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776Contemporary management of upper tract nephrolithiasis: Role of laparoscopic intervention
773
77~
RETROPERITONEOSCOPIC PYELOPLASTY AND LASER ENDOPYELOTOMY FOR THE MANAGEMENT OF URETEROPELVIC J U N C T I O N O B S T R U C T I O N : E X P E R I E N C E W I T H 211 P A T I E N T S T R E A T E D IN 10 Y E A R S
LAPAROSCOPIC PYELOPLASTY FOR URETEROPELVIC JUNCTION OBSTRUCTION: COMPARING DAVINCI ROBOTIC TO CLASSIC LAPAROSCOPIC PYELOPLASTY Am~ F., Burgess S., Mendez-Torres F., Castle E., Thomas R.
Sail K., Subotic S., Teber D., Feist-Schwenk M., Maldonado R., Frede Y., Rassweiler J. Tulane University Health Sciences Center, Urology, New Orleans, United States SLK-Kliniken Heilbrunn, Urology, Heilbronn, Germany INTRODUCTION & OBJECTIVES: Open pyeloplasty has traditionally been the gold standard treatment of ureteropelvic junction obstruction (UP J) with greater than 90% success rate. However, during the last decade the management has been revolutionized with introduction of laparoscopy and endourological tools yielding comparable results and less morbid outcomes. We present our experience with both techniques with emphasis on the impact of the learning curve (i.e.: how to do? how to select?) on our results. MATERIAL & METHODS: Between 1995 and 2004, a total of 211 retroperituneo-scopic pyeloplasties (LAP) and laser endopyelotomies (LEP) were performed in 90 male and 121 female patients with a mean age of 39.6(3-86) years. Mean follow-up was 40 (1-93) months. In the first time era (1995-1999), 68 patients were treated with (LEP) using Nd: YAG laser for intrinsic and extrinsic causes and 26 patients were managed with (LAP). While in the second era (2000-2004), 39 patients had LEP using Holmium-YAG laser mainly for intrinsic causes, 78 patients were treated by (LAP). Laparoscopic procedures included Y-V plasty: 1st era 2 (7:7%), 2~d era 50 (64%), Anderson-Hynes pyeloplasty: 1st era 3 (11.5%), 2'~a era 16 (20.5%), Fenger pyeloplasty: 1st era 9 (34.6%), 2"d era 5 (6.5%) and laparoscopic ureterolysis: 1st era 12 (46%), 2~d era 7 (9%). Aberrant vessels were seen in 75 patients (35.5%). RESULTS: LEP was successful in 80 of 107 patients (74.7 %) of the LEP- group. All of 27 failures occurred during the 1st era and included 6 (22.2%) aberrant vessels, 7 (26%) secondary complicated strictures, 3 (11%) high insertion of ureter and 4 (15%) ureteral kinks. The exclusion of the athrementioned failure subgroups yielded an over all success rate of 93.5%. Blood loss was minimal; mean operative time was 35(10-90) minutes. In the LAPgroup, the overall success rate was 94.2%, and again all the failures occurred during the 1~ era. Ureterolysis, which has been abandoned, was the procedure in 4 out of 6 of the failures. Excluding this, the success rate reaches 98%. Mean operative time was 127.5 (37-257) minutes. No case was converted to open. CONCLUSIONS: With the growing experience in laparoscopy and mastering of intracorporeal suturing, laparoscopic pyeloplasty using either Y-V or Anderson-Hynes techniques proved to be the treatment of choice for symptomatic UPJ obstruction. While acknowledging its minimal invasive nature and it is relatively easy way to perform, laser endopyelotomy should be reserved for the well-selected cases of intrinsic UPJ obstruction. This study was sponsored by Beaumont Transplant Foundation. Dublin, Ireland.
INTRODUCTION & OBJECTIVES: Laparoscopic pyeloplasty is a minimally, invasive method to treat ureteropelvic junction obstruction (UPJO), although this procedure is not widely available due to its technically demanding nature. The introduction of the daVinci Robotic System may allow this procedure to be performed at more centres. We compared our most recent 20 patients who underwent laparoscopic robotic pyeloplasty to patients who underwent classical laparoscnpic pyeloplasty at our institution. MATERIAL & METHODS: From February through October 2004 twenty patienls underwent laparoscopic pye/oplasty with the daVinci Robotic system for UPJ(I. All patients underwent Anderson-Hynes dismembered pyeloplasty, with 7 patienls requiring renal pelvic tailoring. Three patients underwent redo-pyeloplasty after failed open pyeloplasty. Three trans-peritoneal ports were placed for the robot. An umbilical port and two additional ports were placed 8 cm from the umbilicus, 30 ° cranially and caudally from an axis between the umbilicus and UPJ. A fourth port was placed in a subxyphoid location for retraction, suction, and dissection by the bedside surgeon. A ureteral stent and JP drain was placed in all cases. RESULTS: All cases were completed laparoscopically. Sixty percent of robotic patien]:s had a crossing vessel at the UPJO. The average blood loss was 52 cc and 95 cc for tSe robotic and classical laparoscopic groups, respectively. Mean operative time was 230 rain (180-310) for the latest 20 robotic cases, dropping to 210 rain (180-240) in tl~e last 5 cases. The classic laparoscopic group presented a mean operative time of 273 min even after 25 cases. There were no operative or post-operative complications in either group. The average hospital stay was 1.1days (1-3) for the robotic group and 1.4 days (1-3) in the classic group. All patients were evaluated by comparing pre- and postoperative renal scans and/or urograms. CONCLUSIONS: Laparoscopic pyeloplasty is becoming the treatment choice for UPJO, but ituracorporeal laparoscopic suturing and tissue handling remain a challenge to non-experienced laparoscopic surgeons. The seven degrees of motion of the daVin,zi Robotic system greatly enhances the precision in dissection and suturing of the UPJ. This has led to decreased operative times, even in patients who require extensive pelvic tailoring or have had previous endopyelotomy or open pyeloplasty. The reduced learning curve associated with robotics should foster widespread dissemination of this minimally-invasive technique.
775 ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY Patel V.
776 CONTEMPORARY MANAGEMENT OF UPPER TRACT NEPHROLITHIASIS: ROLE OF LAPAROSCOPIC INTERVENTION Atug F., Burgess S., Bejma J., Gupta S., Castle E., Thomas R.
Urology Centers, Urology, Vestavia Hills, Alabama, United States
Tulane University Health Sciences Center, Urology, New Orleans, United States
I N T R O D U C T I O N & O B J E C T I V E S : The introduction of robotic assistance with its advantages of magnification, three dimensional vision and wristed instrumentation has the potential to facilitate traditional laparoscopic procedures. We evaluated the feasibility and efficacy of robotic assisted laparoscopic pyeloplasty.
INTRODUCTION & OBJECTIVES: Treatment of upper tract kidney stones can be accomplished by several different techniques. Laparoscopic ureterolithotomy and pyelolithotomy are both treatment options for patients with large impacted calculi. Refinements in laparoscopic techniques have allowed renal pelvic, proximal ureteral and ew:n calyceal diverticular stones to be removed during a single operative setting. These techniques may provide higher stone-free rates after a single operation compared to percutaneoas treatments without increasing morbidity.
M A T E R I A L & M E T H O D S : Between July 2002 and September 2004, fifty patients with a mean age of 31.2 years (16-62) underwent robotic assisted laparoscopic dismembered pyeloplasty via the classic transperitoneal Anderson Hynes approach. Four trocars were placed. The UPJ was identified and excised,. followed by spatulation and re-anastomosis. Crossing vessels were present in 30% of patients; they were preserved in all cases. Patency of the ureteropelvic junction was assessed.with MAG3 lasix renograms at l, 3, 6, 9, 12 months. RESULTS: Each patient underwent a successful procedure without open conversion or transfusion. Average estimated blood loss was minimal at 20.4cc. Operative time averaged 122 (60-330) minutes overall. Time for the anastomosis averaged 20 minutes (10-100). Intra-operatively no complications were noted. Post operatively the average hospital stay was 1.1 days. Stents were removed at an average of 18 days (14-28). After 6 months of follow-up all patients had improved drainage on renal scan with improved or equivalent renal function. Average follow-up is currently 12.1 months; each patient is doing well with no evidence of recurrent obstruction. C O N C L U S I O N S : Robotic assisted laparoscopic pyeloplasty is a feasible option for UPJ reconstruction. It provides an effective option with minimal morbidity and promising short-term results.
European Urology Supplements 4 (2005) No. 3, pp. 196
MATERIAL & METHODS: Since the inception of urologic laparoscopy in the mid-1990's 25 ureterolithotomy, 4 pyelolithotomy, 7 pyeloplasty with renal pelvic stone removal, and two laparoscopic nephrolithotomies for calyceal diverticular stones have been performed at our institution. We retrospectively reviewed the following patient parameters: stone size, operative time, length of stay, stone-free rates, and perioperative complications. RESULTS: In the ureterolithotomy group, 75% of the stones are in the proximal ureter or at the ureteropelvic junction. Stone size, operative time, length of hospital stay, and stone-free rate are presented below. Procedure Lap Ureterolithotomy (n - 25) Lap Pyelolithotomy (n - 4) Lap Pyeloplasty with Stone Removal (n = 7) Lap Nephrolithotomy (n = 2)
Stone Size (cm) 1.6 (.9-2.3) 2.2 (1.5-3.0) 0.7 (.2-2.0) 3.3 (2.6-4.0)
OR Time (rain) 170 (85-260) 202 (156-220) 243 (170-310) 158 (139-178)
LOS (days) 1.2 (1-4)
Stone-Free Rate 100%
1.3 (1-2)
100%
1
85%
1.5 (1-2)
100%
One ureterolithotomy was complicated by prolonged urinary drainage secondary to a migrated ureteraI stent and one patient required conversion for open pyeloplasty. CONCLUSIONS: Large upper tract stones are often difficult to treat. We report success?ul !aparoscopic management of ureteral, renal pelvic, and calyceal diverticular stones with excellent stone-clearance rates and acceptable morbidity.
77~
RETROPERITONEOSCOPIC PYELOPLASTY AND LASER ENDOPYELOTOMY FOR THE MANAGEMENT OF URETEROPELVIC J U N C T I O N O B S T R U C T I O N : E X P E R I E N C E W I T H 211 P A T I E N T S T R E A T E D IN 10 Y E A R S
LAPAROSCOPIC PYELOPLASTY FOR URETEROPELVIC JUNCTION OBSTRUCTION: COMPARING DAVINCI ROBOTIC TO CLASSIC LAPAROSCOPIC PYELOPLASTY Am~ F., Burgess S., Mendez-Torres F., Castle E., Thomas R.
Sail K., Subotic S., Teber D., Feist-Schwenk M., Maldonado R., Frede Y., Rassweiler J. Tulane University Health Sciences Center, Urology, New Orleans, United States SLK-Kliniken Heilbrunn, Urology, Heilbronn, Germany INTRODUCTION & OBJECTIVES: Open pyeloplasty has traditionally been the gold standard treatment of ureteropelvic junction obstruction (UP J) with greater than 90% success rate. However, during the last decade the management has been revolutionized with introduction of laparoscopy and endourological tools yielding comparable results and less morbid outcomes. We present our experience with both techniques with emphasis on the impact of the learning curve (i.e.: how to do? how to select?) on our results. MATERIAL & METHODS: Between 1995 and 2004, a total of 211 retroperituneo-scopic pyeloplasties (LAP) and laser endopyelotomies (LEP) were performed in 90 male and 121 female patients with a mean age of 39.6(3-86) years. Mean follow-up was 40 (1-93) months. In the first time era (1995-1999), 68 patients were treated with (LEP) using Nd: YAG laser for intrinsic and extrinsic causes and 26 patients were managed with (LAP). While in the second era (2000-2004), 39 patients had LEP using Holmium-YAG laser mainly for intrinsic causes, 78 patients were treated by (LAP). Laparoscopic procedures included Y-V plasty: 1st era 2 (7:7%), 2~d era 50 (64%), Anderson-Hynes pyeloplasty: 1st era 3 (11.5%), 2'~a era 16 (20.5%), Fenger pyeloplasty: 1st era 9 (34.6%), 2"d era 5 (6.5%) and laparoscopic ureterolysis: 1st era 12 (46%), 2~d era 7 (9%). Aberrant vessels were seen in 75 patients (35.5%). RESULTS: LEP was successful in 80 of 107 patients (74.7 %) of the LEP- group. All of 27 failures occurred during the 1st era and included 6 (22.2%) aberrant vessels, 7 (26%) secondary complicated strictures, 3 (11%) high insertion of ureter and 4 (15%) ureteral kinks. The exclusion of the athrementioned failure subgroups yielded an over all success rate of 93.5%. Blood loss was minimal; mean operative time was 35(10-90) minutes. In the LAPgroup, the overall success rate was 94.2%, and again all the failures occurred during the 1~ era. Ureterolysis, which has been abandoned, was the procedure in 4 out of 6 of the failures. Excluding this, the success rate reaches 98%. Mean operative time was 127.5 (37-257) minutes. No case was converted to open. CONCLUSIONS: With the growing experience in laparoscopy and mastering of intracorporeal suturing, laparoscopic pyeloplasty using either Y-V or Anderson-Hynes techniques proved to be the treatment of choice for symptomatic UPJ obstruction. While acknowledging its minimal invasive nature and it is relatively easy way to perform, laser endopyelotomy should be reserved for the well-selected cases of intrinsic UPJ obstruction. This study was sponsored by Beaumont Transplant Foundation. Dublin, Ireland.
INTRODUCTION & OBJECTIVES: Laparoscopic pyeloplasty is a minimally, invasive method to treat ureteropelvic junction obstruction (UPJO), although this procedure is not widely available due to its technically demanding nature. The introduction of the daVinci Robotic System may allow this procedure to be performed at more centres. We compared our most recent 20 patients who underwent laparoscopic robotic pyeloplasty to patients who underwent classical laparoscnpic pyeloplasty at our institution. MATERIAL & METHODS: From February through October 2004 twenty patienls underwent laparoscopic pye/oplasty with the daVinci Robotic system for UPJ(I. All patients underwent Anderson-Hynes dismembered pyeloplasty, with 7 patienls requiring renal pelvic tailoring. Three patients underwent redo-pyeloplasty after failed open pyeloplasty. Three trans-peritoneal ports were placed for the robot. An umbilical port and two additional ports were placed 8 cm from the umbilicus, 30 ° cranially and caudally from an axis between the umbilicus and UPJ. A fourth port was placed in a subxyphoid location for retraction, suction, and dissection by the bedside surgeon. A ureteral stent and JP drain was placed in all cases. RESULTS: All cases were completed laparoscopically. Sixty percent of robotic patien]:s had a crossing vessel at the UPJO. The average blood loss was 52 cc and 95 cc for tSe robotic and classical laparoscopic groups, respectively. Mean operative time was 230 rain (180-310) for the latest 20 robotic cases, dropping to 210 rain (180-240) in tl~e last 5 cases. The classic laparoscopic group presented a mean operative time of 273 min even after 25 cases. There were no operative or post-operative complications in either group. The average hospital stay was 1.1days (1-3) for the robotic group and 1.4 days (1-3) in the classic group. All patients were evaluated by comparing pre- and postoperative renal scans and/or urograms. CONCLUSIONS: Laparoscopic pyeloplasty is becoming the treatment choice for UPJO, but ituracorporeal laparoscopic suturing and tissue handling remain a challenge to non-experienced laparoscopic surgeons. The seven degrees of motion of the daVin,zi Robotic system greatly enhances the precision in dissection and suturing of the UPJ. This has led to decreased operative times, even in patients who require extensive pelvic tailoring or have had previous endopyelotomy or open pyeloplasty. The reduced learning curve associated with robotics should foster widespread dissemination of this minimally-invasive technique.
775 ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY Patel V.
776 CONTEMPORARY MANAGEMENT OF UPPER TRACT NEPHROLITHIASIS: ROLE OF LAPAROSCOPIC INTERVENTION Atug F., Burgess S., Bejma J., Gupta S., Castle E., Thomas R.
Urology Centers, Urology, Vestavia Hills, Alabama, United States
Tulane University Health Sciences Center, Urology, New Orleans, United States
I N T R O D U C T I O N & O B J E C T I V E S : The introduction of robotic assistance with its advantages of magnification, three dimensional vision and wristed instrumentation has the potential to facilitate traditional laparoscopic procedures. We evaluated the feasibility and efficacy of robotic assisted laparoscopic pyeloplasty.
INTRODUCTION & OBJECTIVES: Treatment of upper tract kidney stones can be accomplished by several different techniques. Laparoscopic ureterolithotomy and pyelolithotomy are both treatment options for patients with large impacted calculi. Refinements in laparoscopic techniques have allowed renal pelvic, proximal ureteral and ew:n calyceal diverticular stones to be removed during a single operative setting. These techniques may provide higher stone-free rates after a single operation compared to percutaneoas treatments without increasing morbidity.
M A T E R I A L & M E T H O D S : Between July 2002 and September 2004, fifty patients with a mean age of 31.2 years (16-62) underwent robotic assisted laparoscopic dismembered pyeloplasty via the classic transperitoneal Anderson Hynes approach. Four trocars were placed. The UPJ was identified and excised,. followed by spatulation and re-anastomosis. Crossing vessels were present in 30% of patients; they were preserved in all cases. Patency of the ureteropelvic junction was assessed.with MAG3 lasix renograms at l, 3, 6, 9, 12 months. RESULTS: Each patient underwent a successful procedure without open conversion or transfusion. Average estimated blood loss was minimal at 20.4cc. Operative time averaged 122 (60-330) minutes overall. Time for the anastomosis averaged 20 minutes (10-100). Intra-operatively no complications were noted. Post operatively the average hospital stay was 1.1 days. Stents were removed at an average of 18 days (14-28). After 6 months of follow-up all patients had improved drainage on renal scan with improved or equivalent renal function. Average follow-up is currently 12.1 months; each patient is doing well with no evidence of recurrent obstruction. C O N C L U S I O N S : Robotic assisted laparoscopic pyeloplasty is a feasible option for UPJ reconstruction. It provides an effective option with minimal morbidity and promising short-term results.
European Urology Supplements 4 (2005) No. 3, pp. 196
MATERIAL & METHODS: Since the inception of urologic laparoscopy in the mid-1990's 25 ureterolithotomy, 4 pyelolithotomy, 7 pyeloplasty with renal pelvic stone removal, and two laparoscopic nephrolithotomies for calyceal diverticular stones have been performed at our institution. We retrospectively reviewed the following patient parameters: stone size, operative time, length of stay, stone-free rates, and perioperative complications. RESULTS: In the ureterolithotomy group, 75% of the stones are in the proximal ureter or at the ureteropelvic junction. Stone size, operative time, length of hospital stay, and stone-free rate are presented below. Procedure Lap Ureterolithotomy (n - 25) Lap Pyelolithotomy (n - 4) Lap Pyeloplasty with Stone Removal (n = 7) Lap Nephrolithotomy (n = 2)
Stone Size (cm) 1.6 (.9-2.3) 2.2 (1.5-3.0) 0.7 (.2-2.0) 3.3 (2.6-4.0)
OR Time (rain) 170 (85-260) 202 (156-220) 243 (170-310) 158 (139-178)
LOS (days) 1.2 (1-4)
Stone-Free Rate 100%
1.3 (1-2)
100%
1
85%
1.5 (1-2)
100%
One ureterolithotomy was complicated by prolonged urinary drainage secondary to a migrated ureteraI stent and one patient required conversion for open pyeloplasty. CONCLUSIONS: Large upper tract stones are often difficult to treat. We report success?ul !aparoscopic management of ureteral, renal pelvic, and calyceal diverticular stones with excellent stone-clearance rates and acceptable morbidity.