- Email: [email protected]
Late Failures After Laparoscopic Pyeloplasty
Reconstructive Urology Late Failures After Laparoscopic Pyeloplasty Rabii Madi, William W. Roberts, and J. Stuart Wolf Jr OBJECTIVES METHODS RESULTS
CONCLUSIONS
We present the results of our series of 65 consecutive laparoscopic pyeloplasties, which include some unexpected late failures. We retrospectively reviewed the perioperative course of 65 consecutive patients who underwent transperitoneal laparoscopic pyeloplasty from August 1996 through July 2005 at our institution. Of the obstructions, 47 and 18 were primary and secondary, respectively. Laparoscopic pyeloplasty was successfully performed on 64 patients. Of the patients, 42 (65%) had crossing vessel(s) found intraoperatively. We performed dismembered pyeloplasty for 50 (77%), Y-V plasty for 12 (18%) and Fengerplasty for 3 patients (5%). Mean laparoscopic operative time was 218 minutes, not including a mean of 40 minutes for stent placement and repositioning. The median hospital stay was 2 days. All 9 major complications (14%) pertained to urinary leakage/ureteral obstruction. Of the 60 patients with follow-up, 7 (12%) failed within 1 year of surgery. An additional 3 patients who appeared cured at initial follow-up presented with late recurrences, at 2, 2.5, and 6 years postoperatively. The overall success rate at 1 year was 88%, with a long-term success rate of 83%, and was not related to type of obstruction or repair, or urinary leakage/ureteral obstruction. Contrary to findings in other series, 30% of our failures occurred 2 or more years after pyeloplasty. All failures, however, were symptomatic, such that radiographic follow-up after 1 year in patients with symptoms preoperatively may not be necessary. UROLOGY 71: 677– 681, 2008. © 2008 Elsevier Inc.
O
pen surgical pyeloplasty offers an excellent cure rate for ureteropelvic junction obstruction (UPJO) and is considered the gold standard of treatment.1–3 Laparoscopic pyeloplasty has gained popularity as an alternative to the open technique. Recent studies have shown that laparoscopic pyeloplasty is a safe and effective modality for treating UPJO.4 – 8 Short-term success rates ranging from 83% to 99% have been reported,4 – 8 equivalent to the open approach. The advantages of laparoscopy, including less pain, earlier functional recovery, and better cosmesis, are well translated into this technique. After surgical correction of UPJO, patients are monitored clinically and with imaging. Criteria of cure are radiologic and/or clinical improvement or resolution of obstruction. Most series suggest that recurrence of obstruction after 1 year is uncommon. We present the results of our series of 65 consecutive laparoscopic pyeloplasties, which include some unexpected late failures.
Dr Madi is currently affiliated with the University of Arkansas for Medical Sciences, Little Rock, Arkansas. From the University of Michigan Health System, Ann Arbor, Michigan Reprint requests: J. Stuart Wolf Jr, M.D., Department of Urology, University of Michigan Health System, 1500 East Medical Center Drive, TC 3875, Ann Arbor, MI 48109-0330. E-mail: [email protected] Submitted: January 13, 2007, accepted (with revisions): October 18, 2007
© 2008 Elsevier Inc. All Rights Reserved
MATERIAL AND METHODS Between 1996 and 2005, we performed 65 consecutive standard transperitoneal laparoscopic pyeloplasties at our institution. One pyeloplasty was performed successfully with the robotic approach (December 2001) but was not considered in this study. A UPJO is defined as primary if it was not previously treated with an endoscopic or open procedure. A secondary UPJO is defined as an obstruction that failed a previous endoscopic repair or that occurred secondary to some other intervention or process. All patients had an internal ureteral stent inserted cystoscopically after confirmatory retrograde pyelogram at the beginning of the procedure. A single pigtail stent (Tail stent, Microvasive, Natick, Mass) was used starting in March 2000 (10th case). All procedures were performed by using the Endostitch device (AutoSuture, Norwalk, Conn) for suturing. If an anterior crossing artery was encountered during the dissection of the ureter, it was preserved and the ureter was transposed anterior to the artery (veins were sacrificed if no artery was present). In such cases, a dismembered repair was performed, with or without reduction pyeloplasty at the discretion of the surgeon. If crossing vessels were not present, but reduction pyeloplasty was deemed beneficial, then a dismembered pyeloplasty was also performed. In cases without crossing vessels or need for reduction pyeloplasty, then a nondismembered repair (Y-V plasty or Fengerplasty) was created. A closed suction drain was maintained until minimal output was reached (less than 150 mL per day). The stent was kept in place for 2 to 4 weeks, after which 0090-4295/08/$34.00 doi:10.1016/j.urology.2007.10.070
677
diuretic renal scan was obtained at 3 weeks, 3 months (if the 3 week result was equivocal), 1 year, and variably thereafter. A normal renal scan was defined as prompt excretion of the radiotracer with a T ½ less than 15 minutes. T ½ between 15 minutes and 20 minutes was defined as borderline resolution, and any prolongation of T ½ more than 20 minutes was considered radiologic failure. A Whitaker test was obtained cases of borderline renal scans. The differential renal function is that from the most recent renal scan before surgery, with or without ureteral stent. We performed a retrospective analysis of the preoperative data, perioperative course, and postoperative outcomes. Cure is resolution or improvement of symptoms plus normalization of follow-up renal scan or Whitaker test. Symptomatic cure is defined as the resolution or improvement of symptoms based on patient’s follow-up and telephone calls. Any other outcomes were considered failures. Information was obtained from electronic charts, clinic charts, and telephone calls to patients and their physicians as needed. Statistical analysis was performed using commercially available software on a personal computer (Statview 5.0.1, SAS Institute, Cary, NC). Comparisons of categorical data were performed by using the chi-squared test (Fisher exact method where appropriate). Continuous data were compared between groups with the nonparametric Mann-Whitney U test. P-values 0.05 or less were considered statistically significant.
RESULTS Preoperative characteristics are listed in Table 1. The patients were generally young and healthy, with mean age, body mass index, and American Society of Anesthesiology score of 37 years, 26, and 1.4, respectively. Of the patients, 32 were men and 33 were women, with obstruction of the right and left kidney in 32 and 33 cases, respectively. Horseshoe kidney was present in 3 patients. Of the obstructions, 47 (72%) were primary, and 18 (28%) were secondary. Of those who presented with secondary UPJO, 15 had a failed endopyelotomy, 2 had a failed balloon dilatation, and 1 had UPJO develop after percutaneous nephrostolithotomy. The indication for repair included pain in all but 2 patients in whom the procedure was performed for renal insufficiency. Preoperative differential renal function by renal scan was available in 45 patients. Of these, 4 had differential function less than 25%. Stones were present in the operated kidney in 4 (6%) patients; in 2 patients, the stones were completely removed via pyelolithotomy by using a flexible cystoscope and a basket; in 1 patient, the stones could only be partially removed owing to impaction; and in 1 patient, the stone was in an inaccessible calyceal diverticulum. A ureteral stent was present before pyeloplasty in 34 (52%) of patients. Perioperative characteristics are listed in Table 2. Laparoscopic pyeloplasty was successfully performed on 64 patients, with 1 procedure being completed with open surgery because of extensive fibrosis. Of the patients, 42 (65%) had vessel(s) crossing anterior to the UPJ found intraoperatively, including artery only in 6, vein only in 4, and both in 32. We performed dismembered pyelo678
Table 1. Preoperative characteristics Primary (n ⫽ 47) Mean age (yr) Mean body mass index Mean ASA score Gender Men Women Side Right Left Stent present preoperatively Yes No Differential renal function Mean ⱕ25%
36 24 1.4
Secondary (n ⫽ 18) 40 29 1.5
Overall (n ⫽ 65) 37 26 1.4
23 24
9 9
32 33
22 25
10 8
32 33
23 24
11 7
34 31
42% 2
36% 2
41% 4
ASA ⫽ American Society of Anesthesiology.
plasty on 50 (77%, includes the 1 open procedure), Y-V plasty on 12 (18%), and Fengerplasty on 3 patients (5%). Mean laparoscopic operative time was 218 minutes, with an additional mean of 40 minutes spent placing the ureteral stent and repositioning the patient. In the teaching setting of our institution, the laparoscopic suturing was performed by the resident, fellow, and attending primarily in 34%, 31%, and 35% of cases, respectively. The median hospital stay was 2 days, with an average of 2.6 days. Minor and major complications occurred in 9 patients (14%) each. One patient had both a minor and major complication. The minor complications included prolonged urinary leak requiring discharge from the hospital with urethral catheter and perinephric drain in 4 patients, urinary tract infection in 2, and pseudomembranous colitits, urticaria from drug reaction, and stent retraction above the ureteral orifice requiring basket extraction in 1 each. All major complications pertained to failure of urinary drainage, including stent obstruction in 6 patients (managed with stent exchange in all cases), 2 cases of delayed urinary extravasation treated with nephrostomy tube placement, and 1 case of expulsion of the ureteral stent requiring replacement. For 5 patients no follow-up information was available. Of the remaining 60 patients, 7 patients (12%) failed both symptomatically and radiographically within 1 year of surgery. Subsequent nephrectomy (3), endopyelotomy (3), and stent exchanges (1) have been successful. The other 53 patients all had completely successful procedures radiographically and symptomatically, of whom 49 had complete resolution of pain and 4 had improvement but not complete resolution of symptoms (3 with normal renal scan and 1 with borderline renal scan but a normal Whitaker test). Among these 53 patients, the median initial radiographic follow-up duration was 12 months (range, 3 to 48 months); 35 had completed at least 1 year of radiographic follow-up and 18 had less than 1 year of UROLOGY 71 (4), 2008
Table 2. Perioperative characteristics Primary (n ⫽ 47)
Secondary (n ⫽ 18)
Overall (n ⫽ 65)
33 (70%) 14 (30%)
9 (50%) 9 (50%)
42 (65%) 23 (35%)
26 (79%) 5 (15%) 2 (6%)
6 (67%) 1 (11%) 2 (22%)
32 (76%) 6 (14%) 4 (10%)
39 (83.3) 8 (16.7) — 214 64
11 (55.6) 4 (22.2) 3 (16.7) 231 113
50 (77%) 12 (18%) 3 (5%) 218 78
7 (15%) 8 (17%) 4 (9%) 10 (21%) 2.7
2 (11%) 1 (6%) 2 (11%) 3 (17%) 2.4
9 (14%) 9 (14%) 6 (9%) 13 (20%) 2.6
Crossing vessels Yes No Type of crossing vessels Artery ⫹ vein Artery Vein Type of repair Dismembered (includes 1 converted to open) Y-V Fengerplasty Laparoscopy time (mean, min) Estimated blood loss (mean, mL) Complications Minor Major With urine leak With urine leak or ureteral obstruction Hospitalization (mean, days)
Figure 1. Outcome of laparoscopic pyeloplasty related to timing of failure.
radiographic follow-up. Of the 18 with radiographic follow-up less than 1 year, all had symptomatic cure. The symptomatic follow-up was greater than 1 year in all but 2 patients. Three patients who appeared cured at the conclusion of the routine follow-up described previously presented with late radiographic and symptomatic recurrences, at 2, 2.5, and 6 years postoperatively. All 3 kidneys were without congenital anomalies, 2 had crossing vessels, 1 also contained calculi (that were successfully removed with concomitant laparoscopic pyelolithotomy), and all 3 underwent dismembered pyeloplasty for primary UPJO. Of the 3 patients, 1 had stent obstruction heralded by pain in the early postoperative period, although there was no evidence of urinary extravasation, which was successfully managed with stent exchange. The suturing was UROLOGY 71 (4), 2008
performed by the attending, fellow, and resident in 1 case each. These were the second, twenty-fifth, and thirtyfifth cases in our series. Of these 3 patients, 1 had declined further treatment. The other 2 patients underwent endopyelotomy, with success in one and failure in the other. Figure 1 illustrates the outcome of our laparoscopic pyeloplasties, as related to timing of failure. The overall success rate at 1 year was 88%, with a long-term success rate of 83%. The long-term success for primary and secondary UPJO was 35 of 43 (81%) and 15 of 17 (88%), respectively (P ⫽ NS). Success rate was not associated with age, body mass index, American Society of Anesthesiology score, side, gender, horseshoe kidney, coexisting stone, presence of ureteral stent preoperatively, presence of preoperative symptoms, preoperative differential renal 679
function, presence of crossing vessel, type of crossing vessel, attending surgeon, primary operating surgeon, case order, or operative time (data not shown). Of note, of the 4 patients with renal function 25% or less (range, 16% to 25%), 3 had successful repairs. The long-term radiographic success of nondismembered repairs was 12 of 15 (80%) (P ⫽ NS, compared with dismembered), but 2 of the failures were among the 3 Fengerplasty repairs. Success rate was not associated with urine leak (83% with or without urine leak, P ⫽ NS), or urine leak/ ureteral obstruction (75% with and 85% without urine leak/ureteral obstruction, P ⫽ NS).
COMMENT Laparoscopic pyeloplasty has been widely reported to be safe and effective.4 – 8 Recently, the robotic approach has been introduced, and is also reported to be highly successful.9 –11 In most of these series, success was defined based on either symptomatic or radiologic improvement. It is the general impression from the literature that a 1-year follow-up is sufficient to declare a patient cured after laparoscopic pyeloplasty, in that the vast majority of failures (when timing is defined) occur within 1 year.4,5,8 By using strict definitions of successful repair, we found that 3 of our 10 failures occurred 2 or more years after pyeloplasty. Interestingly, all 3 patients were cured both clinically and radiographically at 1-year follow-up. Neither the short- nor long-term failures were associated with any identifiable factor, and there was specifically no relation to complication by urine leak or ureteral obstruction. An additional notable feature of our report is the high incidence of crossing vessels (65%). This likely is due to the selective referral of patients to our institution for pyeloplasty. Although a crossing vessel may make an endoscopic repair less successful, it does not appear to affect the success rate of laparoscopic repair. We also could not detect any difference in success rate between primary and secondary UPJO. Although nondismembered repairs did as well as dismembered ones in our series overall, in our hands the Fengerplasty was successful in only 1 of 3 procedures, and we now select only a Y-V plasty when performing nondismembered repairs. In addition, we now use free-needle suturing (interrupted sutures that use 4-0 suture) for nondismembered repairs because a finer needle appears to provide a more satisfactory repair. We continue to use the Endostitch device for suturing in dismembered repairs for ease and simplicity. Our success rate in the first year is similar to those presented in the literature, but our longer-term success rate appears to be near the bottom of those reported in the literature. We think this likely is due to the inclusion of the 3 patients with failures delayed beyond 2 years. In support of this contention is the recent report by Dimarco et al.12 from Mayo Clinic that reported 85%, 80%, and 75% recurrence-free survival after pyeloplasty (open and laparoscopic) at 3, 5, and 10 years, respectively. 680
Because our routine follow-up extended beyond 1 year only in selected patients, it is very possible that additional long-term failures have gone undetected. Although all 3 of these patients presented with symptomatic as well as radiographic failure, and as such routine imaging beyond 1 year may not be necessary in patients with preoperative symptoms, these delayed failures suggest that reported results of laparoscopic pyeloplasty at 1 and even 2 years of follow-up must be interpreted cautiously. References 1. Arun N, Kekre NS, Nath V, et al: Is open pyeloplasty still justified? Br J Urol 80: 379 –381, 1997. 2. O’Reilly PH, Brooman PJ, Mak S, et al: The long-term results of Anderson-Hynes pyeloplasty. BJU Int 87: 287–289, 2001. 3. Brooks JD, Kavoussi LR, Preminger GM, et al: Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology 46: 791–795, 1995. 4. Eden C, Gianduzzo T, Chang C, et al: Extraperitoneal laparoscopic pyeloplasty for primary and secondary ureteropelvic junction obstruction. J Urol 172: 2308 –2311, 2004. 5. Inagaki T, Rha KH, Ong AM, et al: Laparoscopic pyeloplasty: current status. BJU Int 95: 102–105, 2005. 6. Turk IA, Davis JW, Winkelmann B, et al: Laparoscopic dismembered pyeloplasty—the method of choice in the presence of an enlarged renal pelvis and crossing vessels. Eur Urol 42: 268 –275, 2002. 7. Sundaram CP, Grubb RL III, Rehman J, et al: Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction. J Urol 169: 2037–2040, 2003. 8. Soulie M, Salomon L, Patard JJ, et al: Extraperitoneal laparoscopic pyeloplasty: a multicenter study of 55 procedures. J Urol 166: 48 –50, 2001. 9. Luke PP, Girvan AR, Al OM, et al: Laparoscopic robotic pyeloplasty using the Zeus Telesurgical System. Can J Urol 11: 2396 – 2400, 2004. 10. Peschel R, Neururer R, Bartsch G, et al: Robotic pyeloplasty: technique and results. Urol Clin North Am 31: 737–741, 2004. 11. Hubert J: Robotic pyeloplasty. Curr Urol Rep 4: 124 –129, 2003. 12. Dimarco DS, Gettman MT, McGee SM, et al: Long-term success of antegrade endopyelotomy compared with pyeloplasty at a single institution. J Endourology 20: 707–712, 2006.
EDITORIAL COMMENT This manuscript highlights important observations regarding longterm durability of laparoscopic pyeloplasty. In a well-delineated cohort of 65 patients with primary and secondary ureteropelvic junction obstruction (UPJO), the authors show that laparoscopic pyeloplasty can be performed with a short hospitalization and few complications. Although 1-year success rates of 88% are reported, the authors importantly point out that the risk of failure exists beyond 1 year. Indeed, 3 patients in their cohort experienced failures at 2, 2.5, and 6 years after treatment, resulting in a long-term success rate of 83%. Urologists have traditionally expected that pyeloplasty performed by using either an open or laparoscopic approach will yield long-term success in more than 90% of patients. In addition to the current report, other studies have found that longterm durability is not guaranteed.1,2 In the report by DiMarco et al.,2 for example, the 3-, 5-, and 10-year treatment cures after pyeloplasty (open or laparoscopic) were 85%, 80%, and 75%, UROLOGY 71 (4), 2008
CONCLUSIONS
We present the results of our series of 65 consecutive laparoscopic pyeloplasties, which include some unexpected late failures. We retrospectively reviewed the perioperative course of 65 consecutive patients who underwent transperitoneal laparoscopic pyeloplasty from August 1996 through July 2005 at our institution. Of the obstructions, 47 and 18 were primary and secondary, respectively. Laparoscopic pyeloplasty was successfully performed on 64 patients. Of the patients, 42 (65%) had crossing vessel(s) found intraoperatively. We performed dismembered pyeloplasty for 50 (77%), Y-V plasty for 12 (18%) and Fengerplasty for 3 patients (5%). Mean laparoscopic operative time was 218 minutes, not including a mean of 40 minutes for stent placement and repositioning. The median hospital stay was 2 days. All 9 major complications (14%) pertained to urinary leakage/ureteral obstruction. Of the 60 patients with follow-up, 7 (12%) failed within 1 year of surgery. An additional 3 patients who appeared cured at initial follow-up presented with late recurrences, at 2, 2.5, and 6 years postoperatively. The overall success rate at 1 year was 88%, with a long-term success rate of 83%, and was not related to type of obstruction or repair, or urinary leakage/ureteral obstruction. Contrary to findings in other series, 30% of our failures occurred 2 or more years after pyeloplasty. All failures, however, were symptomatic, such that radiographic follow-up after 1 year in patients with symptoms preoperatively may not be necessary. UROLOGY 71: 677– 681, 2008. © 2008 Elsevier Inc.
O
pen surgical pyeloplasty offers an excellent cure rate for ureteropelvic junction obstruction (UPJO) and is considered the gold standard of treatment.1–3 Laparoscopic pyeloplasty has gained popularity as an alternative to the open technique. Recent studies have shown that laparoscopic pyeloplasty is a safe and effective modality for treating UPJO.4 – 8 Short-term success rates ranging from 83% to 99% have been reported,4 – 8 equivalent to the open approach. The advantages of laparoscopy, including less pain, earlier functional recovery, and better cosmesis, are well translated into this technique. After surgical correction of UPJO, patients are monitored clinically and with imaging. Criteria of cure are radiologic and/or clinical improvement or resolution of obstruction. Most series suggest that recurrence of obstruction after 1 year is uncommon. We present the results of our series of 65 consecutive laparoscopic pyeloplasties, which include some unexpected late failures.
Dr Madi is currently affiliated with the University of Arkansas for Medical Sciences, Little Rock, Arkansas. From the University of Michigan Health System, Ann Arbor, Michigan Reprint requests: J. Stuart Wolf Jr, M.D., Department of Urology, University of Michigan Health System, 1500 East Medical Center Drive, TC 3875, Ann Arbor, MI 48109-0330. E-mail: [email protected] Submitted: January 13, 2007, accepted (with revisions): October 18, 2007
© 2008 Elsevier Inc. All Rights Reserved
MATERIAL AND METHODS Between 1996 and 2005, we performed 65 consecutive standard transperitoneal laparoscopic pyeloplasties at our institution. One pyeloplasty was performed successfully with the robotic approach (December 2001) but was not considered in this study. A UPJO is defined as primary if it was not previously treated with an endoscopic or open procedure. A secondary UPJO is defined as an obstruction that failed a previous endoscopic repair or that occurred secondary to some other intervention or process. All patients had an internal ureteral stent inserted cystoscopically after confirmatory retrograde pyelogram at the beginning of the procedure. A single pigtail stent (Tail stent, Microvasive, Natick, Mass) was used starting in March 2000 (10th case). All procedures were performed by using the Endostitch device (AutoSuture, Norwalk, Conn) for suturing. If an anterior crossing artery was encountered during the dissection of the ureter, it was preserved and the ureter was transposed anterior to the artery (veins were sacrificed if no artery was present). In such cases, a dismembered repair was performed, with or without reduction pyeloplasty at the discretion of the surgeon. If crossing vessels were not present, but reduction pyeloplasty was deemed beneficial, then a dismembered pyeloplasty was also performed. In cases without crossing vessels or need for reduction pyeloplasty, then a nondismembered repair (Y-V plasty or Fengerplasty) was created. A closed suction drain was maintained until minimal output was reached (less than 150 mL per day). The stent was kept in place for 2 to 4 weeks, after which 0090-4295/08/$34.00 doi:10.1016/j.urology.2007.10.070
677
diuretic renal scan was obtained at 3 weeks, 3 months (if the 3 week result was equivocal), 1 year, and variably thereafter. A normal renal scan was defined as prompt excretion of the radiotracer with a T ½ less than 15 minutes. T ½ between 15 minutes and 20 minutes was defined as borderline resolution, and any prolongation of T ½ more than 20 minutes was considered radiologic failure. A Whitaker test was obtained cases of borderline renal scans. The differential renal function is that from the most recent renal scan before surgery, with or without ureteral stent. We performed a retrospective analysis of the preoperative data, perioperative course, and postoperative outcomes. Cure is resolution or improvement of symptoms plus normalization of follow-up renal scan or Whitaker test. Symptomatic cure is defined as the resolution or improvement of symptoms based on patient’s follow-up and telephone calls. Any other outcomes were considered failures. Information was obtained from electronic charts, clinic charts, and telephone calls to patients and their physicians as needed. Statistical analysis was performed using commercially available software on a personal computer (Statview 5.0.1, SAS Institute, Cary, NC). Comparisons of categorical data were performed by using the chi-squared test (Fisher exact method where appropriate). Continuous data were compared between groups with the nonparametric Mann-Whitney U test. P-values 0.05 or less were considered statistically significant.
RESULTS Preoperative characteristics are listed in Table 1. The patients were generally young and healthy, with mean age, body mass index, and American Society of Anesthesiology score of 37 years, 26, and 1.4, respectively. Of the patients, 32 were men and 33 were women, with obstruction of the right and left kidney in 32 and 33 cases, respectively. Horseshoe kidney was present in 3 patients. Of the obstructions, 47 (72%) were primary, and 18 (28%) were secondary. Of those who presented with secondary UPJO, 15 had a failed endopyelotomy, 2 had a failed balloon dilatation, and 1 had UPJO develop after percutaneous nephrostolithotomy. The indication for repair included pain in all but 2 patients in whom the procedure was performed for renal insufficiency. Preoperative differential renal function by renal scan was available in 45 patients. Of these, 4 had differential function less than 25%. Stones were present in the operated kidney in 4 (6%) patients; in 2 patients, the stones were completely removed via pyelolithotomy by using a flexible cystoscope and a basket; in 1 patient, the stones could only be partially removed owing to impaction; and in 1 patient, the stone was in an inaccessible calyceal diverticulum. A ureteral stent was present before pyeloplasty in 34 (52%) of patients. Perioperative characteristics are listed in Table 2. Laparoscopic pyeloplasty was successfully performed on 64 patients, with 1 procedure being completed with open surgery because of extensive fibrosis. Of the patients, 42 (65%) had vessel(s) crossing anterior to the UPJ found intraoperatively, including artery only in 6, vein only in 4, and both in 32. We performed dismembered pyelo678
Table 1. Preoperative characteristics Primary (n ⫽ 47) Mean age (yr) Mean body mass index Mean ASA score Gender Men Women Side Right Left Stent present preoperatively Yes No Differential renal function Mean ⱕ25%
36 24 1.4
Secondary (n ⫽ 18) 40 29 1.5
Overall (n ⫽ 65) 37 26 1.4
23 24
9 9
32 33
22 25
10 8
32 33
23 24
11 7
34 31
42% 2
36% 2
41% 4
ASA ⫽ American Society of Anesthesiology.
plasty on 50 (77%, includes the 1 open procedure), Y-V plasty on 12 (18%), and Fengerplasty on 3 patients (5%). Mean laparoscopic operative time was 218 minutes, with an additional mean of 40 minutes spent placing the ureteral stent and repositioning the patient. In the teaching setting of our institution, the laparoscopic suturing was performed by the resident, fellow, and attending primarily in 34%, 31%, and 35% of cases, respectively. The median hospital stay was 2 days, with an average of 2.6 days. Minor and major complications occurred in 9 patients (14%) each. One patient had both a minor and major complication. The minor complications included prolonged urinary leak requiring discharge from the hospital with urethral catheter and perinephric drain in 4 patients, urinary tract infection in 2, and pseudomembranous colitits, urticaria from drug reaction, and stent retraction above the ureteral orifice requiring basket extraction in 1 each. All major complications pertained to failure of urinary drainage, including stent obstruction in 6 patients (managed with stent exchange in all cases), 2 cases of delayed urinary extravasation treated with nephrostomy tube placement, and 1 case of expulsion of the ureteral stent requiring replacement. For 5 patients no follow-up information was available. Of the remaining 60 patients, 7 patients (12%) failed both symptomatically and radiographically within 1 year of surgery. Subsequent nephrectomy (3), endopyelotomy (3), and stent exchanges (1) have been successful. The other 53 patients all had completely successful procedures radiographically and symptomatically, of whom 49 had complete resolution of pain and 4 had improvement but not complete resolution of symptoms (3 with normal renal scan and 1 with borderline renal scan but a normal Whitaker test). Among these 53 patients, the median initial radiographic follow-up duration was 12 months (range, 3 to 48 months); 35 had completed at least 1 year of radiographic follow-up and 18 had less than 1 year of UROLOGY 71 (4), 2008
Table 2. Perioperative characteristics Primary (n ⫽ 47)
Secondary (n ⫽ 18)
Overall (n ⫽ 65)
33 (70%) 14 (30%)
9 (50%) 9 (50%)
42 (65%) 23 (35%)
26 (79%) 5 (15%) 2 (6%)
6 (67%) 1 (11%) 2 (22%)
32 (76%) 6 (14%) 4 (10%)
39 (83.3) 8 (16.7) — 214 64
11 (55.6) 4 (22.2) 3 (16.7) 231 113
50 (77%) 12 (18%) 3 (5%) 218 78
7 (15%) 8 (17%) 4 (9%) 10 (21%) 2.7
2 (11%) 1 (6%) 2 (11%) 3 (17%) 2.4
9 (14%) 9 (14%) 6 (9%) 13 (20%) 2.6
Crossing vessels Yes No Type of crossing vessels Artery ⫹ vein Artery Vein Type of repair Dismembered (includes 1 converted to open) Y-V Fengerplasty Laparoscopy time (mean, min) Estimated blood loss (mean, mL) Complications Minor Major With urine leak With urine leak or ureteral obstruction Hospitalization (mean, days)
Figure 1. Outcome of laparoscopic pyeloplasty related to timing of failure.
radiographic follow-up. Of the 18 with radiographic follow-up less than 1 year, all had symptomatic cure. The symptomatic follow-up was greater than 1 year in all but 2 patients. Three patients who appeared cured at the conclusion of the routine follow-up described previously presented with late radiographic and symptomatic recurrences, at 2, 2.5, and 6 years postoperatively. All 3 kidneys were without congenital anomalies, 2 had crossing vessels, 1 also contained calculi (that were successfully removed with concomitant laparoscopic pyelolithotomy), and all 3 underwent dismembered pyeloplasty for primary UPJO. Of the 3 patients, 1 had stent obstruction heralded by pain in the early postoperative period, although there was no evidence of urinary extravasation, which was successfully managed with stent exchange. The suturing was UROLOGY 71 (4), 2008
performed by the attending, fellow, and resident in 1 case each. These were the second, twenty-fifth, and thirtyfifth cases in our series. Of these 3 patients, 1 had declined further treatment. The other 2 patients underwent endopyelotomy, with success in one and failure in the other. Figure 1 illustrates the outcome of our laparoscopic pyeloplasties, as related to timing of failure. The overall success rate at 1 year was 88%, with a long-term success rate of 83%. The long-term success for primary and secondary UPJO was 35 of 43 (81%) and 15 of 17 (88%), respectively (P ⫽ NS). Success rate was not associated with age, body mass index, American Society of Anesthesiology score, side, gender, horseshoe kidney, coexisting stone, presence of ureteral stent preoperatively, presence of preoperative symptoms, preoperative differential renal 679
function, presence of crossing vessel, type of crossing vessel, attending surgeon, primary operating surgeon, case order, or operative time (data not shown). Of note, of the 4 patients with renal function 25% or less (range, 16% to 25%), 3 had successful repairs. The long-term radiographic success of nondismembered repairs was 12 of 15 (80%) (P ⫽ NS, compared with dismembered), but 2 of the failures were among the 3 Fengerplasty repairs. Success rate was not associated with urine leak (83% with or without urine leak, P ⫽ NS), or urine leak/ ureteral obstruction (75% with and 85% without urine leak/ureteral obstruction, P ⫽ NS).
COMMENT Laparoscopic pyeloplasty has been widely reported to be safe and effective.4 – 8 Recently, the robotic approach has been introduced, and is also reported to be highly successful.9 –11 In most of these series, success was defined based on either symptomatic or radiologic improvement. It is the general impression from the literature that a 1-year follow-up is sufficient to declare a patient cured after laparoscopic pyeloplasty, in that the vast majority of failures (when timing is defined) occur within 1 year.4,5,8 By using strict definitions of successful repair, we found that 3 of our 10 failures occurred 2 or more years after pyeloplasty. Interestingly, all 3 patients were cured both clinically and radiographically at 1-year follow-up. Neither the short- nor long-term failures were associated with any identifiable factor, and there was specifically no relation to complication by urine leak or ureteral obstruction. An additional notable feature of our report is the high incidence of crossing vessels (65%). This likely is due to the selective referral of patients to our institution for pyeloplasty. Although a crossing vessel may make an endoscopic repair less successful, it does not appear to affect the success rate of laparoscopic repair. We also could not detect any difference in success rate between primary and secondary UPJO. Although nondismembered repairs did as well as dismembered ones in our series overall, in our hands the Fengerplasty was successful in only 1 of 3 procedures, and we now select only a Y-V plasty when performing nondismembered repairs. In addition, we now use free-needle suturing (interrupted sutures that use 4-0 suture) for nondismembered repairs because a finer needle appears to provide a more satisfactory repair. We continue to use the Endostitch device for suturing in dismembered repairs for ease and simplicity. Our success rate in the first year is similar to those presented in the literature, but our longer-term success rate appears to be near the bottom of those reported in the literature. We think this likely is due to the inclusion of the 3 patients with failures delayed beyond 2 years. In support of this contention is the recent report by Dimarco et al.12 from Mayo Clinic that reported 85%, 80%, and 75% recurrence-free survival after pyeloplasty (open and laparoscopic) at 3, 5, and 10 years, respectively. 680
Because our routine follow-up extended beyond 1 year only in selected patients, it is very possible that additional long-term failures have gone undetected. Although all 3 of these patients presented with symptomatic as well as radiographic failure, and as such routine imaging beyond 1 year may not be necessary in patients with preoperative symptoms, these delayed failures suggest that reported results of laparoscopic pyeloplasty at 1 and even 2 years of follow-up must be interpreted cautiously. References 1. Arun N, Kekre NS, Nath V, et al: Is open pyeloplasty still justified? Br J Urol 80: 379 –381, 1997. 2. O’Reilly PH, Brooman PJ, Mak S, et al: The long-term results of Anderson-Hynes pyeloplasty. BJU Int 87: 287–289, 2001. 3. Brooks JD, Kavoussi LR, Preminger GM, et al: Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology 46: 791–795, 1995. 4. Eden C, Gianduzzo T, Chang C, et al: Extraperitoneal laparoscopic pyeloplasty for primary and secondary ureteropelvic junction obstruction. J Urol 172: 2308 –2311, 2004. 5. Inagaki T, Rha KH, Ong AM, et al: Laparoscopic pyeloplasty: current status. BJU Int 95: 102–105, 2005. 6. Turk IA, Davis JW, Winkelmann B, et al: Laparoscopic dismembered pyeloplasty—the method of choice in the presence of an enlarged renal pelvis and crossing vessels. Eur Urol 42: 268 –275, 2002. 7. Sundaram CP, Grubb RL III, Rehman J, et al: Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction. J Urol 169: 2037–2040, 2003. 8. Soulie M, Salomon L, Patard JJ, et al: Extraperitoneal laparoscopic pyeloplasty: a multicenter study of 55 procedures. J Urol 166: 48 –50, 2001. 9. Luke PP, Girvan AR, Al OM, et al: Laparoscopic robotic pyeloplasty using the Zeus Telesurgical System. Can J Urol 11: 2396 – 2400, 2004. 10. Peschel R, Neururer R, Bartsch G, et al: Robotic pyeloplasty: technique and results. Urol Clin North Am 31: 737–741, 2004. 11. Hubert J: Robotic pyeloplasty. Curr Urol Rep 4: 124 –129, 2003. 12. Dimarco DS, Gettman MT, McGee SM, et al: Long-term success of antegrade endopyelotomy compared with pyeloplasty at a single institution. J Endourology 20: 707–712, 2006.
EDITORIAL COMMENT This manuscript highlights important observations regarding longterm durability of laparoscopic pyeloplasty. In a well-delineated cohort of 65 patients with primary and secondary ureteropelvic junction obstruction (UPJO), the authors show that laparoscopic pyeloplasty can be performed with a short hospitalization and few complications. Although 1-year success rates of 88% are reported, the authors importantly point out that the risk of failure exists beyond 1 year. Indeed, 3 patients in their cohort experienced failures at 2, 2.5, and 6 years after treatment, resulting in a long-term success rate of 83%. Urologists have traditionally expected that pyeloplasty performed by using either an open or laparoscopic approach will yield long-term success in more than 90% of patients. In addition to the current report, other studies have found that longterm durability is not guaranteed.1,2 In the report by DiMarco et al.,2 for example, the 3-, 5-, and 10-year treatment cures after pyeloplasty (open or laparoscopic) were 85%, 80%, and 75%, UROLOGY 71 (4), 2008