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PD40-09 COMPARISON OF ENDOSCOPIC BALLOON DILATION VS LAPAROSCOPIC URETERAL REIMPLANTATION FOR THE TREATMENT OF ADULT PRIMARY OBSTRUCTIVE MEGAURETER
THE JOURNAL OF UROLOGYâ
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reconstruction is very difficult. We are presenting our experience with nephropexy as adjunctive maneuver to gain the necessary additional ureteral length. METHODS: We retrospectively reviewed all upper urinary tract reconstructions from 2007-2015. For the nephropexy procedure, the kidney was mobilized within Gerota’s fascia leaving it only attached at the vascular pedicle. Caudal movement by the kidney occurred primarily by gravity, if an additional decrease in anastomotic tension was necessary the kidney was hitched to the ipsilateral psoas muscle. RESULTS: Of 91 patients undergoing upper urinary tract reconstruction, 17 (18.7%) required a nephropexy as adjunct maneuver. Of 7 ureterocalycostomies performed, 5 (71.4%) were done in conjunction with nephropexy as were 8/26 (30.1%) Boari flap bladder reconfigurations and 4/12 (33.3%) transuretero-ureterostomies. Location of ureteral stenoses in which nephropexies were required was variably distributed over the course of the upper ureter: at the UPJ in 6/ 17 patients (35.3%), at L2-3 in 5/17 patients (29.4%) and at L4-5 in 6/17 patients (35.3%). Nephropexies were performed as open surgery in 15/ 17 (88.2%) cases and laparoscopically in 2/17 (11.8%). After renal mobilization the average distance of downward movement achieved was 3.3 cm (range 1-5 cm). With a mean follow-up of 22.1 months (range 2-80 months), only 2/17 patients (11.8%) required a subsequent nephrectomy for failed upper tract reconstruction and persistent symptomatic hydronephrosis. CONCLUSIONS: Nephropexy as adjunct maneuver to gain additional ureteral length in upper tract reconstruction has a success rate of nearly 90% in our series. This maneuver can be used for ureteral stenoses at any level and be combined with a variety of reconstructive procedures. It is easier to perform than an ileal ureter and may also prevent unnecessary nephrectomies. Source of Funding: none
PD40-08 LAPAROSCOPIC URETERAL SUBSTITUTION WITH ILEUM AND APPENDIX Boris Komyakov, Viktor Ochelenko*, Bahman Guliev, Saint-Petersburg, Russian Federation INTRODUCTION AND OBJECTIVES: The intestinal ureteral reconstruction is an acceptable method in patients with extensive ureteral defects. The aim of this study is to evaluate the long-term results and effectiveness of this operations using laparoscopy. METHODS: From 2001 to 2015 97 patients underwent ureteral substitution with ileum and appendix at our clinic. Ten (10,3%) patients underwent laparoscopic reconstruction of ureter: 7 (7,2%) - with ileal segment and 3 (3,1%) e with appendix. There were 69 (71,1 %) women and 28 (28,9%) men with a median age of 50,5 9,5 years (range from 18 to 69 years). The main causes of ureteral strictures were: retroperitoneal fibrosis following radiation therapy, colorectal and gynecological cancer surgery. We perform a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ureter replacement. All patients underwent long-term follow-up including routine laboratory analysis and urinary tract imaging. Outpatient visits occurred at 3 and 6 months postoperatively and at least annually thereafter. RESULTS: The follow up period was from 3 months up to 14 years (mean 6,30,8 years). The time to convalescence (median 4,2 vs 6 weeks, p < 0.05) was significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 6 vs 12 days, p < 0.05) was also noted in patients in the laparoscopic group. Postoperative complications developed in 7 (9,2%) cases in open surgery group. CONCLUSIONS: Ileal and appendicular ureteral reconstruction is a safe and efficacious procedures in patients with extended and multiple ureteral strictures. The laparoscopic technique is a perspective method which allows to achieve shorter hospital stay and quick rehabilitation of the patient. Source of Funding: none
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
PD40-09 COMPARISON OF ENDOSCOPIC BALLOON DILATION VS LAPAROSCOPIC URETERAL REIMPLANTATION FOR THE TREATMENT OF ADULT PRIMARY OBSTRUCTIVE MEGAURETER Xuesong Li*, Kunlin Yang, Lin Yao, Cuijian Zhang, Lin Cai, Han Hao, Gang Wang, Liqun Zhou, Beijing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: Laparoscopic ureteral reimplantation (LUR) is an established surgery for primary obstructive megaureter (POM) but may be more invasive than endoscopic approach. To determine if endoscopic balloon dilation (EBD) for POM is as effective as LUR in the long-term follow-up. We made a retrospective comparison between EBD and LUR. METHODS: Twenty-four adult patients and 26 megaureters were retrospectively included from August 2010 to September 2015. The surgery indications were following conditions: progressive decreasing of the differential renal function < 40%, recurrent urinary tract infection associated with obstruction, worsening of the renal pelvic and ureter dilation. Ten patients and 11 ureters underwent EBD. The narrow ureterovesical junction was dilated with a high pressure balloon at 20-30 atm for 3 minutes. The constrictive ring was found in five patients and was longitudinally cut to muscle layer by holmium laser. Fourteen patients and 15 megaureters underwent our modified laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy. The success criteria were the disappearance of obstruction and the relief of symptom and hydronephrosis. RESULTS: No perioperative complications occurred in both groups. The mean operative time, the mean blood loss and the mean postoperative hospitalization showed significant differences between EBD and LUR (61.9 vs. 177.7 minutes, p ¼ < 0.001; 0 vs. 22.9 ml, p ¼ 0.004; 2 vs. 4.5 days, p ¼ < 0.001). The mean follow-up time was 28.9 months and 46 months for EBD and LUR, respectively. Two years after EBD, obstruction and hydronephrosis occurred in one female once again who had to receive one more dilation. In LUR group, one female still had hydronephrosis after surgery, but her symptom was relieved and the hydronephrosis was no worse. Forty-three months after LUR, recurrent urinary tract infection occurred in one female. No hydronephorosis was found by intravenous urogrphy. She received flexible ureteroscopy, but on obstruction was found. The success rate of EBD and LUR were 90% (9/10) and 92.9% (13/14). CONCLUSIONS: The EBD seems to be safe and equally effective as the LUR for the treatment of adult POM. In addition, the EBD may be less invasive with shorter the operative time, less blood loss and shorter postoperative hospitalization compared with LUR. However, further multicenter studies or prospective trials studies will be still required to demonstrate definitively real benefits of the EBD. Source of Funding: None
PD40-10 RENDEZVOUS PROCEDURE TO TREAT COMPLEX URETERIC DISCONTINUITIES Giorgio Mazzon*, Marco Bolgeri, Rebecca Dale, Vimoshan Arumuham, Clare Allen, Alex Kirkham, Navin Ramachandran, Sian Allen, Daron Smith, Tim Philp, Simon Choong, London, United Kingdom INTRODUCTION AND OBJECTIVES: When a ureteric stricture occurs, minimally invasive management is usually the first line approach to get the distressed patient out of a complicated situation. In the cases of failed antegrade or retrograde approaches to inserting a ureteric stent, the rendezvous procedure might be used to increase the success rate. The Rendezvous procedure involves a Uro-Radiologist using a variety of wires and catheters antegradely down to the ureteric stricture while the Urologist approaches the ureter retrogradely to visualize and attempt to straighten the stricture and to aid passage of the guidewire across the obstruction. The Urologist may need to laser through a dense ureteric stricture, laser to release a tied suture or traverse a missing section of the ureter to reach the antegrade guidewire
e938
reconstruction is very difficult. We are presenting our experience with nephropexy as adjunctive maneuver to gain the necessary additional ureteral length. METHODS: We retrospectively reviewed all upper urinary tract reconstructions from 2007-2015. For the nephropexy procedure, the kidney was mobilized within Gerota’s fascia leaving it only attached at the vascular pedicle. Caudal movement by the kidney occurred primarily by gravity, if an additional decrease in anastomotic tension was necessary the kidney was hitched to the ipsilateral psoas muscle. RESULTS: Of 91 patients undergoing upper urinary tract reconstruction, 17 (18.7%) required a nephropexy as adjunct maneuver. Of 7 ureterocalycostomies performed, 5 (71.4%) were done in conjunction with nephropexy as were 8/26 (30.1%) Boari flap bladder reconfigurations and 4/12 (33.3%) transuretero-ureterostomies. Location of ureteral stenoses in which nephropexies were required was variably distributed over the course of the upper ureter: at the UPJ in 6/ 17 patients (35.3%), at L2-3 in 5/17 patients (29.4%) and at L4-5 in 6/17 patients (35.3%). Nephropexies were performed as open surgery in 15/ 17 (88.2%) cases and laparoscopically in 2/17 (11.8%). After renal mobilization the average distance of downward movement achieved was 3.3 cm (range 1-5 cm). With a mean follow-up of 22.1 months (range 2-80 months), only 2/17 patients (11.8%) required a subsequent nephrectomy for failed upper tract reconstruction and persistent symptomatic hydronephrosis. CONCLUSIONS: Nephropexy as adjunct maneuver to gain additional ureteral length in upper tract reconstruction has a success rate of nearly 90% in our series. This maneuver can be used for ureteral stenoses at any level and be combined with a variety of reconstructive procedures. It is easier to perform than an ileal ureter and may also prevent unnecessary nephrectomies. Source of Funding: none
PD40-08 LAPAROSCOPIC URETERAL SUBSTITUTION WITH ILEUM AND APPENDIX Boris Komyakov, Viktor Ochelenko*, Bahman Guliev, Saint-Petersburg, Russian Federation INTRODUCTION AND OBJECTIVES: The intestinal ureteral reconstruction is an acceptable method in patients with extensive ureteral defects. The aim of this study is to evaluate the long-term results and effectiveness of this operations using laparoscopy. METHODS: From 2001 to 2015 97 patients underwent ureteral substitution with ileum and appendix at our clinic. Ten (10,3%) patients underwent laparoscopic reconstruction of ureter: 7 (7,2%) - with ileal segment and 3 (3,1%) e with appendix. There were 69 (71,1 %) women and 28 (28,9%) men with a median age of 50,5 9,5 years (range from 18 to 69 years). The main causes of ureteral strictures were: retroperitoneal fibrosis following radiation therapy, colorectal and gynecological cancer surgery. We perform a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ureter replacement. All patients underwent long-term follow-up including routine laboratory analysis and urinary tract imaging. Outpatient visits occurred at 3 and 6 months postoperatively and at least annually thereafter. RESULTS: The follow up period was from 3 months up to 14 years (mean 6,30,8 years). The time to convalescence (median 4,2 vs 6 weeks, p < 0.05) was significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 6 vs 12 days, p < 0.05) was also noted in patients in the laparoscopic group. Postoperative complications developed in 7 (9,2%) cases in open surgery group. CONCLUSIONS: Ileal and appendicular ureteral reconstruction is a safe and efficacious procedures in patients with extended and multiple ureteral strictures. The laparoscopic technique is a perspective method which allows to achieve shorter hospital stay and quick rehabilitation of the patient. Source of Funding: none
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
PD40-09 COMPARISON OF ENDOSCOPIC BALLOON DILATION VS LAPAROSCOPIC URETERAL REIMPLANTATION FOR THE TREATMENT OF ADULT PRIMARY OBSTRUCTIVE MEGAURETER Xuesong Li*, Kunlin Yang, Lin Yao, Cuijian Zhang, Lin Cai, Han Hao, Gang Wang, Liqun Zhou, Beijing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: Laparoscopic ureteral reimplantation (LUR) is an established surgery for primary obstructive megaureter (POM) but may be more invasive than endoscopic approach. To determine if endoscopic balloon dilation (EBD) for POM is as effective as LUR in the long-term follow-up. We made a retrospective comparison between EBD and LUR. METHODS: Twenty-four adult patients and 26 megaureters were retrospectively included from August 2010 to September 2015. The surgery indications were following conditions: progressive decreasing of the differential renal function < 40%, recurrent urinary tract infection associated with obstruction, worsening of the renal pelvic and ureter dilation. Ten patients and 11 ureters underwent EBD. The narrow ureterovesical junction was dilated with a high pressure balloon at 20-30 atm for 3 minutes. The constrictive ring was found in five patients and was longitudinally cut to muscle layer by holmium laser. Fourteen patients and 15 megaureters underwent our modified laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy. The success criteria were the disappearance of obstruction and the relief of symptom and hydronephrosis. RESULTS: No perioperative complications occurred in both groups. The mean operative time, the mean blood loss and the mean postoperative hospitalization showed significant differences between EBD and LUR (61.9 vs. 177.7 minutes, p ¼ < 0.001; 0 vs. 22.9 ml, p ¼ 0.004; 2 vs. 4.5 days, p ¼ < 0.001). The mean follow-up time was 28.9 months and 46 months for EBD and LUR, respectively. Two years after EBD, obstruction and hydronephrosis occurred in one female once again who had to receive one more dilation. In LUR group, one female still had hydronephrosis after surgery, but her symptom was relieved and the hydronephrosis was no worse. Forty-three months after LUR, recurrent urinary tract infection occurred in one female. No hydronephorosis was found by intravenous urogrphy. She received flexible ureteroscopy, but on obstruction was found. The success rate of EBD and LUR were 90% (9/10) and 92.9% (13/14). CONCLUSIONS: The EBD seems to be safe and equally effective as the LUR for the treatment of adult POM. In addition, the EBD may be less invasive with shorter the operative time, less blood loss and shorter postoperative hospitalization compared with LUR. However, further multicenter studies or prospective trials studies will be still required to demonstrate definitively real benefits of the EBD. Source of Funding: None
PD40-10 RENDEZVOUS PROCEDURE TO TREAT COMPLEX URETERIC DISCONTINUITIES Giorgio Mazzon*, Marco Bolgeri, Rebecca Dale, Vimoshan Arumuham, Clare Allen, Alex Kirkham, Navin Ramachandran, Sian Allen, Daron Smith, Tim Philp, Simon Choong, London, United Kingdom INTRODUCTION AND OBJECTIVES: When a ureteric stricture occurs, minimally invasive management is usually the first line approach to get the distressed patient out of a complicated situation. In the cases of failed antegrade or retrograde approaches to inserting a ureteric stent, the rendezvous procedure might be used to increase the success rate. The Rendezvous procedure involves a Uro-Radiologist using a variety of wires and catheters antegradely down to the ureteric stricture while the Urologist approaches the ureter retrogradely to visualize and attempt to straighten the stricture and to aid passage of the guidewire across the obstruction. The Urologist may need to laser through a dense ureteric stricture, laser to release a tied suture or traverse a missing section of the ureter to reach the antegrade guidewire