with revisions): January 28, I994

122

proaches have been used to accomplish this proce! dure, but the convalescence might be complicat~t by wound pain and infection. In our institute, tgi{ patients with circumcaval ureter underwent opel surgery according to the method described g{ Harrill. 4 In one patient the procedure was via thll transperitoneal approach and in the other by flan{ incision. Regardless of the approach, both patien~ had gastrointestinal ileus in the immediate post0g] erative period for 2 and 4 days, respectively. Afiet the operation, analgesics were required at lea~] three times. The patients were allowed to walk o{ the fifth and sixth day. The hospital stay average! 19.6 days. The patients resumed normal activii on average on the 40th day after the surgical inte vention. Laparoscopy has been used to perform a varlet of ablative procedures such as cholecystectomY nephrectomy,6 and pelvic lymph node dissection!t With the use of laparoscopic techniques, we su!l cessfully completed the transposition and reana~ tomosls of a circumcaval right ureter• We behe :! that laparoscopic correction of the circumCaV!i ureter has advantages over conventional surfer] because of less pain and a shorter hospital sta1 with the former. UROLOGY / JuLY 1994 / VOLUME44, N UlvlB~a!

(,4) The preoperative intravenous urograrn (IVU), shows right hydronephrosis with no dye passage in the ureter. (B) A right retrograde ureterogram in conjunction with inferior venacavogram confirms the medial deviation of the right ureter that passes behind the F I G U R E 1.

v e n a CQVU.

CASE REPORT i}~A 52.year-old m a n had the complaint of vague ~ r m i t t e n t right flank pain for the previous 5 ~ela~Slan intravenous u r o g r a m (IVU) revealed ~gh{:hydronephrosis with no passage of the con~i'~st m e d i u m in the ureter (Fig. 1A). He was ~}ferred to Keio University Hospital for further ~Vgination. Physical examination, including mea%,rement of blood pressure, was unremarkable ~r!natysis showed microscopic hematuria (3 to 4 ~ed blood cells per high-power field [HPF]). Peripheral blood counts and serum chemistry were 24-hour creatinine clearright retrograde ureteroh an inferior venacavo~1 deviation of the upper passes behind the vena 13111hippuran renogram, that the time to the peak and to its half-value (h/2; ated well with the pelvic ~pace volume and that these could be useful P aeg ~gmeters for estimating renal function. 8 The pre~.~p rative renoeram~, showed delayed clearance from i~,~~nght kidney; t and t.._ for the right kidney ~ere i1.0 and 18m8~ m i n u t e s , respectively. The ~wer . . . . caiix of the ri g ht kidne Y was P unctured and ;~9 F nephrostomv pigtail catheter was inserted. A i}.~ffusion studv was performed bred erativel to ~', alUate the ureteral obstruction, and as part of i!~ p°stoperative evaluation of the patency of the ~ikapproxlmated ureter The right ureter was con~;IROLOGY / duLY1994 / VOLUME44, NUMBER 1

sidered to be obstructive, because the perfusion study revealed an intrapelvic pressure of 30 cm of water at the standard perfusion rate of 10 mlJmin. 9 Preoperatively, the patient u n d e r w e n t bowel p r e p a r a t i o n a n d r e c e i v e d 1000 m g f l o m o x e f sodium intravenously. After satisfactory induction of endotracheal anesthesia, a cystoscopy was performed to introduce a guide wire up into the renal pelvis. A 16 F Foley catheter was introduced into the bladder. An open technique was used to access the peritoneal cavity. With the patient in the supine Trendelenburg position, an 11 m m Hasson cannula was first introduced through a small incision at the lower crease of the umbilicus. A second 11 m m trocar was inserted in the midline at a site approximately halfway between the umbilicus and pubic bone. Both of these cannulas were used as camera ports, depending on which site afforded the best image of the operative field. Two 11 m m trocars were inserted in the midclavicular line, 5 cm above and below the level of the umbilicus. A 5 m m cannula was placed at a site 5 cm above the right iliac crest in the middle axillary line. The operating table was tilted so that the ascending colon would fall away from the area of dissection. Once the ports were p u t in place, the p n e u m o p e r i toneum was maintained at the m a x i m u m pressure of 10 m m Hg. Mobilization of the ascending colon required incision of the lateral peritoneal reflection, starting below the appendix and going up to the hepatic flexure anterior to the right kidney. Laparoscopic 1 23

FIGURE 2. The middle third segment of the right ureter, passing behind the vena cava (*) up to the ureteropelvic junction (laparoscopic view).

Babcock clamps were used to keep the ascending colon away from the operative field. The right ureter was dissected from the surrounding fatty tissue at the level of the right common iliac vessels. The anterior aspect of the vend cava was subsequently dissected from its fibrous sheath. The middle third segmen t of the right ureter crossed the anterior wall of the vend cava toward the midline to pass behind the vessel up to the ureteropelvic junction (Fig. 2). To mobilize the renal pelvis and the upper third of the ureter, the right spermatic artery and vein had to be clipped and transected. After this procedure, the upper ureter was easily dissected up to the renal hilum along the borders of the vend card. The postcaval segment of the right ureter was loosely attached to the posterior wall of the vend cava. The right renal pelvis was transected just above the pyeloureteral junction, and the guide wire placed in the ureter was retracted to come down to halfway between the renal pelvis and the common iliac artery. The right ureter was then pulled out from the aortocaval fossa. A 5 cm proximal ureteral segment was excised and the proximal end of the remaining ureter was spatulated. The ureter and the renal pelvis were reapproximated with 000 polyglactin interrupted sutures. This procedure was a c c o m p l i s h e d - w i t h intracorporeal knot tying. Five sutures seemed to be satisfactory for the anastomosis. The guide wire was advanced again up to the renal pelvis, and a 6 F double pigtail stent was placed over the guide wire under laparoscopic and fluoroscopic observation. The position of the distal end of the stent was finally readjusted with the aid of a flexible cystoscope. The anastomosis was covered with adjacent fatty tissue and a Penrose drain was placed in the retroperitoneum through the port on the middle 124

An IVU taken 2 months after the operatJ demonstrates improvement of hydronephrosis on t right. FIGURE 3.

axillary line. At the end of the procedure, all ports:i. were inspected carefully and the fascia of the l a r g ~ laparoscopic ports were closed. The time of th~ii.!: procedure was 560 minutes. The patient was allowed to walk and resume ora intake on the second postoperative day. Because ~ the small incisions, administration of analgesi¢i was not required. He was discharged on the nin!i postoperative day. The ureteral stent was remove~ on the 18th day after the operation, when a perf,! sion pressure study showed a marked decrease~ii the maximum intrapelvic pressure (19 cm H2' .... The nephrostomy catheter was removed 3 week~ ; after the operation and the patient immediately re~' turned to his full activity. An IVU taken 2 mont h/~ after the operation confirmed the improvemeni 0i the right hydronephrosis (Fig 3) The postoper~ tive renogram again showed furtt~er lmproveme~ of the right renal function The tin,x value of th right kidney had decreased by 48%, and the tin was reduced by 21% (Fig. 4). UROLOGY / JULY1994 / VOLUM~44, Nu~BEg1

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RL. Kidney "~,before Operation

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Renograrn of the right kidney before and peration.

COMMENT surgery is rapidly becoming the ae in limited fields of urology such !~hrectomy6 and pelvic lymph node dissec!:because it offers dramatic reduction in pain iuration of hospitalization as well as cosmetic ~ement. The present report clearly demon!s that correction of circumcaval ureter can be ~pIished by laparoscopic surgery, and it has ~1advantages over conventional open surgery: }:~r!ier ambulation (postoperative day 2), }~r hospital stay (8 vs 19 days), absence of ~[ications such as w o u n d pain or gastroini~al ileus, and shorter postoperative convales~:C~before resumption of normal activity (21 vs :!h increasing experience in laparoscopic }rectolny, we find that laparoscopic dissection ~g retroperitoneal space including the aortoil fossa is much easier from the right than the ~gite Side. To dissect the aortocaval fossa safely i!paroscopic surgery, retraction of the bowel ind the site of the peritoneal incision is most i0ttant The approach through the peritoneal iSi~n beginning at the ligament of Treitz along !eft leaf of the small-bowel mesentery allows a mt exposure of the of frequent migratt into the operative ms are through the e the root of the ashat of the descendLzation of the entire right paracolic gut~gr around the inferior margin of the cecum pro~{des the best exposure of the retroperitoneal area !i~ithe right of the left renal arte r y above and the in f~l:: o ~erior mesenteric artery below. ~ . . ':i&was expected, dissection ot the inferior vend

~IR~LOGY / JuLY 1994 / VOLUME44, NUMBER1

while tilting the operating table to keep the patient in the half-recumbent position. With blunt dissection and gentle traction, the postcaval segment of the right ureter was safely dissected with instruments inserted through the two 11 mm trocars placed in the midclavicular line. The 5 mm port placed in the middle axillary Iine was used for dissection and lifting the extrarenal pelvis and the upper third of the ureter. To mobilize the ureteropelvic junction, the gonadal vessels had to be secured with Endoclips and transected. The gonadal vein could be easily recognized on the right lateral wall of the vena cava at the level of the lower pole of the right kidney. The right gonadal artery lies in front of the vend cava, surrounded by fatty tissue, so that dissection should be meticulously performed. The most challenging part of the p r o c e d u r e was the e n d - t o - e n d anastomosis of the ureter, which took almost 2 1/2 hours. At first, the reapproximation was attempted by extracorporeal knot tying, but the use of a knot pusher caused uncontrollable tension of the tissue, frequently tearing the ureteral wall. Therefore, the procedure was accomplished by intracorporeal knot tying, which was tedious but turned out to he more reliable. Instead of using a ski-needle specially designed for laparoscopic surgery, an 18 mm half circle needle with 000 polyglactin was introduced through an 11 m m port after slightly stretching the needle to adapt its size. We initially placed two anchoring sutures on the anterior wall of each end of the ureter, to keep from twisting the ureter. This procedure, however, caused unexpected traction of the ureter and became an obstacle to subsequent anastomosis, so the sutures were finally removed. Difficulty in reapproximating the ureter and renal pelvis accounted for almost one third of the operative time. Nonetheless, the patient tolerated the lengthy procedure well, with the maximum end-tidal carbon dioxide pressure of 40 mm Hg. For pediatric patients or patients with respiratory problems, however, laparoscopy-assisted surgical correction is recommended to shorten the time of the procedure and avoid possible morbidity due to long-term pneumoperitoneum. The dissection and transposition of the circumcaval ureter can be accomplished under laparoscopy, and the rest of the procedure including reanastomosis can be performed through a small skin incision. In the present case, the postoperative perfusion study was performed on the same day the stent was removed. This explains why the intrapelvic pressure was still in the range of mild obstruction. The renogram parameters obtained 2 months after I 25

the operation, however, s h o w e d m a r k e d resolution of the obstruction. In this initial case of laparoscopic c o r r e c t i o n of circumcaval ureter, m a n y of the possible complications s e c o n d a r y to a surgical w o u n d were avoided by this minimally invasive approach, resulting in brief convalescence. This o p e r a t i o n is essentially a d i s m e m b e r e d pyeloplasty u n d e r laparoscopy, and has the obvious advantage of m i n i m a l disfigurem e n t and m o r b i d i t y to the patient. Shiro Baba, M.D. Keio University, School of Medicine 35 Shinanomachi Shinjuku-ku, Tokyo 160, Japan REFERENCES 1. Sener RN: Nonobstructive right circumcaval ureter associated with double inferior vena cava. Urology 41: 356-360 1993.

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2. Goodwin WE, Burke DE, and Muller WH: RetrocaV~i ureter. Surg Gynecol Obstet 104: 337-345, 1957. '~: 3. Shown TE, and Moore CA: Retrocaval ureter: 4 casesl) Urol 105: 497-501, 1971. 4. Harrill HC: Retrocaval ureter. Report of a case with op~ erative correction of the defect. J Uro144: 450-457, 1940. ~: 5. Reddick EJ, and Olsen DO: Laparoscopic laser choie~ cystectomy. A comparison with mini-lap cholecystectom~ Surg Endosc 3: 131-133, 1989. 6. Clayman RV, Kavoussi LR, McDougall EM, Soper Nii Figenshau RS, Chandhoke PS, and Albala DM: Laparoscolii~ nephrectomy: a review of 16 cases. Surg Laparosc Endosc ~t 29-34, 1992. :..,::~t 7. Winfield HN, Donovan JE See WA, Loening SA, a~{ Williams RD: Urological laparoscopic surgery. J Urol 14~i 941-948, 1991. 8. Bergstrom H: Influence on the radiorenogram of va~ tions in renal clearance, renal pelvic volume and urinary fl0! rate. An experimental model study. Scand J Clin Lab inv~ 28: 299-311, 1971. 9. Newhouse JH, Pfister RC, Hendren WH, and Yoder I Whitaker test after pyeloplasty: establishment of norm ureteral perfusion pressures. Am J Roentgenol 137: 223-Z 1981.

UROLOGY / JuLY 1994 / VOLt,ME44, NU~a~F~:~