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LAPAROSCOPIC PYELOPLASTY: THE FIRST 100 CASES
0022-5347/02/1673-1253/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 167, 1253–1256, March 2002 Printed in U.S.A.
LAPAROSCOPIC PYELOPLASTY: THE FIRST 100 CASES THOMAS W. JARRETT,* DAVID Y. CHAN, TANYA C. CHARAMBURA, OSCAR FUGITA, LOUIS R. KAVOUSSI†
AND
From The James Buchanan Brady Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland
ABSTRACT
Purpose: Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction obstruction. Long-term followup has not yet been reported. We present experience with the first 100 consecutive cases of laparoscopic pyeloplasty performed at our institution. Materials and Methods: A retrospective review of 100 consecutive laparoscopic pyeloplasties in 99 patients (means age 37.3 years) between August 1993 and January 1999 was performed. All patients had radiographic evidence of obstruction with signs, symptoms or deterioration of renal function. Repair was for primary ureteropelvic junction obstruction in 83 patients and secondary obstruction in 17. The 4 types of repairs performed were Anderson-Hynes dismembered (71 cases), Y-V plasty (20), Heineke-Mirhulicz (8) and Davis intubated ureterotomy (1). Type of repair used was dictated by intraoperative findings. Twenty patients had nonobstructing renal stones and underwent concomitant pyelolithotomy. All patients were assessed for symptoms and radiographic evaluation for anatomical obstruction. Results: Average operating room time was 4.2 hours, which decreased with surgeon experience. Average blood loss was 181 cc and hospital stay was 3.3 days. Two patients required blood transfusion. A crossing vessel was found in 57 patients. With a mean clinical and radiographic followup of 2.7 and 2.2 years, respectively, 96% of the patients were free of obstruction on followup radiographic imaging. Of the patients who underwent concomitant pyelolithotomy, 18 (90%) were stone-free at last followup. All failures occurred within the first postoperative year. There were 12 complications in this series. Conclusions: In experienced hands laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction. The results appear durable and comparable to open pyeloplasty with decreased postoperative morbidity. KEY WORDS: laparoscopy; obstruction, ureteral
Ureteropelvic junction obstruction leads to progressive dilatation of the renal collecting system, and can result in pain and progressive deterioration of renal function.1 Most cases are congential and are not clinically apparent until later in life.2 The gold standard therapy for repair of ureteropelvic junction obstruction has been open pyeloplasty with success rates greater than 90%.3– 8 Endoscopic incision either in an antegrade or retrograde fashion provides an attractive minimally invasive alternative. However, these procedures have lower success rates of 70% to 89% even in highly select patients.9 –16 Patients at high risk for failure include those with a large redundant renal pelvis, crossing vessels or poor renal function (less than 20%).17–19 In such cases reconstructive pyeloplasty may provide an advantage. Laparoscopic pyeloplasty was first described in 1993 by Schuessler et al as a less invasive means of reconstructing the ureteropelvic junction under direct vision.20 The hope was to preserve the principles of open pyeloplasty without the associated morbidity of a large flank incision. We review our experience with the first 100 consecutive laparoscopic pyeloplasty procedures in 99 patients. Accepted for publication September 28, 2001. * Financial interest and/or other relationship with Valley Lab and Merck. † Financial interest and/or other relationship with Bard and Tramoun.
MATERIALS AND METHODS
We performed a retrospective review of 100 consecutive pyeloplasty procedures performed in 99 patients between August 1993 and January 1999. All patients had radiographic evidence of ureteropelvic junction obstruction on diuresis renography or hydronephrosis with delayed function on excretory urography (IVP) in conjunction with signs, symptoms or deterioration of renal function. Our technique has been described previously.21 All patients underwent cystoscopy with retrograde pyelography to confirm ureteropelvic junction obstruction and double pigtail ureteral stent placement (6 or 7Fr ) followed by laparoscopic reconstruction of the ureteropelvic. Patient position is demonstrated in figure 1. Four types of repairs were used depending on the anatomical findings at the time of dissection of the ureteropelvic junction (figs. 2 to 4). Twenty patients had nonobstructing renal stones that required 21 concomitant pyelolithotomies. One patient had bilateral ureteropelvic junction obstruction and renal calculi. Stone removal was performed through a pyelotomy under laparoscopic vision with or without the aid of flexible nephroscopy. A closed suction drain was placed adjacent to the repair and a Foley catheter was left indwelling. Foley catheter and drain output was monitored postoperatively. The Foley catheter was removed on postoperative day 2. The closed suction drain was subsequently removed if the drainage output did not increase after Foley catheter removal. Patients were scheduled for followup at 4 weeks for stent removal, IVP or nuclear renography was performed at 2 to 3
Editor’s Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1454 and 1455. 1253
1254
LAPAROSCOPIC PYELOPLASTY
FIG. 1. Position for laparoscopic pyeloplasty. Following cystoscopy and retrograde pyelogram with stent insertion patient is placed in modified flank position. Trocar sites are demarcated at 5 mm. (X) and 10 mm. (O).
FIG. 3. Foley Y-V plasty repair, which is preferred repair in absence of crossing vessels or high insertion. A, Y incision of ureteropelvic junction as outlined to ensure vascular viability of flap. B and C, apex of flap is advanced to distal ureteral incision and secured using interrupted sutures. D, tension-free, watertight repair.
FIG. 2. Anderson-Hynes dismembered pyeloplasty, which is procedure of choice for crossing vessel. A, dissection of proximal ureter and ureteropelvic junction. B, incision of renal pelvis and reduction of redundant pelvis. Proximal ureter is spatulated medially. C, EndoStitch is used to perform interrupted intracorporeal suturing and tying of repair. D, redundant pelvis is closed in running fashion.
months and annually thereafter, and clinical followup was performed every 6 to 12 months depending on symptoms. Radiographic success was defined as improvement of hydronephrosis with a patent ureteropelvic junction on IVP or improved drainage on diuresis renography. RESULTS
A total of 99 patients underwent 100 laparoscopic pyeloplasties. One patient underwent bilateral laparoscopic pyeloplasties in the same setting. Patient demographics are summarized in the table. Average patient age was 37.3 years (range 12 to 85) and average length of hospitalization was 3.3 days (range 2 to 8). The majority of patients underwent dismembered pyeloplasty. Mean operating time, which includes cystoscopy, retrograde ureteropyelography and stent placement, was 4.2 hours (range 2 to 8).
FIG. 4. Heineke-Mikulicz repair, which is useful for short stenotic segment in absence of crossing vessel. A, vertical incision extending 1 cm. proximal and distal to stenotic segment. B, horizontal closure of incision to provide widely patent segment.
Mean blood loss was 181 cc (range 25 to 800). With a minimum of 12 months of followup mean clinical and radiographic followup was 2.7 (range 1 to 7) and 2.2 (range 1 to 6) years, respectively. Of the patients 96% were unobstructed on followup radiographic studies. For primary and secondary ureteropelvic junction obstruction the success rates were 98% and 88%, respectively. Concomitant pyelolithotomy was performed in 20 kidneys in 19 patients with nonobstructing caliceal stone. Smaller stones were grasped and extracted under direct vision. Larger stones were placed in an EndoCatch bag (US Surgical, Norwalk, Connecticut) and removed through the lower 12 mm. trocar site at the end of the procedure. All stones were sent for analysis. Patients with recurrent stones were recommended to undergo a full metabolic evaluation.
1255
LAPAROSCOPIC PYELOPLASTY No./Total No. (%) No. Pts. (%)
Primary Obstruction
Ureteropelvic junction reconstruction 71 (71) 59 8 (8) 7 1 (1) 0 17 20 (20) 100 83 Radiographic followup: 96 (96) 81/83 (97.6) 4 (4) 2/83 (2.4) 2 1 1 2 2 Crossing vessels 57 (57) 46 43 (43) 37
Dismembered Heineke-Mikulicz Intubated ureterotomy Y-V plasty Totals Success Obstruction: Dismembered Y-V plasty Heineke-Mikulicz Primary obstruction Secondary obstruction Yes No
Obstruction persisted after laparoscopic pyeloplasty in 4 patients. One patient underwent laparoscopic pyeloplasty 3 days after sustaining ureteropelvic junction disruption during percutaneous nephrolithotomy for renal calculi. That renal unit has become atrophic and nonfunctional. A second patient required laparoscopic nephrectomy for persistent pain and atrophic kidney 2 years after failed laparoscopic pyeloplasty. The remaining 2 patients have prolonged halftime times on diethylenetetramine-pentaacetic acid with furosemide and have been treated conservatively. Complications developed in 13 patients. In 1 patient a colonic diverticulum was inadvertently clipped, and was managed by excising the diverticulum with a laparoscopic gastrointestinal arastomosis stapler. An intraoperative serosal injury was repaired laparoscopically without sequelae. In 2 patients postoperative urinary ascites developed secondary to drain migration, and both required laparoscopic exploration and repositioning of Jackson-Pratt drains. In 1 patient retroperitoneal bleeding occurred, which required hospitalisation and temporary urinary diversion with percutaneous nephrostomy. Blood transfusion was required in 2 patients who had preoperative anemia with hematocrit 32% and in 1 who had increased blood loss of 800 cc. Other complications included congestive heart failure, pneumonia, superficial antecubital thrombophlebitis, transient ileus, and persistent urinoma requiring percutaneous drainage. DISCUSSION
The gold standard therapy for repair of ureteropelvic junction obstruction has been open pyeloplasty. Endoscopic incision via a retrograde or antegrade approach was developed to provide a minimally invasive alternative to open pyeloplasty. Despite the success of endoscopic incision, success rates can be lower than those of pyeloplasty in certain circumstances, including marked hydronephrosis, poor renal function and presence of a crossing vessel.22, 23 Decreased renal function and marked hydronephrosis can be determined preoperatively. However, confirmation of a crossing vessel requires angiography, 3-dimensional spiral computerized tomography or intraoperative transluminal ultrasound.24 –26 This anomaly can be missed by radiographic imaging and discovered only during surgical exploration after the incisional procedure fails. The incidence of crossing vessels is high probably secondary to referral patterns as crossing vessels are increasingly discovered with spiral computerized tomography angiography and endoluminal ultrasound. Laparoscopic pyeloplasty provides a minimally invasive alternative to repair ureteropelvic junction obstruction. Reconstruction of the ureteropelvic junction can be tailored to the anatomical findings at the time of surgery. We have not
Secondary Obstruction 12 2 1 2 17 15/17 (88.2) 2/17 (11.8)
11 6
obtained preoperative studies to detect crossing vessels, as intraoperative recognition is readily apparent. Some have advocated intraoperative transluminal sonography for the diagnosis and exclusion of patients with a crossing vessel just before retrograde endopyelotomy.13 However, the 25% incidence of crossing vessels excluded them from a definitive procedure in the same setting and, thus, a significant number of patients who presented for a definitive procedure had care deferred. Although the early results of laparoscopic pyeloplasty were encouraging, there has been skepticism surrounding durability of results. Our overall success rate of 96% with up to a 6-year followup without late failures (after 1 year) indicates the durability of results. These results are comparable to those of most open pyeloplasty adult series. Scardino and Prince reported an overall success rate of 95% without late failures.5 With regard to pain control, almost all patients (including those with persistent obstruction) showed dramatic improvement compared to pre-operative controls. This finding indicates a distinct advantage over incisional procedures when a significant number of patients have persistent pain despite success by radiographic criteria.27, 28 Concomitant pyelolithotomy was performed successfully in many patients in a single session. All stones were sent for analysis. Patients with recurrent stones were recommended to undergo a full metabolic evaluation. Percutaneous stone removal followed by antegrade endopyelotomy was previously performed but this usually required several sessions due to concern of stone fragments embedding in the endopyelotomy site leading to stricture formation and failure.29 In our series laparoscopic pyeloplasty had a higher success rate for primary obstruction repairs. The overall success rate for secondary obstruction repairs was 88%, and these repairs following previous incisional procedures were technically more difficult but feasible. Additionally, previous ureteral stenting subjectively complicated the surgical dissection. Postoperative complications were usually related to urine leak and persistent drainage, which are also associated with open pyeloplasty,30 and were usually treated conservatively without sequelae. With experience, we have minimized these complications by improved methods of creating the anastomosis and securing drains. We now place the drain from a skin site posterior to the line of Toldt crossing posterior to the repair, which minimizes the chance of drain migration with patient movement. In addition, we prefer a running watertight anastomosis when feasible. Although 3 patients required blood transfusion in our series, only 1 had excessive blood loss during the procedure from a lower pole vein. Disadvantages of the procedure remain the long operative times, and the need for special skills for intracorporeal tying
1256
LAPAROSCOPIC PYELOPLASTY
and suturing which can increase hospital costs. With experience however, the operative times have been reduced significantly to those comparable to open surgical times. For a single surgeon (L. R. K.) the initial 10 cases, including cystoscopy, retrograde pyelogram and stent placement, required more than 5 hours. His current procedure time is consistently less than 3.5 hours. New advances in laparoscopic instrumentation allow for suturing and tying using the EndoStitch (US Surgical), which has significantly eased the burden of such tasks. In addition, our series was performed at an academic training center and reflects the learning curve of 6 surgeons.21 With improved techniques and surgeon experience, the costs should decrease to comparable levels. Factors not directly assessed were cosmesis and quicker patient recovery. CONCLUSIONS
Laparoscopic pyeloplasty was developed to maintain the advantages of open reconstruction of the ureteropelvic junction while minimizing the morbidity due to a large flank incision. Improvements in techniques and instrumentation have led to acceptable procedure times. In addition, longer followup has shown success rates comparable to open surgery. REFERENCES
1. Whitaker, R. H.: Clinical assessment of pelvic and ureteral function. Urology, 12: 146, 1978 2. Jacobs, J. A., Berger, B. W., Goldman, S. M. et al.: Ureteropelvic obstruction in adults with previously normal pyelograms: a report of 5 cases. J Urol, 121: 242, 1979 3. Persky, L., Krause, J. R. and Boltuch, R. L.: Initial complications and late results in dismembered pyeloplasty. J Urol, 118: 162, 1977 4. Foley, F. E. B.: A new plastic operation for stricture at the ureteropelvic junction: report of 20 operations. J Urol, 38: 643, 1937 5. Scardino, P. L. and Prince, C. L.: Vertical flap ureteropelvioplasty preliminary report. South Med Journal, 46: 325, 1953 6. Nguyen, D. H., Aliabadi, H., Ercole, C. J. et al: Nonintubated Anderson-Hynes repair of ureteropelvic junction obstruction in 60 patients. J Urol, 142: 704, 1989 7. Lowe, F. C., and Marshall, F. F.: Ureteropelvic junction obstruction in adults. Urology, 23: 33, 1984 8. O’Reilly, P. H., Brooman, P. J., Mak, S. et al: The long-term results of Anderson-Hynes pyeloplasty. BJU Int, 87: 287, 2001 9. Cassis, A. N., Brannen, G. E., Bush, W. H. et al: Endopyelotomy: review of results and complications. J Urol, 146: 1492, 1991 10. Motola, J. A., Badlani, G. H. and Smith, A. D.: Results of 212 consecutive endopyelotomies: an 8-year followup. J Urol, 149: 453, 1993 11. Kunkel, M. and Korth, K.: Long-term results following percutaneous pyeloplasty Urologe, A 29: 325, 1990 12. Gallucci, M. and Alpi, G.: Antegrade transpelvic endopyelotomy in primary obstruction of the ureteropelvic junction. J Endourol, 10: 127, 1996
13. Tawfiek, E. R., Liu, J. B. and Bagley, D. H.: Ureteroscopic treatment of ureteropelvic junction obstruction. J Urol, 160: 1643, 1998 14. Thomas, R., Monga, M. and Klein, E. W.: Ureteroscopic retrograde endopyelotomy for management of ureteropelvic junction obstruction. J Endourol, 10: 141, 1996 15. Shalhav, A. L., Giusti, G., Elbahnasy, A. M. et al: Adult endopyelotomy: impact of etiology and antegrade versus retrograde approach on outcome. J Urol, 160: 685, 1998 16. Preminger, G. M., Clayman, R. V., Nakada, S. Y. et al: A multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction. J Urol, 157: 1625, 1997 17. Badlani, G., Karlin, G. and Smith, A. D.: Complications of endopyelotomy: analysis in series of 64 patients. J Urol, 140: 473, 1988 18. Meretyk, I., Meretyk, S. and Clayman, R. V.: Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques. J Urol, 148: 775, 1992 19. Van Cangh, P. J., Wilmart, J. F., Opsomer, R. J. et al: Long-term results and late recurrence after endoureteropyelotomy: a critical analysis of prognostic factors. J Urol, 151: 934, 1994 20. Schuessler, W. W., Grune, M. T., Tecuanhuey, L. V. et al: Laparoscopic dismembered pyeloplasty. J Urol, 150: 1795, 1993 21. Chen, R. N., Moore, R. G. and Kavoussi, L. R.: Laparoscopic pyeloplasty: indications, technique, and long-term outcome. Urol Clin North Am, 25: 323, 1998 22. Gupta, M., Tuncay, O. L., and Smith, A. D.: Open surgical exploration after failed endopyelotomy: a 12-year perspective. J Urol, 157: 1613, 1997 23. Van Cangh, P. J. and Nesa, S.: Endopyelotomy.: prognostic factors and patient selection. Urol Clin North Am, 25: 281, 1998 24. Rouviere, O., Lyonnet, D., Berger, P. et al: Ureteropelvic junction obstruction: use of helical CT for preoperative assessment– comparison with intraarterial angiography. Radiology, 213: 668, 1999 25. Quillin, S. P., Brink, J. A., Heiken, J. P. et al: Helical (spiral) CT angiography for identification of crossing vessels at the ureteropelvic junction. AJR Am J Roentgenol, 166: 1125, 1996 26. Siegel, C. L., McDougall, E. M., Middleton, W. D. et al: Preoperative assessment of ureteropelvic junction obstruction with endoluminal sonography and helical CT. AJR Am J Roentgenol, 168: 623, 1997 27. Soulie, M., Thoulouzan, M., Seguin, P. et al: Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches. Urology, 57: 443, 2001 28. Bauer, J. J., Bishoff, J. T., Moore, R. G. et al: Laparoscopic versus open pyeloplasty: assessment of objective and subjective outcome. J Urol, 162: 692, 1999 29. Giddens, J. L., Grotas, A. B. and Grasso, M.: Stone granuloma causes ureteropelvic junction obstruction after percutaneous nephrolithotomy and antegrade endopyelotomy. J Urol, 164: 118, 2000 30. Novick, A. C. and Streem, S. B.: Surgery of the Kidney. In: Campbell’s Urology, 7th ed. Edited by P. C. Walsh, A. B. Retik, E. D. Vaughan, Jr. et al. Philadelphia: W. B. Saunders Co., vol. 3, chapt. 97, pp. 2973–3050, 1998
Vol. 167, 1253–1256, March 2002 Printed in U.S.A.
LAPAROSCOPIC PYELOPLASTY: THE FIRST 100 CASES THOMAS W. JARRETT,* DAVID Y. CHAN, TANYA C. CHARAMBURA, OSCAR FUGITA, LOUIS R. KAVOUSSI†
AND
From The James Buchanan Brady Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland
ABSTRACT
Purpose: Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction obstruction. Long-term followup has not yet been reported. We present experience with the first 100 consecutive cases of laparoscopic pyeloplasty performed at our institution. Materials and Methods: A retrospective review of 100 consecutive laparoscopic pyeloplasties in 99 patients (means age 37.3 years) between August 1993 and January 1999 was performed. All patients had radiographic evidence of obstruction with signs, symptoms or deterioration of renal function. Repair was for primary ureteropelvic junction obstruction in 83 patients and secondary obstruction in 17. The 4 types of repairs performed were Anderson-Hynes dismembered (71 cases), Y-V plasty (20), Heineke-Mirhulicz (8) and Davis intubated ureterotomy (1). Type of repair used was dictated by intraoperative findings. Twenty patients had nonobstructing renal stones and underwent concomitant pyelolithotomy. All patients were assessed for symptoms and radiographic evaluation for anatomical obstruction. Results: Average operating room time was 4.2 hours, which decreased with surgeon experience. Average blood loss was 181 cc and hospital stay was 3.3 days. Two patients required blood transfusion. A crossing vessel was found in 57 patients. With a mean clinical and radiographic followup of 2.7 and 2.2 years, respectively, 96% of the patients were free of obstruction on followup radiographic imaging. Of the patients who underwent concomitant pyelolithotomy, 18 (90%) were stone-free at last followup. All failures occurred within the first postoperative year. There were 12 complications in this series. Conclusions: In experienced hands laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction. The results appear durable and comparable to open pyeloplasty with decreased postoperative morbidity. KEY WORDS: laparoscopy; obstruction, ureteral
Ureteropelvic junction obstruction leads to progressive dilatation of the renal collecting system, and can result in pain and progressive deterioration of renal function.1 Most cases are congential and are not clinically apparent until later in life.2 The gold standard therapy for repair of ureteropelvic junction obstruction has been open pyeloplasty with success rates greater than 90%.3– 8 Endoscopic incision either in an antegrade or retrograde fashion provides an attractive minimally invasive alternative. However, these procedures have lower success rates of 70% to 89% even in highly select patients.9 –16 Patients at high risk for failure include those with a large redundant renal pelvis, crossing vessels or poor renal function (less than 20%).17–19 In such cases reconstructive pyeloplasty may provide an advantage. Laparoscopic pyeloplasty was first described in 1993 by Schuessler et al as a less invasive means of reconstructing the ureteropelvic junction under direct vision.20 The hope was to preserve the principles of open pyeloplasty without the associated morbidity of a large flank incision. We review our experience with the first 100 consecutive laparoscopic pyeloplasty procedures in 99 patients. Accepted for publication September 28, 2001. * Financial interest and/or other relationship with Valley Lab and Merck. † Financial interest and/or other relationship with Bard and Tramoun.
MATERIALS AND METHODS
We performed a retrospective review of 100 consecutive pyeloplasty procedures performed in 99 patients between August 1993 and January 1999. All patients had radiographic evidence of ureteropelvic junction obstruction on diuresis renography or hydronephrosis with delayed function on excretory urography (IVP) in conjunction with signs, symptoms or deterioration of renal function. Our technique has been described previously.21 All patients underwent cystoscopy with retrograde pyelography to confirm ureteropelvic junction obstruction and double pigtail ureteral stent placement (6 or 7Fr ) followed by laparoscopic reconstruction of the ureteropelvic. Patient position is demonstrated in figure 1. Four types of repairs were used depending on the anatomical findings at the time of dissection of the ureteropelvic junction (figs. 2 to 4). Twenty patients had nonobstructing renal stones that required 21 concomitant pyelolithotomies. One patient had bilateral ureteropelvic junction obstruction and renal calculi. Stone removal was performed through a pyelotomy under laparoscopic vision with or without the aid of flexible nephroscopy. A closed suction drain was placed adjacent to the repair and a Foley catheter was left indwelling. Foley catheter and drain output was monitored postoperatively. The Foley catheter was removed on postoperative day 2. The closed suction drain was subsequently removed if the drainage output did not increase after Foley catheter removal. Patients were scheduled for followup at 4 weeks for stent removal, IVP or nuclear renography was performed at 2 to 3
Editor’s Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 1454 and 1455. 1253
1254
LAPAROSCOPIC PYELOPLASTY
FIG. 1. Position for laparoscopic pyeloplasty. Following cystoscopy and retrograde pyelogram with stent insertion patient is placed in modified flank position. Trocar sites are demarcated at 5 mm. (X) and 10 mm. (O).
FIG. 3. Foley Y-V plasty repair, which is preferred repair in absence of crossing vessels or high insertion. A, Y incision of ureteropelvic junction as outlined to ensure vascular viability of flap. B and C, apex of flap is advanced to distal ureteral incision and secured using interrupted sutures. D, tension-free, watertight repair.
FIG. 2. Anderson-Hynes dismembered pyeloplasty, which is procedure of choice for crossing vessel. A, dissection of proximal ureter and ureteropelvic junction. B, incision of renal pelvis and reduction of redundant pelvis. Proximal ureter is spatulated medially. C, EndoStitch is used to perform interrupted intracorporeal suturing and tying of repair. D, redundant pelvis is closed in running fashion.
months and annually thereafter, and clinical followup was performed every 6 to 12 months depending on symptoms. Radiographic success was defined as improvement of hydronephrosis with a patent ureteropelvic junction on IVP or improved drainage on diuresis renography. RESULTS
A total of 99 patients underwent 100 laparoscopic pyeloplasties. One patient underwent bilateral laparoscopic pyeloplasties in the same setting. Patient demographics are summarized in the table. Average patient age was 37.3 years (range 12 to 85) and average length of hospitalization was 3.3 days (range 2 to 8). The majority of patients underwent dismembered pyeloplasty. Mean operating time, which includes cystoscopy, retrograde ureteropyelography and stent placement, was 4.2 hours (range 2 to 8).
FIG. 4. Heineke-Mikulicz repair, which is useful for short stenotic segment in absence of crossing vessel. A, vertical incision extending 1 cm. proximal and distal to stenotic segment. B, horizontal closure of incision to provide widely patent segment.
Mean blood loss was 181 cc (range 25 to 800). With a minimum of 12 months of followup mean clinical and radiographic followup was 2.7 (range 1 to 7) and 2.2 (range 1 to 6) years, respectively. Of the patients 96% were unobstructed on followup radiographic studies. For primary and secondary ureteropelvic junction obstruction the success rates were 98% and 88%, respectively. Concomitant pyelolithotomy was performed in 20 kidneys in 19 patients with nonobstructing caliceal stone. Smaller stones were grasped and extracted under direct vision. Larger stones were placed in an EndoCatch bag (US Surgical, Norwalk, Connecticut) and removed through the lower 12 mm. trocar site at the end of the procedure. All stones were sent for analysis. Patients with recurrent stones were recommended to undergo a full metabolic evaluation.
1255
LAPAROSCOPIC PYELOPLASTY No./Total No. (%) No. Pts. (%)
Primary Obstruction
Ureteropelvic junction reconstruction 71 (71) 59 8 (8) 7 1 (1) 0 17 20 (20) 100 83 Radiographic followup: 96 (96) 81/83 (97.6) 4 (4) 2/83 (2.4) 2 1 1 2 2 Crossing vessels 57 (57) 46 43 (43) 37
Dismembered Heineke-Mikulicz Intubated ureterotomy Y-V plasty Totals Success Obstruction: Dismembered Y-V plasty Heineke-Mikulicz Primary obstruction Secondary obstruction Yes No
Obstruction persisted after laparoscopic pyeloplasty in 4 patients. One patient underwent laparoscopic pyeloplasty 3 days after sustaining ureteropelvic junction disruption during percutaneous nephrolithotomy for renal calculi. That renal unit has become atrophic and nonfunctional. A second patient required laparoscopic nephrectomy for persistent pain and atrophic kidney 2 years after failed laparoscopic pyeloplasty. The remaining 2 patients have prolonged halftime times on diethylenetetramine-pentaacetic acid with furosemide and have been treated conservatively. Complications developed in 13 patients. In 1 patient a colonic diverticulum was inadvertently clipped, and was managed by excising the diverticulum with a laparoscopic gastrointestinal arastomosis stapler. An intraoperative serosal injury was repaired laparoscopically without sequelae. In 2 patients postoperative urinary ascites developed secondary to drain migration, and both required laparoscopic exploration and repositioning of Jackson-Pratt drains. In 1 patient retroperitoneal bleeding occurred, which required hospitalisation and temporary urinary diversion with percutaneous nephrostomy. Blood transfusion was required in 2 patients who had preoperative anemia with hematocrit 32% and in 1 who had increased blood loss of 800 cc. Other complications included congestive heart failure, pneumonia, superficial antecubital thrombophlebitis, transient ileus, and persistent urinoma requiring percutaneous drainage. DISCUSSION
The gold standard therapy for repair of ureteropelvic junction obstruction has been open pyeloplasty. Endoscopic incision via a retrograde or antegrade approach was developed to provide a minimally invasive alternative to open pyeloplasty. Despite the success of endoscopic incision, success rates can be lower than those of pyeloplasty in certain circumstances, including marked hydronephrosis, poor renal function and presence of a crossing vessel.22, 23 Decreased renal function and marked hydronephrosis can be determined preoperatively. However, confirmation of a crossing vessel requires angiography, 3-dimensional spiral computerized tomography or intraoperative transluminal ultrasound.24 –26 This anomaly can be missed by radiographic imaging and discovered only during surgical exploration after the incisional procedure fails. The incidence of crossing vessels is high probably secondary to referral patterns as crossing vessels are increasingly discovered with spiral computerized tomography angiography and endoluminal ultrasound. Laparoscopic pyeloplasty provides a minimally invasive alternative to repair ureteropelvic junction obstruction. Reconstruction of the ureteropelvic junction can be tailored to the anatomical findings at the time of surgery. We have not
Secondary Obstruction 12 2 1 2 17 15/17 (88.2) 2/17 (11.8)
11 6
obtained preoperative studies to detect crossing vessels, as intraoperative recognition is readily apparent. Some have advocated intraoperative transluminal sonography for the diagnosis and exclusion of patients with a crossing vessel just before retrograde endopyelotomy.13 However, the 25% incidence of crossing vessels excluded them from a definitive procedure in the same setting and, thus, a significant number of patients who presented for a definitive procedure had care deferred. Although the early results of laparoscopic pyeloplasty were encouraging, there has been skepticism surrounding durability of results. Our overall success rate of 96% with up to a 6-year followup without late failures (after 1 year) indicates the durability of results. These results are comparable to those of most open pyeloplasty adult series. Scardino and Prince reported an overall success rate of 95% without late failures.5 With regard to pain control, almost all patients (including those with persistent obstruction) showed dramatic improvement compared to pre-operative controls. This finding indicates a distinct advantage over incisional procedures when a significant number of patients have persistent pain despite success by radiographic criteria.27, 28 Concomitant pyelolithotomy was performed successfully in many patients in a single session. All stones were sent for analysis. Patients with recurrent stones were recommended to undergo a full metabolic evaluation. Percutaneous stone removal followed by antegrade endopyelotomy was previously performed but this usually required several sessions due to concern of stone fragments embedding in the endopyelotomy site leading to stricture formation and failure.29 In our series laparoscopic pyeloplasty had a higher success rate for primary obstruction repairs. The overall success rate for secondary obstruction repairs was 88%, and these repairs following previous incisional procedures were technically more difficult but feasible. Additionally, previous ureteral stenting subjectively complicated the surgical dissection. Postoperative complications were usually related to urine leak and persistent drainage, which are also associated with open pyeloplasty,30 and were usually treated conservatively without sequelae. With experience, we have minimized these complications by improved methods of creating the anastomosis and securing drains. We now place the drain from a skin site posterior to the line of Toldt crossing posterior to the repair, which minimizes the chance of drain migration with patient movement. In addition, we prefer a running watertight anastomosis when feasible. Although 3 patients required blood transfusion in our series, only 1 had excessive blood loss during the procedure from a lower pole vein. Disadvantages of the procedure remain the long operative times, and the need for special skills for intracorporeal tying
1256
LAPAROSCOPIC PYELOPLASTY
and suturing which can increase hospital costs. With experience however, the operative times have been reduced significantly to those comparable to open surgical times. For a single surgeon (L. R. K.) the initial 10 cases, including cystoscopy, retrograde pyelogram and stent placement, required more than 5 hours. His current procedure time is consistently less than 3.5 hours. New advances in laparoscopic instrumentation allow for suturing and tying using the EndoStitch (US Surgical), which has significantly eased the burden of such tasks. In addition, our series was performed at an academic training center and reflects the learning curve of 6 surgeons.21 With improved techniques and surgeon experience, the costs should decrease to comparable levels. Factors not directly assessed were cosmesis and quicker patient recovery. CONCLUSIONS
Laparoscopic pyeloplasty was developed to maintain the advantages of open reconstruction of the ureteropelvic junction while minimizing the morbidity due to a large flank incision. Improvements in techniques and instrumentation have led to acceptable procedure times. In addition, longer followup has shown success rates comparable to open surgery. REFERENCES
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