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Re: Failure After Laparoscopic Pyeloplasty: Prevention and Management
LAPAROSCOPY/NEW TECHNOLOGY
1715
unclear, although in light of this study resting a just activated ultrasonic energy device on the bowel or skin is not recommended. Jeffrey A. Cadeddu, M.D.
Re: Patient-Reported Body Image and Cosmesis Outcomes Following Kidney Surgery: Comparison of Laparoendoscopic Single-Site, Laparoscopic, and Open Surgery S. K. Park, E. O. Olweny, S. L. Best, C. R. Tracy, S. A. Mir and J. A. Cadeddu Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas Eur Urol 2011; 60: 1097–1104.
Background: Laparoendoscopic single-site surgery (LESS) is reported to result in superior cosmesis versus alternative surgical approaches, based solely on surgeon assessment or anecdotal evidence. Objective: Evaluate patient-reported body image and cosmesis outcomes following kidney surgery. Design, Setting, and Participants: We conducted a prospective and retrospective observational cohort study involving patients who underwent kidney surgery (n⫽114) via LESS (n⫽35), laparoscopic (n⫽52), or open (n⫽27) approaches. Cosmesis was evaluated using a comprehensive survey administered ⱖ3 mo postoperatively. Measurements: Survey components were a body image questionnaire (BIQ) consisting of body image and cosmesis subscales, a photo-series questionnaire (PSQ) assessing scar preferences after knowledge of scar outcomes for alternative surgical approaches, and query of preference for future surgical approach using a trade-off method. Body image, cosmesis, and PSQ scales ranged from 5 to 20, 3 to 24, and 1 to 10, respectively. Results and Limitations: Median BIQ component scores did not significantly differ across surgical approaches. Median ratings for the LESS, laparoscopy, and open scar photographs were 8, 5, and 5, respectively (p⫽0.0001). Before viewing photographs, median self-scar ratings for LESS, laparoscopy, and open approaches were 9, 5, and 6.5, respectively (p⫽0.02); after photographs, ratings were 9, 7, and 7, respectively (p⫽0.008). Assuming equivalent surgical risk among the approaches, overall preference for future LESS, laparoscopy, or open surgery was 39%, 33%, or 4%, respectively. As theoretical risk of LESS was raised, preference for LESS decreased, whereas preference for laparoscopy and open surgery increased. Study limitations are a nonrandomized design and the use of a nonvalidated scale. Conclusions: Urologic patients favor LESS cosmesis outcomes over those for laparoscopy or open surgery. Considering the superior scar satisfaction among LESS patients, who were younger and more likely to be undergoing surgery for benign disease, we infer that this demographic most values the cosmetic advantages of LESS. Editorial Comment: Several general surgery and gynecologic studies have demonstrated that there is a subset of patients who value and would prefer laparoendoscopic single site surgery. This is the first study to query urology patients undergoing kidney surgery with similar findings. Although its detractors argue that LESS is a gimmick, this study suggests there is a role for LESS in urology. Younger patients with benign pathology value the cosmetic advantages of LESS, and this issue should not be minimized. Jeffrey A. Cadeddu, M.D.
Re: Failure After Laparoscopic Pyeloplasty: Prevention and Management H. J. Tan, Z. Ye, W. W. Roberts and J. S. Wolf Department of Urology, Division of Endourology and Stone Disease, University of Michigan, Ann Arbor, Michigan J Endourol 2011; 25: 1457–1462.
Background and Purpose: Because of the high success of laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction, strategies for managing failures are less well described. We report our
1716
LAPAROSCOPY/NEW TECHNOLOGY
experience with persistent or recurrent obstruction after LP. Patients and Methods: We reviewed 128 patients who were treated with LP at our institution from 1996 through 2008. Success was defined as objective resolution of obstruction by renal scintigraphy, Whitaker testing, or direct visualization. We extracted data by chart review regarding patient demographics, medical history, operative technique, and salvage treatments. We then assessed for association between patient characteristics and treatment failure. Results: Overall, 102 patients had sufficient follow-up, of which 84 (82%) were successes. Of 18 failures, median time to failure was 2.5 months (0.5– 88 mos). Of 10 failures managed endoscopically, 7 were salvaged. One of two patients treated conservatively ultimately had resolution while six patients needed simple nephrectomy. Overall, 8 (44%) were salvageable with median follow-up of 19 months (4 –58 mos). Patients with failure were more likely to have diabetes mellitus, longer length of stay, higher American Society of Anesthesiologists (ASA) score, a stent placed at the time of pyeloplasty, or ureteral stent malfunction (P⬍0.05). Patients with failure despite salvage were more likely to have stent malfunction or body mass index ⬎30 kg/m(2) (P⬍0.05). Adjusting for the above factors, stent placement at time of surgery and ASA score ⬎2 were associated with failure (P⬍0.05) while periureteral fibrosis trended toward a significant association (P⫽0.061). Conclusion: Nearly half of failures after LP are salvageable, many with endoscopic management. Editorial Comment: When performing laparoscopic or robotic pyeloplasty the surgeon needs to be prepared to manage the occasional, but inevitable, failure. This study is an important contribution in this regard. It reinforces that many failures (essentially secondary ureteropelvic junction obstructions) can be salvaged endoscopically, which is my preference. Interestingly a urine leak was not a risk factor for failure, although ureteral stent malposition and stent placed at surgery were. I am not sure why a stent placed at surgery, as opposed to before, increases the chance of failure (odds ratio of 12.5!). Could it be the choice of stent diameter or length, which was not specified in this report? As do many other surgeons, I preferentially and routinely place a ureteral stent at surgery and have not found it to result in frequent stent malposition or an unacceptable failure rate. Further investigation of this issue is needed. Jeffrey A. Cadeddu, M.D.
1715
unclear, although in light of this study resting a just activated ultrasonic energy device on the bowel or skin is not recommended. Jeffrey A. Cadeddu, M.D.
Re: Patient-Reported Body Image and Cosmesis Outcomes Following Kidney Surgery: Comparison of Laparoendoscopic Single-Site, Laparoscopic, and Open Surgery S. K. Park, E. O. Olweny, S. L. Best, C. R. Tracy, S. A. Mir and J. A. Cadeddu Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas Eur Urol 2011; 60: 1097–1104.
Background: Laparoendoscopic single-site surgery (LESS) is reported to result in superior cosmesis versus alternative surgical approaches, based solely on surgeon assessment or anecdotal evidence. Objective: Evaluate patient-reported body image and cosmesis outcomes following kidney surgery. Design, Setting, and Participants: We conducted a prospective and retrospective observational cohort study involving patients who underwent kidney surgery (n⫽114) via LESS (n⫽35), laparoscopic (n⫽52), or open (n⫽27) approaches. Cosmesis was evaluated using a comprehensive survey administered ⱖ3 mo postoperatively. Measurements: Survey components were a body image questionnaire (BIQ) consisting of body image and cosmesis subscales, a photo-series questionnaire (PSQ) assessing scar preferences after knowledge of scar outcomes for alternative surgical approaches, and query of preference for future surgical approach using a trade-off method. Body image, cosmesis, and PSQ scales ranged from 5 to 20, 3 to 24, and 1 to 10, respectively. Results and Limitations: Median BIQ component scores did not significantly differ across surgical approaches. Median ratings for the LESS, laparoscopy, and open scar photographs were 8, 5, and 5, respectively (p⫽0.0001). Before viewing photographs, median self-scar ratings for LESS, laparoscopy, and open approaches were 9, 5, and 6.5, respectively (p⫽0.02); after photographs, ratings were 9, 7, and 7, respectively (p⫽0.008). Assuming equivalent surgical risk among the approaches, overall preference for future LESS, laparoscopy, or open surgery was 39%, 33%, or 4%, respectively. As theoretical risk of LESS was raised, preference for LESS decreased, whereas preference for laparoscopy and open surgery increased. Study limitations are a nonrandomized design and the use of a nonvalidated scale. Conclusions: Urologic patients favor LESS cosmesis outcomes over those for laparoscopy or open surgery. Considering the superior scar satisfaction among LESS patients, who were younger and more likely to be undergoing surgery for benign disease, we infer that this demographic most values the cosmetic advantages of LESS. Editorial Comment: Several general surgery and gynecologic studies have demonstrated that there is a subset of patients who value and would prefer laparoendoscopic single site surgery. This is the first study to query urology patients undergoing kidney surgery with similar findings. Although its detractors argue that LESS is a gimmick, this study suggests there is a role for LESS in urology. Younger patients with benign pathology value the cosmetic advantages of LESS, and this issue should not be minimized. Jeffrey A. Cadeddu, M.D.
Re: Failure After Laparoscopic Pyeloplasty: Prevention and Management H. J. Tan, Z. Ye, W. W. Roberts and J. S. Wolf Department of Urology, Division of Endourology and Stone Disease, University of Michigan, Ann Arbor, Michigan J Endourol 2011; 25: 1457–1462.
Background and Purpose: Because of the high success of laparoscopic pyeloplasty (LP) for ureteropelvic junction obstruction, strategies for managing failures are less well described. We report our
1716
LAPAROSCOPY/NEW TECHNOLOGY
experience with persistent or recurrent obstruction after LP. Patients and Methods: We reviewed 128 patients who were treated with LP at our institution from 1996 through 2008. Success was defined as objective resolution of obstruction by renal scintigraphy, Whitaker testing, or direct visualization. We extracted data by chart review regarding patient demographics, medical history, operative technique, and salvage treatments. We then assessed for association between patient characteristics and treatment failure. Results: Overall, 102 patients had sufficient follow-up, of which 84 (82%) were successes. Of 18 failures, median time to failure was 2.5 months (0.5– 88 mos). Of 10 failures managed endoscopically, 7 were salvaged. One of two patients treated conservatively ultimately had resolution while six patients needed simple nephrectomy. Overall, 8 (44%) were salvageable with median follow-up of 19 months (4 –58 mos). Patients with failure were more likely to have diabetes mellitus, longer length of stay, higher American Society of Anesthesiologists (ASA) score, a stent placed at the time of pyeloplasty, or ureteral stent malfunction (P⬍0.05). Patients with failure despite salvage were more likely to have stent malfunction or body mass index ⬎30 kg/m(2) (P⬍0.05). Adjusting for the above factors, stent placement at time of surgery and ASA score ⬎2 were associated with failure (P⬍0.05) while periureteral fibrosis trended toward a significant association (P⫽0.061). Conclusion: Nearly half of failures after LP are salvageable, many with endoscopic management. Editorial Comment: When performing laparoscopic or robotic pyeloplasty the surgeon needs to be prepared to manage the occasional, but inevitable, failure. This study is an important contribution in this regard. It reinforces that many failures (essentially secondary ureteropelvic junction obstructions) can be salvaged endoscopically, which is my preference. Interestingly a urine leak was not a risk factor for failure, although ureteral stent malposition and stent placed at surgery were. I am not sure why a stent placed at surgery, as opposed to before, increases the chance of failure (odds ratio of 12.5!). Could it be the choice of stent diameter or length, which was not specified in this report? As do many other surgeons, I preferentially and routinely place a ureteral stent at surgery and have not found it to result in frequent stent malposition or an unacceptable failure rate. Further investigation of this issue is needed. Jeffrey A. Cadeddu, M.D.