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Prospective Randomized Comparison of Retroperitoneoscopic vs Open Pyeloplasty With Minimal Incision: Subjective and Objective Assessment in Adults
Laparoscopy and Robotics Prospective Randomized Comparison of Retroperitoneoscopic vs Open Pyeloplasty With Minimal Incision: Subjective and Objective Assessment in Adults Manish Garg, Vishwajeet Singh, Rahul Janak Sinha, and Satya Narayan Sankhwar OBJECTIVE METHODS
RESULTS
CONCLUSION
To determine the subjective and objective outcomes of retroperitoneoscopic vs open pyeloplasty with minimal incision in a prospective randomized comparison study. In this study between August 2011 to July 2013, 30 patients underwent retroperitoneal laparoscopic pyeloplasty and 30 open pyeloplasty with minimal incision (incision length <10 cm) after randomization. The 2 groups were compared for the visual pain score on the first and second postoperative days as the primary end point of the study. Complications were recorded and graded using Dindo-modified Clavien classification of surgical complications. Success rates were evaluated by improvement in pain score and objectively by diethylene triamine penta-acetic acid renal scan and other parameters. Statistical analysis was performed with SPSS version 16.0 (IBM) with P <.05 considered statistically significant. The difference in the visual pain score (5.6 vs 3.2 on day 1; 3.8 vs 1.5 on day 2) and the diclofenac requirements (333.3 vs 178.75 mg) were statistically significant and more in the open pyeloplasty. The hospital stay and convalescence were significantly lower in retroperitoneoscopic group. Success rate was found to be 96.67% with 1 failure in each group. Two patients in retroperitoneoscopic group required conversion. Both groups showed significant improvement in pain score and drainage pattern on diethylene triamine penta-acetic acid scan with decrease in hydronephrosis on ultrasound evaluation. Although subjective and objective outcomes are equivalent in both the groups, the retroperitoneoscopic approach is associated with significantly less pain, less analgesic requirement, shorter hospital stay and short convalescence in comparison with open pyeloplasty. UROLOGY 83: 805e811, 2014. 2014 Elsevier Inc.
T
he treatment of ureteropelvic junction obstruction (UPJO) continues to develop with advancements in technology from open technique to minimally invasive procedures. Traditionally, open pyeloplasty is considered as the reference standard for UPJO with success rates of 90%-100%.1,2 The growing experience of laparoscopy has emerged as a means to minimize the morbidity of open surgery especially in ablative and reconstructive urologic procedures. Although procedures like antegrade and retrograde endopyelotomy are minimally invasive, they tend to have comparatively lower success rates with significant risk of bleeding.3 The laparoscopic techniques are increasingly used for urologic diseases and can be done via transperitoneal or
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, King George Medical University (Chhatrapati Shahuji Maharaj Medical University), Lucknow, India Reprint requests: Manish Garg, M.B.B.S., M.S., Department of Urology, King George Medical University, Lucknow, India. E-mail: [email protected] Submitted: September 30, 2013, accepted (with revisions): November 20, 2013
ª 2014 Elsevier Inc. All Rights Reserved
retroperitoneal approaches.4,5 Although preliminary reports have demonstrated the feasibility of retroperitoneal laparoscopic approach with results comparable with those with open techniques,6,7 randomized comparison has not done till now to analyze the results of open vs retroperitoneoscopic pyeloplasty in the prospective design. The present study is executed as the first prospective, randomized comparison between open pyeloplasty using minimal incision (MIP) and retroperitoneoscopic pyeloplasty and assessed the objective and subjective outcomes.
MATERIALS AND METHODS A total of 60 consecutive patients with UPJO were enrolled in this prospective study from January 2011 to July 2013. The institutional ethical approval was obtained, and it was in accordance with the Declaration of Helsinki. Patients were randomized according to computer-generated randomization table, and MIP and retroperitoneal laparoscopic pyeloplasty (RP) were done in 30 patients each. The patients with differential renal function (DRF) of less than 15%, uncorrected 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.11.024
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coagulopathy, vertebro-spinal deformity, or cardiopulmonary or respiratory compromised status were excluded from the study. All patients were explained about the minimal incision and laparoscopic pyeloplasties for the treatment of UPJO and the objectives of the present study. The patients who refused to undergo randomization or with age <18 years were excluded from the study. Apart from the clinical history, physical examination, and blood investigations, imaging studies like ultrasonography kidney, ureter and bladder (USG KUB), intravenous urography, or contrast-enhanced computerized tomography of KUB were done. Diuretic technetium-99m-ethylenedicysteine (EC) renal scan was done in all patients to assess the drainage pattern of the kidney, radiotracer washout time (T1/2) and DRF. In patients with infected hydronephrosis presented with pain or fever, percutaneous nephrostomy tube was inserted preoperatively. Seven patients were found to have associated renal pelvic or calyceal calculi at diagnosis. Two patients had horseshoe kidney with UPJO and 1 patient has crossed ectopic kidney with UPJO in the lower kidney. The primary objective of the study was to compare the pain scores on postoperative days 1 and 2 in retroperitoneoscopic and minimal incision pyeloplasty in the treatment of UPJO. Secondary objectives were to compare each of the operative techniques in terms of duration of surgery, complication rates, and postoperative convalescence and to assess the subjective and objective outcomes. Success was defined as when a patient became subjectively asymptomatic in the postoperative period, and there was no evidence of obstruction in the drainage pattern of the kidney on the renal scan in the follow-up period. There were separate retroperitoneoscopic and open surgeon, both expert in their respective approaches.
Open Technique For open pyeloplasty, lumber subcostal incision was made with incision length of <10 cm. The abdominal muscles were separated, and while the peritoneum was pushed back, retroperitoneal space was reached. Anderson-Hynes dismembered pyeloplasty was done in all patients. Antegrade double-J (DJ) stent was placed in all patients. We found the advantage of direct access to ureteropelvic junction with good exposure of pelvis and renal vessels with this extraperitoneal approach without extending the incision.
Retroperitoneoscopic Pyeloplasty Under general anesthesia, retrograde pyelography was done, and ureteric catheter was kept in place for easy identification of the ureter. The patients were placed in the lateral decubitus (kidney position) with a bridge at the flank. Open-port placement for the camera was done (10 mm) just distal and anterior to the 12th rib in midaxillary line. Blunt finger dissection and indigenous balloon dissection methods were used for creating the retroperitoneal space. Two other ports (12 and 5 mm) were placed in the posterior axillary line and the anterior axillary line above and in front of the level of iliac crest. Rest of the procedure was same as of open technique following general principles of pyeloplasty.
Postoperative Course and Care The patient was kept on intravenous fluid till the recovery of bowel sounds. Intravenous broad-spectrum antibiotic (ceftriaxone) and injection diclofenac on patient demand were 806
administered. Visual analog scale (VAS) for rating pain was recorded just before surgery, on the first and second postoperative days and 3 months after surgery. The DJ stent was removed after 6 weeks of operation under intravenous sedation and antibiotic cover. Objective parameters were evaluated by EC renal scan, serum creatinine, urine culture, and USG KUB performed at 3 months of follow-up. Subsequent follow-up of patients were done at 6 months and then annually. At each visit, apart from the history and clinical examination, serum creatinine and USG KUB were done.
Statistical Analysis Power calculation for the study was based on the primary end point of VAS at day 2 and blood loss. The sample size calculation was adjusted for the 2 primary comparisons using Bonferroni correction and a corresponding z-score for a 2-sided P value of .025. Preliminary data indicated that enrollment of 30 patients was necessary to detect difference in VAS and blood loss with a power of 95.0% using a 2-sided P value of .025. The normalcy of the data was tested by using Kolmogorov test, and the data was found to be normally distributed; therefore, the paired t test was used instead of nonparametric test. Statistical analysis was performed using unpaired t test, and preoperative to postoperative changes in variables were compared by paired t test. SPSS version 16.0 (IBM) was used, and a P value <.05 was considered statistically significant.
RESULTS A flow diagram of the study shows the randomization procedure in Figure 1, and the baseline demographic characteristics of patients are presented in Table 1. A total of 60 patients were eligible for the study. All patients underwent Anderson-Hynes dismembered pyeloplasty using minimal incision technique or retroperitoneal laparoscopic approach after randomization. Both groups are comparable with respect to number of patients, age, sex, and other baseline parameters. The mean operating time in MIP was 124 24.4 minutes vs 135.6 27.7 minutes in RP group (Table 2). Operating time includes from port insertion to port closure in retroperitoneoscopic group. The mean blood loss was 64.84 24.65 mL in MIP and 56.32 18.43 mL in RP group (Table 2). None of the patients required blood transfusion. Mean VAS on postoperative day 1 was 5.6 1.8 in MIP vs 3.2 1.5 in RP group and on second postoperative day, mean VAS was 3.8 1.6 in MIP vs 1.5 1.1 in RP group (Table 2). Patients in RP group required significantly less analgesic in comparison with MIP group. Complications were recorded and graded using Dindo-modified Clavien classification of surgical complications (Table 3). The overall complications were 10% in MIP vs 13.33% in RP group. No major complications occurred during or after the surgery, except 2 patients developed excessive drainage. Excessive urinary leakage in 1 patient in MIP group disappeared itself on the sixth postoperative day. Another patient in RP group had persistent high drain output, which on evaluation was because of a blocked DJ stent. The patient was managed by the change of DJ catheter. Two patients in MIP group and 1 patient in RP group UROLOGY 83 (4), 2014
Assessed for eligibility for pyeloplasty (n=71)
Excluded (n=11) (n=3 )
Randomized (n=60)
Underwent MIP (n= 30)
Underwent RP (n= 30) 2 conversions to open surgery
Follow-Up Lost to follow-up (n=0)
Lost to follow-up (n=0)
Analysis Analysed (n=30)
Analysed (n=30)
Figure 1. Flow chart of the study. (Color version available online.)
Table 1. Baseline demographic characteristics of the patients Variables Age (y), mean SD Male/female Right/left side of involvement Symptoms Lumbar pain Lump Asymptomatic Patients with associated stones Patients with preoperative PCN Patients with comorbidity DM HT Patients with associated anomalies Horseshoe kidney Crossed ectopia with UPJO in lower moiety H/O previous ipsilateral pyeloplasty
MIP Group (n ¼ 30)
RP Group (n ¼ 30)
P Value
23.47 10.26 17/13 13/17
27.27 9.3 15/15 09/21
.14* .60y .28y
18 9 3 3 2
23 5 2 4 1
e 1
1 2
1 e 1
1 1
.22z .68 .55 .50 1.00 NA
DM, diabetes mellitus; HT, hypertension; H/O, history of; MIP, open pyeloplasty using minimal incision; NA, not applicable; PCN, pancreatic cystic neoplasms; RP, retroperitoneal laparoscopic pyeloplasty; SD, standard deviation; UPJO, ureteropelvic junction obstruction. * Unpaired t test. y Chi-square test. z Chi-square for trend.
developed postoperative febrile urinary tract infection, managed by culture-specific antibiotics. In 16 patients (26.67%), anterior crossing vessels were encountered and preserved during ureteropelvic junction reconstruction. Intraoperatively, 2 patients required conversions from retroperitoneal laparoscopic to open surgery. One of these patients had a history of infection and percutaneous nephrostomy tube insertion 1 year back. Another patient developed CO2 retention and intraoperative bradycardia. UROLOGY 83 (4), 2014
The mean hospital stay was 6.2 2.36 days in MIP vs 5.03 1.7 days in RP group (Table 2). The DJ stent was removed 6 weeks postoperatively under local anesthesia and sedation. In 7 patients, concomitant calyceal stones were successfully removed, and no recurrence of renal calculi was noted till the last follow-up. The overall success rate was 96.67% with 1 failure in each group. Two patients, 1 in each group, developed pain after DJ stent removal with development of a renal 807
Table 2. Perioperative and postoperative parameters Variables
MIP Group
Operative time (min), mean SD Mean SD VAS on day 1 Mean SD VAS on day 2 Mean diclofenac requirement (mg) Patients with crossing vessels Blood loss (mL), mean SD Mean Hb in postoperative period Days of drain removal, mean SD Mean oral intake (d) Hospital stay (d), mean SD Median follow-up (mo) Overall complications (%) Overall Success rate (%)
0.57 1.8 1.6 85.91 7 64.84 24.65 9.83 0.8 3.9 1.15 2.57 0.73 6.2 2.36 12.7 10 96.67
2.05 5.6 3.8 333.3
RP Group
P Value
0.69 1.5 1.1 79.81 9 56.32 18.43 9.79 0.89 2.7 1.4 1.8 0.66 5.03 1.7 13.3 13.33 96.67
.06* .001* .001* .001* .55y .13* .84* .0007* .0001* .028* .78* .08y .18y
2.37 3.2 1.5 178.75
Hb, hemoglobin; VAS, visual analog scale; other abbreviations as in Table 1. * Unpaired t test. y Chi-square test.
Table 3. Postoperative complications by Dindo-modified Clavien classification of surgical complications Clavien Grading I II II IIIa IIIb
Complication Surgical emphysema Prolonged drain output (conservative) Febrile UTI Hypotension Blocked DJ stent with high drain output with fever Reintervention Endopyelotomy-redo open
MIP RP Group Group P Value 1
NA NA
2 e
1 1 1
.55 NA NA
1 e
e 1
NA
1
DJ, double J; UTI, urinary tract infection; other abbreviations as in Table 1.
lump. DJ stent was reinserted and again kept for 2 months. But the symptoms reappeared after stent removal. Ultrasonography and EC renal scan confirmed gross hydronephrosis, and renal scan was suggestive of an obstructed drainage pattern. Both the patients underwent open pyeloplasty and were asymptomatic till the last follow-up period. The median follow-up period in the present study was 12.7 months in minimal incision and 13.3 months in RP group, respectively (Table 2). All patients were symptom-free during the follow-up period. Mean VAS preoperatively was 3.43 0.97 and 3.2 0.89 in MIP and RP group and was 0.97 0.96 and 0.83 1.0, respectively, at 3 months after surgery showing significant improvement in pain scores in both groups. Most patients had grade III or IV hydronephrosis on ultrasound before surgical intervention. Postoperative renal ultrasound demonstrated decrease or complete resolution of hydronephrosis in almost all the patients at 6 months. The follow-up EC scan was suggestive of significant improvement in drainage in comparison with previous scans. Preoperatively, the time to reach peak in EC renogram curve showed rising curve in all patients on the symptomatic side, whereas, postoperatively, the time to reach peak was decreased to 5.6 3.6 minutes (range, 808
2.12-7.0 minutes) in MIP and 3.84 1.6 minutes (range, 2.36-16.11 minutes) in RP group, respectively (Table 4). Forty-three patients presented with T1/2 of 20 minutes or higher in preoperative diuretic renal scan. In the rest of the patients, T1/2 could not be commented due to poor function and drainage. Although preoperative mean T1/2 was 23.31 5.3 minutes in MIP group and 19.35 5.1 in RP group, postoperative mean halftime decreased to 10.31 4.0 minutes and 8.6 2.5 minutes, respectively, at 3 months. Mean preoperative DRF on EC scan was 31.83 7.74% in MIP and 35.34 13.4% in RP group, and it was improved to 33.28 7.9% and 38 14.16% in MIP and RP groups, respectively, in the follow-up renal scan (Table 4).
COMMENT Technological advances have significantly improved both the diagnostic and therapeutic alternatives available in the contemporary management of upper urinary tract obstruction. Open pyeloplasty, originally described by Foley in 1937 and modified by Anderson and Hynes, remains the reference standard, with which all other treatment modalities are compared.8 A significant postoperative pain and a long recovery time with incision site scar are the major disadvantages of the open pyeloplasty. Many minimally invasive approaches come into limelight to minimize the drawbacks of open pyeloplasty, which include endopyelotomies by antegrade or retrograde route, Acucise endopyelotomy (Applied Medical), balloon dilation techniques, laparoscopic pyeloplasty, or more recently robotic pyeloplasties.9 However, with the exception of laparoscopic and robotic pyeloplasties, these must be measured against the lower success rates (61%-89%) with significant risk of bleeding compared with open pyeloplasty.10-12 Laparoscopic pyeloplasty as a treatment option for the UPJO combines the advantage of an open reconstruction under direct magnified vision with the low morbidity of an endoscopic approach.1,13,14 Schuessler et al15 described the first transperitoneal access in 1993, and the initial retroperitoneoscopic approach to pyeloplasty UROLOGY 83 (4), 2014
Table 4. Comparison of preoperative and postoperative parameters Subjective Outcome
Preoperative Mean Pain Score
Postoperative Mean Pain Score at 3 mo
P Value
MIP group RP group Objective outcome MIP group RP group
3.43 0.97 3.2 0.89 Preoperative mean T1/2 (min) 23.31 5.3 19.35 5.1
0.97 0.96 0.83 1.0 Postoperative mean T1/2 (min) 10.31 4.0 8.6 2.5
.0001* .0001* P Value .0001* .0001*
Objective Outcome MIP group RP group MIP group RP group HDN Grade on USG
Preoperative %DRF
Postoperative %DRF
P Value
31.83 7.74 35.34 13.4 Preoperative serum creatinine 0.78 0.26 0.714 0.23
33.28 7.9 38 14.16 Postoperative serum creatinine 0.78 0.31 0.80 0.23
.0285* .0112* P Value .99* .21*
Minimal Incision Preoperatively (n ¼ 30)
At 3 mo (n ¼ 30)
At 6 mo (n ¼ 30)
Retroperitoneoscopic Preoperatively (n ¼ 30)
At 3 mo (n ¼ 30)
At 6 mo (n ¼ 30)
18 12
7 11 9 3
4 7 6 4 9
19 11
9 8 10 2 1
3 7 5 9 6
IV III II I No HDN
DRF, differential renal function; HDN, hydronephrosis; USG, ultrasonography; other abbreviations as in Table 1. * Paired t test.
was first reported by Janetschek et al16 in 1996. Laparoscopic pyeloplasty is reported in several series, but transperitoneal route was more commonly used approach in these studies.17 In open pyeloplasty, the standard of care consists of lumbar posterior approach rather than the transperitoneal, because it is a more anatomical direct approach, and the exposure of the renal pelvis is better.16 To our mind, the use of laparoscopic techniques should not involve a change in the surgical approach. Liapis et al18 concluded that retroperitoneoscopic route may be preferable for most upper urinary tract surgeries after analyzing the complications of retroperitoneoscopic procedures in more than 600 patients. However, laparoscopic surgery in the retroperitoneal zone requires more precise orientation, more delicate maneuvering, and a longer learning curve in comparison with transperitoneal approach.19,20 These limitations of the laparoscopic pyeloplasty can be overcome by the da Vinci Surgical Robotic System (Intuitive Surgical). The results of robotic pyeloplasty appear equivalent to that of open and laparoscopic repairs. According to a metaanalysis study, although cost and availability are the restraint factors at present, robotic pyeloplasty is a minimally invasive standard of care equivalent to laparoscopic pyeloplasty because of its precise suturing and shorter learning curve.21 Robotic-assisted dismembered pyeloplasty can also be performed efficiently by the retroperitoneal laparoscopic technique.9 Nevertheless, there are few studies that have compared the open and laparoscopic pyeloplasty techniques, but most of these studies were not randomized or actually comparative.6,22-24 Bonnard et al24 also had the view that the comparison results of retroperitoneal laparoscopic vs open pyeloplasty should be confirmed by a prospective, randomized studies. Rather most of these UROLOGY 83 (4), 2014
studies used transperitoneal than retroperitoneal approach for comparison.25,26 Also, none of these studies had assessed both subjective and objective outcomes on uniform format, nor did they use Clavien classifications for grading complications. We solely used retroperitoneal route for ureteropelvic junction reconstruction in this series. In the present study, the retroperitoneoscopic laparoscopic dismembered Anderson-Hynes pyeloplasty was done in 30 patients, and results were compared between open pyeloplasty and minimal incision after randomization. Open pyeloplasty is traditionally done by long musclecutting incision, which resulted in longer operating times and increased morbidity. We used relatively shorter muscle-splitting incision, thus, avoiding injury to subcostal neurovascular bundle, which lies between internal oblique and transversus abdominis muscles to reduce the wound-related pain and other complications. Because most patients included in the present study were adults, a mean length of 7.6 cm incision was used. While Klingler et al2 and Zhang et al6 used 23.8 9.1 and 21 cm incisions, respectively, in their comparison study of open vs laparoscopic pyeloplasty with consequent abdominal wall herniations and thromboembolism due to long incision and subsequent prolonged stay. No such complications occurred in the present study. The mean operating time in RP and MIP groups was 135.6 27.7 and 124 24.4 minutes, respectively, and no significant difference in the duration of surgery was found between 2 groups (P ¼ .06). Soulie et al9 also found the mean operating time similar in both groups (165 vs 145 minutes). Zhang et al6 in their comparative study even had less operating time in retroperitoneoscopic group as compared with open group (80 vs 120 minutes). 809
The mean blood loss in this study was 64.84 mL in MIP and 56.32 mL in RP group, which is comparable with other studies.9,21-26 The conversion rate in the present series (6.7%) is comparable with other published series (0%-9%).9,21-26 There was significant difference in pain scores between the 2 groups in postoperative period with significantly fewer requirements of analgesics. The lower pain score and the decreased consumption of postoperative analgesics allow early ambulation and resumption of oral intake in the RP group. Calvert et al27 concluded that the efficacy of laparoscopic pyeloplasty is equivalent to that of open pyeloplasty with less wound pain at 6 months. In the present study, complications were recorded and graded according to Dindo-modified Clavien classification of surgical complications. Overall complication rate was 10% in MIP and 13.33% in RP group, which is comparable with those reported in literature.9,21-26 There was no major complication occurred in our series, and most of them were managed conservatively. In our study, the success rate in RP approached to that of MIP with 1 failure in each group. Both of these patients underwent redo surgery and were asymptomatic till the last followup. Scarring in the lumber region due to previous surgery or prior nephrostomy insertion may result in difficulty in creating the retroperitoneal space and difficult dissection due to local adhesions. Thus, retroperitoneoscopic pyeloplasty might not be feasible in these cases, and open approach seems better in such conditions. Historically, success rates of retroperitoneoscopic pyeloplasty ranges from 67%-98%.28 Further studies showed that with increase in experience, overall success rate is above 95%.29 High success rates are the sheer advantage of retroperitoneoscopic pyeloplasty over other minimally invasive endoscopic techniques. We observed that retroperitoneoscopic pyeloplasty was also feasible in the anomalous kidneys. In the present study, 3 of the 60 patients had associated congenital anomalies. Retroperitoneoscopic approach was used in 2 of these patients. One patient had a horseshoe kidney with UPJO, and another had fused crossed ectopic kidney with UPJO in the lower moiety. Third patient with horseshoe kidney underwent minimal incision pyeloplasty. All these surgeries were uneventful. Patients in both groups were asymptomatic in the follow-up period with significant relief of pain. Mean VAS has significantly decreased at 3 months of followup period (P ¼ .0001). There was significant improvement in drainage pattern on follow-up EC renal scan. Although renal scan at 6 months of follow-up in 4 and 3 patients in MIP and RP groups, respectively, showed sluggish but nonobstructed drainage, they were completely asymptomatic. Mean T1/2 was more than 20 minutes in most patients, preoperatively. Significant decrease in halftime was observed postoperatively at 3 months renal scan and reached at nonobstructed level in both groups (P ¼ .0001). Mean DRF on follow-up EC scan showed improvement in 810
differential function in comparison with the previous scan. The present study was limited by relatively small number of patients when considering each group, and further studies are required to comment on long-term success. In this series, the retroperitoneoscopic pyeloplasty was done by the expert surgeon. Definitely, transperitoneal laparoscopic approach has less learning curve compared with retroperitoneoscopic pyeloplasty, and many centers still need to use the retroperitoneoscopic approach.
CONCLUSION Excellent subjective and objective outcomes can be achieved through both minimal incision and retroperitoneoscopic pyeloplasty in experienced hands with an acceptable operating time. Retroperitoneoscopic approach is associated with lower pain scores, better cosmesis, and early convalescence in comparison with open technique but relatively a difficult procedure with steep learning curve. References 1. O’Reilly PH, Brooman PJ, Mak S. The long-term results of Anderson-Hynes pyeloplasty. BJU Int. 2001;87:287-289. 2. Klingler HC, Remzi M, Janetschek G. Comparison of open versus laparoscopic pyeloplasty: techniques in treatment of uretero-pelvic junction obstruction. Eur Urol. 2003;44:340-345. 3. Baldwin DD, Dunbar JA, Wells N, et al. Single-center comparison of laparoscopic pyeloplasty, Acucise endopyelotomy, and open pyeloplasty. J Endourol. 2003;17:155-160. 4. Madi R, Roberts WW, Wolf JS Jr. Late failures after laparoscopic pyeloplasty. Urology. 2008;71:677-681. 5. Hafron J, Kaouk JH. Technical advances in urological laparoscopic surgery. Expert Rev Med Devices. 2008;5:145-151. 6. Zhang X, Li HZ, Ma X, et al. Retrospective comparison of retroperitoneal laparoscopic versus open dismembered pyeloplasty for ureteropelvic junction obstruction. J Urol. 2006 Sep;176: 1077-1080. 7. Moalic R, Pacheco P, Pages A, et al. Retroperitoneal laparoscopic pyeloplasty: retrospective study of 45 consecutive adult cases. Prog Urol. 2006 Sep;16:439-444. 8. Persky L, Kraurse JR, Boltuch RL. Initial complications and late results in dismembered pyeloplasty. J Urol. 1977;118:162-165. 9. Kaouk JH, Hafron J, Parekattil S, et al. Is retroperitoneal approach feasible for robotic dismembered pyeloplasty: initial experience and long-term results. J Endourol. 2008;22:2153-2159. 10. Faerber GJ, Richardson TD, Farah N, et al. Retrograde treatment of ureteropelvic junction obstruction using the ureteral cutting balloon catheter. J Urol. 1997;157:454-458. 11. Sampaio FJ. Vascular anatomy at the ureteropelvic junction. Urol Clin North Am. 1998 May;25:251-258. 12. Brooks JD, Kavoussi LR, Preminger GM, et al. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology. 1995 Dec;46:791-795. 13. Bryant RJ, Craig E, Oakley N. Laparoscopic pyeloplasty: the retroperitoneal approach is suitable for establishing a de novo practice. J Postgrad Med. 2008;54:263-267. 14. 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. 2002;42: 268-275. 15. Schuessler WW, Grune MT, Tecuanhuey LV, et al. Laparoscopic dismembered pyeloplasty. J Urol. 1993;150:1795-1799.
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16. Janetschek G, Peschel R, Altarac S, et al. Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction. Urology. 1996;47:311-316. 17. Inagaki T, Rha KH, Ong AM, et al. Laparoscopic pyeloplasty: current status. BJU Int. 2005;95(suppl 2):102-105. 18. Liapis D, Taille AD, Ploussard G, et al. Analysis of complications from 600 retroperitoneoscopic procedures of the upper urinary tract during the last 10 years. World J Urol. 2008;26:523-530. 19. Coptcoat MJ. Overview of extraperitoneal laparoscopy. Endosc Surg Allied Technol. 1995;3:1-2. 20. Davenport K, Minervini A, Timoney AG, et al. Our experience with retroperitoneal and transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction obstruction. Eur Urol. 2005;48:973-977. 21. Autorino R, Eden C, El-Ghoneimi A, et al. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis. Eur Urol. 2014;65:430-452. 22. Soulie M, Thoulouzan M, Seguin P, et al. Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches. Urology. 2001 Mar;57:443-447. 23. Wu JT, Gao ZL, Shi L, et al. Small incision combined with laparoscopy for ureteropelvic junction obstruction: comparison with
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retroperitoneal laparoscopic pyeloplasty. Chin Med J (Engl). 2009 Nov 20;122:2728-2732. Bonnard A, Fouquet V, Carricaburu E, et al. Retroperitoneal laparoscopic versus open pyeloplasty in children. J Urol. 2005 May; 173:1710-1713; discussion 1713. Bansal P, Gupta A, Mongha R, et al. Laparoscopic versus open pyeloplasty: comparison of two surgical approaches- a single centre experience of three years. Indian J Surg. 2011 Aug;73:264-267. Penn HA, Gatti JM, Hoestje SM, et al. Laparoscopic versus open pyeloplasty in children: preliminary report of a prospective randomized trial. J Urol. 2010 Aug;184:690-695. Calvert RC, Morsy MM, Zelhof B, et al. Comparison of laparoscopic and open pyeloplasty in 100 patients with pelvi-ureteric junction obstruction. Surg Endosc. 2008 Feb;22:411-414. Abuanz S, Game X, Roche JB, et al. Laparoscopic pyeloplasty: comparison between retroperitoneoscopic and transperitoneal approach. Urology. 2010 Oct;76:877-881. Martina GR, Verze P, Giummelli P, et al. A single institute’s experience in retroperitoneal laparoscopic dismembered pyeloplasty: results with 86 consecutive patients. J Endourol. 2011 Jun;25: 999-1003.
811
RESULTS
CONCLUSION
To determine the subjective and objective outcomes of retroperitoneoscopic vs open pyeloplasty with minimal incision in a prospective randomized comparison study. In this study between August 2011 to July 2013, 30 patients underwent retroperitoneal laparoscopic pyeloplasty and 30 open pyeloplasty with minimal incision (incision length <10 cm) after randomization. The 2 groups were compared for the visual pain score on the first and second postoperative days as the primary end point of the study. Complications were recorded and graded using Dindo-modified Clavien classification of surgical complications. Success rates were evaluated by improvement in pain score and objectively by diethylene triamine penta-acetic acid renal scan and other parameters. Statistical analysis was performed with SPSS version 16.0 (IBM) with P <.05 considered statistically significant. The difference in the visual pain score (5.6 vs 3.2 on day 1; 3.8 vs 1.5 on day 2) and the diclofenac requirements (333.3 vs 178.75 mg) were statistically significant and more in the open pyeloplasty. The hospital stay and convalescence were significantly lower in retroperitoneoscopic group. Success rate was found to be 96.67% with 1 failure in each group. Two patients in retroperitoneoscopic group required conversion. Both groups showed significant improvement in pain score and drainage pattern on diethylene triamine penta-acetic acid scan with decrease in hydronephrosis on ultrasound evaluation. Although subjective and objective outcomes are equivalent in both the groups, the retroperitoneoscopic approach is associated with significantly less pain, less analgesic requirement, shorter hospital stay and short convalescence in comparison with open pyeloplasty. UROLOGY 83: 805e811, 2014. 2014 Elsevier Inc.
T
he treatment of ureteropelvic junction obstruction (UPJO) continues to develop with advancements in technology from open technique to minimally invasive procedures. Traditionally, open pyeloplasty is considered as the reference standard for UPJO with success rates of 90%-100%.1,2 The growing experience of laparoscopy has emerged as a means to minimize the morbidity of open surgery especially in ablative and reconstructive urologic procedures. Although procedures like antegrade and retrograde endopyelotomy are minimally invasive, they tend to have comparatively lower success rates with significant risk of bleeding.3 The laparoscopic techniques are increasingly used for urologic diseases and can be done via transperitoneal or
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, King George Medical University (Chhatrapati Shahuji Maharaj Medical University), Lucknow, India Reprint requests: Manish Garg, M.B.B.S., M.S., Department of Urology, King George Medical University, Lucknow, India. E-mail: [email protected] Submitted: September 30, 2013, accepted (with revisions): November 20, 2013
ª 2014 Elsevier Inc. All Rights Reserved
retroperitoneal approaches.4,5 Although preliminary reports have demonstrated the feasibility of retroperitoneal laparoscopic approach with results comparable with those with open techniques,6,7 randomized comparison has not done till now to analyze the results of open vs retroperitoneoscopic pyeloplasty in the prospective design. The present study is executed as the first prospective, randomized comparison between open pyeloplasty using minimal incision (MIP) and retroperitoneoscopic pyeloplasty and assessed the objective and subjective outcomes.
MATERIALS AND METHODS A total of 60 consecutive patients with UPJO were enrolled in this prospective study from January 2011 to July 2013. The institutional ethical approval was obtained, and it was in accordance with the Declaration of Helsinki. Patients were randomized according to computer-generated randomization table, and MIP and retroperitoneal laparoscopic pyeloplasty (RP) were done in 30 patients each. The patients with differential renal function (DRF) of less than 15%, uncorrected 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.11.024
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coagulopathy, vertebro-spinal deformity, or cardiopulmonary or respiratory compromised status were excluded from the study. All patients were explained about the minimal incision and laparoscopic pyeloplasties for the treatment of UPJO and the objectives of the present study. The patients who refused to undergo randomization or with age <18 years were excluded from the study. Apart from the clinical history, physical examination, and blood investigations, imaging studies like ultrasonography kidney, ureter and bladder (USG KUB), intravenous urography, or contrast-enhanced computerized tomography of KUB were done. Diuretic technetium-99m-ethylenedicysteine (EC) renal scan was done in all patients to assess the drainage pattern of the kidney, radiotracer washout time (T1/2) and DRF. In patients with infected hydronephrosis presented with pain or fever, percutaneous nephrostomy tube was inserted preoperatively. Seven patients were found to have associated renal pelvic or calyceal calculi at diagnosis. Two patients had horseshoe kidney with UPJO and 1 patient has crossed ectopic kidney with UPJO in the lower kidney. The primary objective of the study was to compare the pain scores on postoperative days 1 and 2 in retroperitoneoscopic and minimal incision pyeloplasty in the treatment of UPJO. Secondary objectives were to compare each of the operative techniques in terms of duration of surgery, complication rates, and postoperative convalescence and to assess the subjective and objective outcomes. Success was defined as when a patient became subjectively asymptomatic in the postoperative period, and there was no evidence of obstruction in the drainage pattern of the kidney on the renal scan in the follow-up period. There were separate retroperitoneoscopic and open surgeon, both expert in their respective approaches.
Open Technique For open pyeloplasty, lumber subcostal incision was made with incision length of <10 cm. The abdominal muscles were separated, and while the peritoneum was pushed back, retroperitoneal space was reached. Anderson-Hynes dismembered pyeloplasty was done in all patients. Antegrade double-J (DJ) stent was placed in all patients. We found the advantage of direct access to ureteropelvic junction with good exposure of pelvis and renal vessels with this extraperitoneal approach without extending the incision.
Retroperitoneoscopic Pyeloplasty Under general anesthesia, retrograde pyelography was done, and ureteric catheter was kept in place for easy identification of the ureter. The patients were placed in the lateral decubitus (kidney position) with a bridge at the flank. Open-port placement for the camera was done (10 mm) just distal and anterior to the 12th rib in midaxillary line. Blunt finger dissection and indigenous balloon dissection methods were used for creating the retroperitoneal space. Two other ports (12 and 5 mm) were placed in the posterior axillary line and the anterior axillary line above and in front of the level of iliac crest. Rest of the procedure was same as of open technique following general principles of pyeloplasty.
Postoperative Course and Care The patient was kept on intravenous fluid till the recovery of bowel sounds. Intravenous broad-spectrum antibiotic (ceftriaxone) and injection diclofenac on patient demand were 806
administered. Visual analog scale (VAS) for rating pain was recorded just before surgery, on the first and second postoperative days and 3 months after surgery. The DJ stent was removed after 6 weeks of operation under intravenous sedation and antibiotic cover. Objective parameters were evaluated by EC renal scan, serum creatinine, urine culture, and USG KUB performed at 3 months of follow-up. Subsequent follow-up of patients were done at 6 months and then annually. At each visit, apart from the history and clinical examination, serum creatinine and USG KUB were done.
Statistical Analysis Power calculation for the study was based on the primary end point of VAS at day 2 and blood loss. The sample size calculation was adjusted for the 2 primary comparisons using Bonferroni correction and a corresponding z-score for a 2-sided P value of .025. Preliminary data indicated that enrollment of 30 patients was necessary to detect difference in VAS and blood loss with a power of 95.0% using a 2-sided P value of .025. The normalcy of the data was tested by using Kolmogorov test, and the data was found to be normally distributed; therefore, the paired t test was used instead of nonparametric test. Statistical analysis was performed using unpaired t test, and preoperative to postoperative changes in variables were compared by paired t test. SPSS version 16.0 (IBM) was used, and a P value <.05 was considered statistically significant.
RESULTS A flow diagram of the study shows the randomization procedure in Figure 1, and the baseline demographic characteristics of patients are presented in Table 1. A total of 60 patients were eligible for the study. All patients underwent Anderson-Hynes dismembered pyeloplasty using minimal incision technique or retroperitoneal laparoscopic approach after randomization. Both groups are comparable with respect to number of patients, age, sex, and other baseline parameters. The mean operating time in MIP was 124 24.4 minutes vs 135.6 27.7 minutes in RP group (Table 2). Operating time includes from port insertion to port closure in retroperitoneoscopic group. The mean blood loss was 64.84 24.65 mL in MIP and 56.32 18.43 mL in RP group (Table 2). None of the patients required blood transfusion. Mean VAS on postoperative day 1 was 5.6 1.8 in MIP vs 3.2 1.5 in RP group and on second postoperative day, mean VAS was 3.8 1.6 in MIP vs 1.5 1.1 in RP group (Table 2). Patients in RP group required significantly less analgesic in comparison with MIP group. Complications were recorded and graded using Dindo-modified Clavien classification of surgical complications (Table 3). The overall complications were 10% in MIP vs 13.33% in RP group. No major complications occurred during or after the surgery, except 2 patients developed excessive drainage. Excessive urinary leakage in 1 patient in MIP group disappeared itself on the sixth postoperative day. Another patient in RP group had persistent high drain output, which on evaluation was because of a blocked DJ stent. The patient was managed by the change of DJ catheter. Two patients in MIP group and 1 patient in RP group UROLOGY 83 (4), 2014
Assessed for eligibility for pyeloplasty (n=71)
Excluded (n=11) (n=3 )
Randomized (n=60)
Underwent MIP (n= 30)
Underwent RP (n= 30) 2 conversions to open surgery
Follow-Up Lost to follow-up (n=0)
Lost to follow-up (n=0)
Analysis Analysed (n=30)
Analysed (n=30)
Figure 1. Flow chart of the study. (Color version available online.)
Table 1. Baseline demographic characteristics of the patients Variables Age (y), mean SD Male/female Right/left side of involvement Symptoms Lumbar pain Lump Asymptomatic Patients with associated stones Patients with preoperative PCN Patients with comorbidity DM HT Patients with associated anomalies Horseshoe kidney Crossed ectopia with UPJO in lower moiety H/O previous ipsilateral pyeloplasty
MIP Group (n ¼ 30)
RP Group (n ¼ 30)
P Value
23.47 10.26 17/13 13/17
27.27 9.3 15/15 09/21
.14* .60y .28y
18 9 3 3 2
23 5 2 4 1
e 1
1 2
1 e 1
1 1
.22z .68 .55 .50 1.00 NA
DM, diabetes mellitus; HT, hypertension; H/O, history of; MIP, open pyeloplasty using minimal incision; NA, not applicable; PCN, pancreatic cystic neoplasms; RP, retroperitoneal laparoscopic pyeloplasty; SD, standard deviation; UPJO, ureteropelvic junction obstruction. * Unpaired t test. y Chi-square test. z Chi-square for trend.
developed postoperative febrile urinary tract infection, managed by culture-specific antibiotics. In 16 patients (26.67%), anterior crossing vessels were encountered and preserved during ureteropelvic junction reconstruction. Intraoperatively, 2 patients required conversions from retroperitoneal laparoscopic to open surgery. One of these patients had a history of infection and percutaneous nephrostomy tube insertion 1 year back. Another patient developed CO2 retention and intraoperative bradycardia. UROLOGY 83 (4), 2014
The mean hospital stay was 6.2 2.36 days in MIP vs 5.03 1.7 days in RP group (Table 2). The DJ stent was removed 6 weeks postoperatively under local anesthesia and sedation. In 7 patients, concomitant calyceal stones were successfully removed, and no recurrence of renal calculi was noted till the last follow-up. The overall success rate was 96.67% with 1 failure in each group. Two patients, 1 in each group, developed pain after DJ stent removal with development of a renal 807
Table 2. Perioperative and postoperative parameters Variables
MIP Group
Operative time (min), mean SD Mean SD VAS on day 1 Mean SD VAS on day 2 Mean diclofenac requirement (mg) Patients with crossing vessels Blood loss (mL), mean SD Mean Hb in postoperative period Days of drain removal, mean SD Mean oral intake (d) Hospital stay (d), mean SD Median follow-up (mo) Overall complications (%) Overall Success rate (%)
0.57 1.8 1.6 85.91 7 64.84 24.65 9.83 0.8 3.9 1.15 2.57 0.73 6.2 2.36 12.7 10 96.67
2.05 5.6 3.8 333.3
RP Group
P Value
0.69 1.5 1.1 79.81 9 56.32 18.43 9.79 0.89 2.7 1.4 1.8 0.66 5.03 1.7 13.3 13.33 96.67
.06* .001* .001* .001* .55y .13* .84* .0007* .0001* .028* .78* .08y .18y
2.37 3.2 1.5 178.75
Hb, hemoglobin; VAS, visual analog scale; other abbreviations as in Table 1. * Unpaired t test. y Chi-square test.
Table 3. Postoperative complications by Dindo-modified Clavien classification of surgical complications Clavien Grading I II II IIIa IIIb
Complication Surgical emphysema Prolonged drain output (conservative) Febrile UTI Hypotension Blocked DJ stent with high drain output with fever Reintervention Endopyelotomy-redo open
MIP RP Group Group P Value 1
NA NA
2 e
1 1 1
.55 NA NA
1 e
e 1
NA
1
DJ, double J; UTI, urinary tract infection; other abbreviations as in Table 1.
lump. DJ stent was reinserted and again kept for 2 months. But the symptoms reappeared after stent removal. Ultrasonography and EC renal scan confirmed gross hydronephrosis, and renal scan was suggestive of an obstructed drainage pattern. Both the patients underwent open pyeloplasty and were asymptomatic till the last follow-up period. The median follow-up period in the present study was 12.7 months in minimal incision and 13.3 months in RP group, respectively (Table 2). All patients were symptom-free during the follow-up period. Mean VAS preoperatively was 3.43 0.97 and 3.2 0.89 in MIP and RP group and was 0.97 0.96 and 0.83 1.0, respectively, at 3 months after surgery showing significant improvement in pain scores in both groups. Most patients had grade III or IV hydronephrosis on ultrasound before surgical intervention. Postoperative renal ultrasound demonstrated decrease or complete resolution of hydronephrosis in almost all the patients at 6 months. The follow-up EC scan was suggestive of significant improvement in drainage in comparison with previous scans. Preoperatively, the time to reach peak in EC renogram curve showed rising curve in all patients on the symptomatic side, whereas, postoperatively, the time to reach peak was decreased to 5.6 3.6 minutes (range, 808
2.12-7.0 minutes) in MIP and 3.84 1.6 minutes (range, 2.36-16.11 minutes) in RP group, respectively (Table 4). Forty-three patients presented with T1/2 of 20 minutes or higher in preoperative diuretic renal scan. In the rest of the patients, T1/2 could not be commented due to poor function and drainage. Although preoperative mean T1/2 was 23.31 5.3 minutes in MIP group and 19.35 5.1 in RP group, postoperative mean halftime decreased to 10.31 4.0 minutes and 8.6 2.5 minutes, respectively, at 3 months. Mean preoperative DRF on EC scan was 31.83 7.74% in MIP and 35.34 13.4% in RP group, and it was improved to 33.28 7.9% and 38 14.16% in MIP and RP groups, respectively, in the follow-up renal scan (Table 4).
COMMENT Technological advances have significantly improved both the diagnostic and therapeutic alternatives available in the contemporary management of upper urinary tract obstruction. Open pyeloplasty, originally described by Foley in 1937 and modified by Anderson and Hynes, remains the reference standard, with which all other treatment modalities are compared.8 A significant postoperative pain and a long recovery time with incision site scar are the major disadvantages of the open pyeloplasty. Many minimally invasive approaches come into limelight to minimize the drawbacks of open pyeloplasty, which include endopyelotomies by antegrade or retrograde route, Acucise endopyelotomy (Applied Medical), balloon dilation techniques, laparoscopic pyeloplasty, or more recently robotic pyeloplasties.9 However, with the exception of laparoscopic and robotic pyeloplasties, these must be measured against the lower success rates (61%-89%) with significant risk of bleeding compared with open pyeloplasty.10-12 Laparoscopic pyeloplasty as a treatment option for the UPJO combines the advantage of an open reconstruction under direct magnified vision with the low morbidity of an endoscopic approach.1,13,14 Schuessler et al15 described the first transperitoneal access in 1993, and the initial retroperitoneoscopic approach to pyeloplasty UROLOGY 83 (4), 2014
Table 4. Comparison of preoperative and postoperative parameters Subjective Outcome
Preoperative Mean Pain Score
Postoperative Mean Pain Score at 3 mo
P Value
MIP group RP group Objective outcome MIP group RP group
3.43 0.97 3.2 0.89 Preoperative mean T1/2 (min) 23.31 5.3 19.35 5.1
0.97 0.96 0.83 1.0 Postoperative mean T1/2 (min) 10.31 4.0 8.6 2.5
.0001* .0001* P Value .0001* .0001*
Objective Outcome MIP group RP group MIP group RP group HDN Grade on USG
Preoperative %DRF
Postoperative %DRF
P Value
31.83 7.74 35.34 13.4 Preoperative serum creatinine 0.78 0.26 0.714 0.23
33.28 7.9 38 14.16 Postoperative serum creatinine 0.78 0.31 0.80 0.23
.0285* .0112* P Value .99* .21*
Minimal Incision Preoperatively (n ¼ 30)
At 3 mo (n ¼ 30)
At 6 mo (n ¼ 30)
Retroperitoneoscopic Preoperatively (n ¼ 30)
At 3 mo (n ¼ 30)
At 6 mo (n ¼ 30)
18 12
7 11 9 3
4 7 6 4 9
19 11
9 8 10 2 1
3 7 5 9 6
IV III II I No HDN
DRF, differential renal function; HDN, hydronephrosis; USG, ultrasonography; other abbreviations as in Table 1. * Paired t test.
was first reported by Janetschek et al16 in 1996. Laparoscopic pyeloplasty is reported in several series, but transperitoneal route was more commonly used approach in these studies.17 In open pyeloplasty, the standard of care consists of lumbar posterior approach rather than the transperitoneal, because it is a more anatomical direct approach, and the exposure of the renal pelvis is better.16 To our mind, the use of laparoscopic techniques should not involve a change in the surgical approach. Liapis et al18 concluded that retroperitoneoscopic route may be preferable for most upper urinary tract surgeries after analyzing the complications of retroperitoneoscopic procedures in more than 600 patients. However, laparoscopic surgery in the retroperitoneal zone requires more precise orientation, more delicate maneuvering, and a longer learning curve in comparison with transperitoneal approach.19,20 These limitations of the laparoscopic pyeloplasty can be overcome by the da Vinci Surgical Robotic System (Intuitive Surgical). The results of robotic pyeloplasty appear equivalent to that of open and laparoscopic repairs. According to a metaanalysis study, although cost and availability are the restraint factors at present, robotic pyeloplasty is a minimally invasive standard of care equivalent to laparoscopic pyeloplasty because of its precise suturing and shorter learning curve.21 Robotic-assisted dismembered pyeloplasty can also be performed efficiently by the retroperitoneal laparoscopic technique.9 Nevertheless, there are few studies that have compared the open and laparoscopic pyeloplasty techniques, but most of these studies were not randomized or actually comparative.6,22-24 Bonnard et al24 also had the view that the comparison results of retroperitoneal laparoscopic vs open pyeloplasty should be confirmed by a prospective, randomized studies. Rather most of these UROLOGY 83 (4), 2014
studies used transperitoneal than retroperitoneal approach for comparison.25,26 Also, none of these studies had assessed both subjective and objective outcomes on uniform format, nor did they use Clavien classifications for grading complications. We solely used retroperitoneal route for ureteropelvic junction reconstruction in this series. In the present study, the retroperitoneoscopic laparoscopic dismembered Anderson-Hynes pyeloplasty was done in 30 patients, and results were compared between open pyeloplasty and minimal incision after randomization. Open pyeloplasty is traditionally done by long musclecutting incision, which resulted in longer operating times and increased morbidity. We used relatively shorter muscle-splitting incision, thus, avoiding injury to subcostal neurovascular bundle, which lies between internal oblique and transversus abdominis muscles to reduce the wound-related pain and other complications. Because most patients included in the present study were adults, a mean length of 7.6 cm incision was used. While Klingler et al2 and Zhang et al6 used 23.8 9.1 and 21 cm incisions, respectively, in their comparison study of open vs laparoscopic pyeloplasty with consequent abdominal wall herniations and thromboembolism due to long incision and subsequent prolonged stay. No such complications occurred in the present study. The mean operating time in RP and MIP groups was 135.6 27.7 and 124 24.4 minutes, respectively, and no significant difference in the duration of surgery was found between 2 groups (P ¼ .06). Soulie et al9 also found the mean operating time similar in both groups (165 vs 145 minutes). Zhang et al6 in their comparative study even had less operating time in retroperitoneoscopic group as compared with open group (80 vs 120 minutes). 809
The mean blood loss in this study was 64.84 mL in MIP and 56.32 mL in RP group, which is comparable with other studies.9,21-26 The conversion rate in the present series (6.7%) is comparable with other published series (0%-9%).9,21-26 There was significant difference in pain scores between the 2 groups in postoperative period with significantly fewer requirements of analgesics. The lower pain score and the decreased consumption of postoperative analgesics allow early ambulation and resumption of oral intake in the RP group. Calvert et al27 concluded that the efficacy of laparoscopic pyeloplasty is equivalent to that of open pyeloplasty with less wound pain at 6 months. In the present study, complications were recorded and graded according to Dindo-modified Clavien classification of surgical complications. Overall complication rate was 10% in MIP and 13.33% in RP group, which is comparable with those reported in literature.9,21-26 There was no major complication occurred in our series, and most of them were managed conservatively. In our study, the success rate in RP approached to that of MIP with 1 failure in each group. Both of these patients underwent redo surgery and were asymptomatic till the last followup. Scarring in the lumber region due to previous surgery or prior nephrostomy insertion may result in difficulty in creating the retroperitoneal space and difficult dissection due to local adhesions. Thus, retroperitoneoscopic pyeloplasty might not be feasible in these cases, and open approach seems better in such conditions. Historically, success rates of retroperitoneoscopic pyeloplasty ranges from 67%-98%.28 Further studies showed that with increase in experience, overall success rate is above 95%.29 High success rates are the sheer advantage of retroperitoneoscopic pyeloplasty over other minimally invasive endoscopic techniques. We observed that retroperitoneoscopic pyeloplasty was also feasible in the anomalous kidneys. In the present study, 3 of the 60 patients had associated congenital anomalies. Retroperitoneoscopic approach was used in 2 of these patients. One patient had a horseshoe kidney with UPJO, and another had fused crossed ectopic kidney with UPJO in the lower moiety. Third patient with horseshoe kidney underwent minimal incision pyeloplasty. All these surgeries were uneventful. Patients in both groups were asymptomatic in the follow-up period with significant relief of pain. Mean VAS has significantly decreased at 3 months of followup period (P ¼ .0001). There was significant improvement in drainage pattern on follow-up EC renal scan. Although renal scan at 6 months of follow-up in 4 and 3 patients in MIP and RP groups, respectively, showed sluggish but nonobstructed drainage, they were completely asymptomatic. Mean T1/2 was more than 20 minutes in most patients, preoperatively. Significant decrease in halftime was observed postoperatively at 3 months renal scan and reached at nonobstructed level in both groups (P ¼ .0001). Mean DRF on follow-up EC scan showed improvement in 810
differential function in comparison with the previous scan. The present study was limited by relatively small number of patients when considering each group, and further studies are required to comment on long-term success. In this series, the retroperitoneoscopic pyeloplasty was done by the expert surgeon. Definitely, transperitoneal laparoscopic approach has less learning curve compared with retroperitoneoscopic pyeloplasty, and many centers still need to use the retroperitoneoscopic approach.
CONCLUSION Excellent subjective and objective outcomes can be achieved through both minimal incision and retroperitoneoscopic pyeloplasty in experienced hands with an acceptable operating time. Retroperitoneoscopic approach is associated with lower pain scores, better cosmesis, and early convalescence in comparison with open technique but relatively a difficult procedure with steep learning curve. References 1. O’Reilly PH, Brooman PJ, Mak S. The long-term results of Anderson-Hynes pyeloplasty. BJU Int. 2001;87:287-289. 2. Klingler HC, Remzi M, Janetschek G. Comparison of open versus laparoscopic pyeloplasty: techniques in treatment of uretero-pelvic junction obstruction. Eur Urol. 2003;44:340-345. 3. Baldwin DD, Dunbar JA, Wells N, et al. Single-center comparison of laparoscopic pyeloplasty, Acucise endopyelotomy, and open pyeloplasty. J Endourol. 2003;17:155-160. 4. Madi R, Roberts WW, Wolf JS Jr. Late failures after laparoscopic pyeloplasty. Urology. 2008;71:677-681. 5. Hafron J, Kaouk JH. Technical advances in urological laparoscopic surgery. Expert Rev Med Devices. 2008;5:145-151. 6. Zhang X, Li HZ, Ma X, et al. Retrospective comparison of retroperitoneal laparoscopic versus open dismembered pyeloplasty for ureteropelvic junction obstruction. J Urol. 2006 Sep;176: 1077-1080. 7. Moalic R, Pacheco P, Pages A, et al. Retroperitoneal laparoscopic pyeloplasty: retrospective study of 45 consecutive adult cases. Prog Urol. 2006 Sep;16:439-444. 8. Persky L, Kraurse JR, Boltuch RL. Initial complications and late results in dismembered pyeloplasty. J Urol. 1977;118:162-165. 9. Kaouk JH, Hafron J, Parekattil S, et al. Is retroperitoneal approach feasible for robotic dismembered pyeloplasty: initial experience and long-term results. J Endourol. 2008;22:2153-2159. 10. Faerber GJ, Richardson TD, Farah N, et al. Retrograde treatment of ureteropelvic junction obstruction using the ureteral cutting balloon catheter. J Urol. 1997;157:454-458. 11. Sampaio FJ. Vascular anatomy at the ureteropelvic junction. Urol Clin North Am. 1998 May;25:251-258. 12. Brooks JD, Kavoussi LR, Preminger GM, et al. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology. 1995 Dec;46:791-795. 13. Bryant RJ, Craig E, Oakley N. Laparoscopic pyeloplasty: the retroperitoneal approach is suitable for establishing a de novo practice. J Postgrad Med. 2008;54:263-267. 14. 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. 2002;42: 268-275. 15. Schuessler WW, Grune MT, Tecuanhuey LV, et al. Laparoscopic dismembered pyeloplasty. J Urol. 1993;150:1795-1799.
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16. Janetschek G, Peschel R, Altarac S, et al. Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction. Urology. 1996;47:311-316. 17. Inagaki T, Rha KH, Ong AM, et al. Laparoscopic pyeloplasty: current status. BJU Int. 2005;95(suppl 2):102-105. 18. Liapis D, Taille AD, Ploussard G, et al. Analysis of complications from 600 retroperitoneoscopic procedures of the upper urinary tract during the last 10 years. World J Urol. 2008;26:523-530. 19. Coptcoat MJ. Overview of extraperitoneal laparoscopy. Endosc Surg Allied Technol. 1995;3:1-2. 20. Davenport K, Minervini A, Timoney AG, et al. Our experience with retroperitoneal and transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction obstruction. Eur Urol. 2005;48:973-977. 21. Autorino R, Eden C, El-Ghoneimi A, et al. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis. Eur Urol. 2014;65:430-452. 22. Soulie M, Thoulouzan M, Seguin P, et al. Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches. Urology. 2001 Mar;57:443-447. 23. Wu JT, Gao ZL, Shi L, et al. Small incision combined with laparoscopy for ureteropelvic junction obstruction: comparison with
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