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Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches
ADULT UROLOGY CME ARTICLE
RETROPERITONEAL LAPAROSCOPIC VERSUS OPEN PYELOPLASTY WITH A MINIMAL INCISION: COMPARISON OF TWO SURGICAL APPROACHES MICHEL SOULIE´, MATHIEU THOULOUZAN, PHILIPPE SEGUIN, PATRICK MOULY, NICOLAS VAZZOLER, FRANCIS PONTONNIER, AND PIERRE PLANTE
ABSTRACT Objectives. To compare the complications, hospital stay, and functional results of retroperitoneal laparoscopic (RL) pyeloplasty versus open pyeloplasty (OP) with a minimal subcostal incision. Methods. From October 1997 to January 2000, 53 consecutive nonrandomized patients underwent 26 RL pyeloplasties, of which 1 was bilateral (group 1), and 28 OP (group 2). The decision between the two techniques depended on the patient’s anesthetic ability to tolerate RL, previous ureteropelvic junction surgery, associated renal pathologic findings, and the surgeon’s laparoscopic experience. Subjective outcomes as to postoperative pain and convalescence and objective findings on intravenous urography were assessed at 3 months postoperatively in both groups. Results. The mean operating time (165 versus 145 minutes) and mean blood loss (92 versus 84 mL) were similar in both groups. No intraoperative complications occurred in either group; in group 1, 1 patient required open conversion. Postoperative complications occurred in 11.5% of group 1 and 14.3% of group 2. The mean hospital stay was 4.5 days for group 1 and 5.5 days for group 2. At 3 months, 23 patients (92%) in group 1 and 25 (89.2%) in group 2 were pain-free or improved. Intravenous urography showed a patent ureteropelvic junction in all cases and improvement of hydronephrosis in 88.5% of group 1 and 89.3% of group 2. Conclusions. The incidence of complications, hospital stay, and functional results were equivalent for RL pyeloplasty and OP with a minimal incision, but the return to painless activity was more rapid with laparoscopy in younger patients. UROLOGY 57: 443–447, 2001. © 2001, Elsevier Science Inc.
A
mong the current surgical techniques to treat ureteropelvic junction (UPJ) obstruction, open pyeloplasty is the reference standard, with long-term success rates exceeding 90%.1–3 Since 1993, laparoscopic surgeons have continued to use the Anderson-Hynes dismembered pyeloplasty, the Foley Y-V advancement, and Fenger-plasty.4 – 8 Preliminary reports have demonstrated the feasibility of laparoscopic procedures in experienced hands, with a lower morbidity and shorter convalescence, and operative success rates comparable with those of open techniques.3–5,9 –12 In this prospective study, we compared retroperitoneal laparoscopic (RL) pyeloplasty and open pyeloplasty From the Department of Urologic Surgery and Andrology, University Hospital of Rangueil, Toulouse, France Reprint requests: Michel Soulie´, M.D., Service d’Urologie et d’Andrologie, CHU Rangueil, F-31403 Toulouse Cedex 4, France Submitted: August 11, 2000, accepted (with revisions): October 20, 2000 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
(OP) using a minimal subcostal incision with regard to operative complications, length of hospital stay, functional results on postoperative pain and return to normal activity, and radiographic outcome at 3 months. MATERIAL AND METHODS Between October 1997 and January 2000, 53 consecutive nonrandomized patients underwent 54 pyeloplasties for UPJ obstruction in our department. Group 1 consisted of 25 patients (17 women and 8 men, mean age 35.2 years, range 17 to 68) who underwent RL pyeloplasty, with one bilateral procedure. Group 2 consisted of 28 patients (16 women and 12 men, mean age 42.3 years, range 18 to 81) who underwent OP with a minimal subcostal incision. Two patients in group 2 had a secondarily obstructed UPJ after a previous percutaneous endopyelotomy at another institution. The body mass index (BMI) ⫾ SD was 21.6 ⫾ 2.2 kg/m2 in group 1 and 22.4 ⫾ 2.6 in group 2. The decision as to which of the two techniques was used depended on the patient’s anesthesic ability to tolerate RL, previous UPJ surgery, associated renal pathologic findings, 0090-4295/01/$20.00 PII S0090-4295(00)01065-7 443
and the laparoscopic expertise of the four different surgeons during the study period.
PREOPERATIVE EVALUATION All patients were symptomatic and had sterile urine and a normal bleeding profile before surgery. The diagnosis of UPJ obstruction was assessed by intravenous urography (IVU) with diuretic renogram (Lasilix), dating from less than 1 year in all cases. Each renal unit with UPJ obstruction was functional. In the RL group, no patient had associated renal pathologic findings or previous renal surgery. All the renal pelves examined on IVU were extrasinusal and dilated. Fourteen patients had left-sided and 11 had right-sided UPJ obstruction. A young woman 26 years old had bilateral symptomatic UPJ obstruction and underwent two procedures at an interval of 3 months. In the OP group, 2 patients had secondary UPJ obstruction, previously treated by antegrade endopyelotomy. The renal pelvis was dilated on IVU in 25 patients and retracted in 3 patients. Fifteen patients had left-sided and 13 right-sided UPJ obstruction. Nine patients (32%) had associated renal pathologic findings: lithiasis in 4 patients (10 and 12-mm pelvic calculi and 6 and 5-mm middle and inferior caliceal calculi), cortical benign cysts in 3 patients (40, 48, and 60 mm in size), and renal ptosis with major pelvic dilation in 2 young women. In these 2 patients, a retrograde pyelogram confirmed the UPJ obstruction. Furthermore, 5 patients had anesthesic contraindications to RL because of impaired lung function: 2 with recurrent pneumothorax, 2 with chronic obstructive pulmonary disease, and 1 with atelectasia secondary to pulmonary tuberculosis.
SURGICAL TECHNIQUES In group 1, the retroperitoneal approach to the UPJ was similar to the primary description by Gasman et al.13 for renal and adrenal surgery. We always used four trocars: two posterior 10 and 5 mm, one anterior 5 mm, and the lateral opening site 15 mm with a trocar Origin for the lens. In group 2, a short skin incision of 4 to 6 cm (mean 5) was made horizontally along an anterior axillary line below the rib cage. The abdominal muscle aponevrosis was cut, the muscles were split, and the peritoneum was pushed back. We used a Gausset retractor with a flexible blade. This anterior extraperitoneal approach allows direct access to the UPJ with good exposure of the pelvis and renal vessels. In both groups, ureteropelvic anastomosis and pelvic repair were done using 4-0 polyglycolic acid sutures. After completion of the posterior ureteropelvic anastomosis, a double pigtail stent was inserted through the pelvis to the bladder in all patients in group 2 (OP) and in the last 18 patients in group 1 (RL). Fluoroscopy showed the adequate position of the stent in the urinary tract. In the 8 early RL procedures, the stent was inserted before initiating RL pyeloplasty and the operating time included the stent insertion. A 5-mm retroperitoneal drain and Foley catheter were placed, usually for 48 hours. Prophylactic antibiotics (third-generation cephalosporin) were routinely prescribed. A regular diet was resumed on postoperative day 1. The ureteral stent was removed 4 weeks postoperatively, and IVU was performed during the following 2 months.
EVALUATION OF POSTOPERATIVE PAIN AND RADIOLOGIC OUTCOME Postoperative parenteral analgesia consisted of profacetamol and morphine sulfate equivalent during the first postoperative day and paracetamol plus dextropropoxifen from the second day on. Analgesics were discontinued after a mean of 2 444
days (range 1 to 5) according to patient requirements. No medication was prescribed after discharge. All patients were assessed at 3 months with an oral questionnaire by one physician (M.T.). They were asked to comment on their postoperative pain, time to resumption of normal activity at 1 month, and current status. Current pain was assessed in four grades: pain-free, improved, no change, or worse than preoperative pain. Preoperative and postoperative IVU were read by the same physician (M.T.). A good result on the IVU was a patent UPJ with improved hydronephrosis. When there was a persistent dilated renal pelvis or a delayed evacuation of iodine, the result was considered unsatisfactory. Two years of follow-up was planned in both groups with annual clinical examination and urinary tract ultrasound scanning.
STATISTICAL ANALYSIS The characteristics of the two groups were compared using the chi-square test and the Student t test. A P value less than 0.05 was considered statistically significant.
RESULTS In both groups, there was no significant difference in BMI. Dismembered pyeloplasty with excision of the UPJ was performed in 24 patients in group 1 and in 20 patients in group 2. The spatuled ureter was attached to the incised renal pelvis with interrupted or running sutures, as previously described.4,7 Two patients with a high ureteral insertion in group 1 and 8 in group 2 with an intrasinusal renal pelvis underwent Y-V plasty. Crossing vessels were present in 10 patients (38.5%) in group 1 and in 9 (32%) in group 2. The ureter and renal pelvis were displaced to the other side of the vessels before completion of the anastomosis. In group 2, all patients had an adequate exposure of the UPJ and none required an enlarged incision. In this group, extraction of calculi (n ⫽ 4), cyst resection (n ⫽ 3), and nephropexy (n ⫽ 2) were performed uneventfully before anastomosis confection, with a mean operating time of 12 minutes (range 5 to 20), which was included in the analysis. The mean operating time (165 versus 145 minutes), estimated blood loss (92 versus 84 mL), and hospital stay average (4.5 versus 5.5 days) in the two groups are summarized in Table I. The difference in these parameters was not significant between the RL and OP procedures. None of the patients required blood transfusion. INTRAOPERATIVE COMPLICATIONS No intraoperative complications occurred in either group, but open conversion was necessary in 1 patient (3.8%) in group 1 because marked adhesions after pyelonephritis hindered dissection of the ureter and UPJ. He underwent dismembered pyeloplasty. UROLOGY 57 (3), 2001
TABLE I. Comparison of clinical parameters in retroperitoneal laparoscopic and open pyeloplasty procedures (n ⴝ 54)*
Parameter Age (yr) Operating time (min) Blood loss (mL) Hospital stay (days)
Laparoscopic Group* (n ⴝ 26)
Open Pyeloplasty Group (n ⴝ 28)
35.2 (17–68) 165 (120–260)
42.3 (18–81) 145 (80–250)
92 (50–250) 4.5 (3–7)
84 (30–300) 5.5 (4–9)
Numbers in parentheses are the range. No significant differences were found between the two groups. * One patient had a bilateral ureteropelvic junction obstruction.
POSTOPERATIVE COMPLICATIONS In group 1, 1 case of severe pyelonephritis due to pigtail stent obstruction resolved with antibiotics, and the stent had to be removed 3 weeks postoperatively. Anemia (8.5 g/dL) due to a parietal hematoma occurred at postoperative day 6 in 1 young woman. No delayed transfusion or revision procedure was necessary. The main complication was migration of the pigtail stent below the UPJ anastomosis, identified at 3 weeks because the patient had lumbar pain. An established anastomotic stenosis was impassable endoscopically and required open end-to-end anastomosis of the renal pelvis with secondary success. In group 2, 2 cases of delayed pyelonephritis were treated with antibiotics with no need for immediate removal of the pigtail stent. Two wound infections were observed beneath the incision at 1 week and spontaneously resolved after 2 weeks with antibiotics. A comparison of the two groups showed no significant difference in the incidence of postoperative complications, with 11.5% in group 1 and 14.3% in group 2. FUNCTIONAL RESULTS The mean clinical follow-up of the series was 14.3 months (range 6 to 32), but 20 patients in group 1 and 23 in group 2 had at least 1 year of clinical follow-up. Table II summarizes the results of pain assessment in both groups, which were based on the above-mentioned four items of the questionnaire filled out at 3 months. In group 1, 23 patients (92%) were pain-free (n ⫽ 20, 80%) or improved (n ⫽ 3, 12%), and in group 2, 25 patients (89.3%) were pain-free (n ⫽ 19, 67.9%) or improved (n ⫽ 6, 21.4%). The differences between the two groups were not significant. Patients with symptomatic pain in the lumbar area did not require any medication or additional surgery. Pain at the sites of the trocars or subcostal UROLOGY 57 (3), 2001
TABLE II. Comparison of functional results of retroperitoneal laparoscopic and open pyeloplasty in the two groups of patients
Parameter Evaluation of pain Pain-free Improved No change Worse Normal activity At 1 mo At 3 mo IVU at 3 mo Patent UPJ Improved HDN
Laparoscopic Group (n ⴝ 25) 20 3 1 1
(80) (12) (4) (4)
Open Pyeloplasty Group (n ⴝ 28) 19 6 2 1
(67.9) (21.4) (7.2) (3.6)
23 (92) 25 (100)
21 (75) 25 (89.3)
25 (100) 22 (88)
28 (100) 25 (89.3)
KEY: IVU ⫽ intravenous urography; UPJ ⫽ ureteropelvic junction; HDN ⫽ hydronephrosis. Numbers in parentheses are percentages. No significant differences were found between the two groups.
incision was reported by the patient with the poorest results. Normal activity at 1 month was reported by 22 patients (88%) in group 1 and by 21 patients (75%) in group 2. At 3 months, all asymptomatic patients had resumed full activity, even the patient with bilateral UPJ in group 1 who was treated with two procedures. It was interesting to observe that 90% of the younger patients (younger than 40 years old) in group 1 and 70% of those in group 2 were able to resume normal activity (without sports) 15 days postoperatively (P ⫽ 0.14). The radiographic outcome on IVU at 3 months showed a patent UPJ in all patients in both groups, with improvement of hydronephrosis in 22 (88%) of 25 patients in group 1, including the 2 patients later treated by open pyeloplasty, and in 25 (89.3%) of 28 patients in group 2 (P ⫽ 0.7). In the other patients, a dilated renal pelvis or difficulty in evacuation of iodine persisted, but these patients were pain-free and under surveillance, with a second IVU planned during the year. At 12 months, 17 patients in group 1 (68%) and 18 in group 2 (64%) were reassessed, and no patient had an unsuccessful outcome. COMMENT OP is the reference standard for UPJ obstruction repair.1–3,11 Transperitoneal and, recently, RL pyeloplasty were developed to reproduce the success rates achieved with OP, but with lower morbidity, less postoperative pain, and a shorter convalescence.4,5,9 –12 The success rates of minimally invasive endoscopic surgery (antegrade percutaneous endopyelotomy, retrograde endopyelotomy, and 445
Acucise cutting ballon) are approximately 10% to 25% lower than those of OP or laparoscopy, and hemorrhagic complications are more frequent.14 –18 In our experience, we use these endoscopic techniques in older patients and in secondary UPJ stricture after prior pyeloplasty. Our objective was to compare pyeloplasty with RL and open approach. The short anterior incision (mean 5 cm) with muscle splitting reduces the risk of chronic pain and wound herniation. The results of this study revealed no significant difference between the two techniques in terms of morbidity, functional results, postoperative pain, or return to normal activity. Laparoscopic pyeloplasty is classified as a difficult procedure, requiring careful ureteral dissection and considerable familiarity and proficiency in intracorporeal suturing.4,11,19 However, the transperitoneal or RL approach allows UPJ repair under magnified direct vision even with a large dilated renal pelvis and lower pole crossing vessels.4,5,9,10,19 Anterior lower pole crossing vessels were encountered in 38.5% of patients in the RL group and in 32% of the OP group and were uncrossed without difficulty. Crossing vessels are recognized as a cause of failure in endoscopic procedures.5,14,18 Renal calculi can be removed at the same time during laparoscopy and secondary UPJ obstruction can be treated by laparoscopy, especially after failure of endoscopic procedures.9,12,20,21 The operating time (165 minutes) with the extraperitoneal approach was relatively short in group 1, similar to a recent series4 (178 minutes), compared with the longer operating times (mean 240 minutes) with the transperitoneal approach.6 –10 No intraoperative complications occurred and only one conversion (3.8%) was necessary because of a difficult dissection in group 1. The reported conversion rates vary from 0% to 7%.4,5,9,21 The postoperative complication rate was similar in both groups; however, in group 1, another patient required open pyeloplasty because of the delayed stenosis of the ureteropelvic anastomosis. Moore et al.10 had 2 cases of acute obstruction after stent removal, requiring a new stent and nephrostomy. Parietal hematoma and pyelonephritis due to stent obstruction were also encountered in previous reports of laparoscopic pyeloplasty and OP.2–5,14,21 The subjective outcome criterion was the comparison of postoperative pain with preoperative pain. In the present study, RL patients recovered faster and more had resumed normal activity at 3 months. Moore et al.10 and Janetschek et al.5 claimed the complete disappearance of preoperative pain; however, other investigators have been more circumspect in this regard, reporting improvement rates of 85% to 90%.9,11,21 In our 446
study, more patients who were younger than 40 years were active 15 days after RL pyeloplasty (90%) than after OP (70%), which could be expected because of the simpler parietal healing. The objective outcome on IVU at 3 months was based on the quality of the UPJ patency and decreased dilation of the renal pelvis. Despite a nonblind random reading, the results were equivalent for the physician, with a patent UPJ in all patients in both groups and an improvement in hydronephrosis in 88% and 89.3% of patients, respectively, in groups 1 and 2, in agreement with the major series of laparoscopic pyeloplasty and OP.2–5,9 –11,21 Bauer et al.11 found no significant difference in the long-term outcome between 35 OP procedures analyzed retrospectively and 42 transperitoneal laparoscopies, with overall success rates of 94% and 98%, respectively. Transperitoneal laparoscopic pyeloplasty yields a high overall success rate of 97%, with minor complications in 12% for Chen et al.9 Jarret et al.12 reported a 92% and 96% success rate, respectively, in primary and secondary UPJ repair with a 5-year experience. It is necessary to assess the long-term outcome because in rare cases, UPJ obstruction can recur 1 year or more postoperatively.10,21 The suturing technique and the functional results of RL pyeloplasty may be further improved in the future by the extensive use of robotic-assisted technology, which is beginning to be used in several urologic procedures.22 However, these advanced and appealing techniques are costly and should be assessed from the standpoint of their true value to the patients. CONCLUSIONS RL pyeloplasty can reproduce the performance of the reference standard OP, yielding comparable operating time and functional results on postoperative pain and IVU at 3 months. The only advantage of RL pyeloplasty over OP with a minimal incision is a more rapid return to normal activity, particularly in younger patients. RL pyeloplasty requires surgical training specifically in laparoscopic suturing to obtain the same results as OP, for which the morbidity can be dramatically decreased with a shorter incision. However, the long-term outcome of RL pyeloplasty is necessary before complete validation. ACKNOWLEDGMENT. To Nina Crowte for translation of the paper. REFERENCES 1. Notley RG, and Beaugie JM: The long-term follow-up of Anderson-Hynes pyeloplasty for hydronephrosis. Br J Urol 145: 464 – 467, 1973. 2. Persky L, Krause JR, and Boltuch RL: Initial complicaUROLOGY 57 (3), 2001
tions and late results in dismembered pyeloplasty. J Urol 118: 162–165, 1977. 3. Scardino PT, and Scardino PL: Obstruction at the ureteropelvic junction, in Bergman H (Ed): The Ureter. New York, Springer-Verlag, 1981, pp 697–716. 4. Ben Slama RM, Salomon L, Hoznek A, et al: Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases. Urology 56: 45– 48, 2000. 5. Janetschek G, Peschel R, Altarac S, et al: Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction. Urology 47: 311–316, 1996. 6. Kavoussi LR, and Peters CA: Laparoscopic pyeloplasty. J Urol 150: 1891–1894, 1993. 7. Recker F, Subotic B, Goepel M, et al: Laparoscopic dismembered pyeloplasty: preliminary report. J Urol 153: 1601– 1604, 1995. 8. Schuessler WW, Grune MT, Tecuanhuey LV, et al: Laparoscopic dismembered pyeloplasty. J Urol 150: 1795–1799, 1993. 9. Chen RN, Moore RG, and Kavoussi LR: Laparoscopic pyeloplasty: indications, technique and long-term outcome. Urol Clin North Am 25: 323–330, 1998. 10. Moore RG, Averch TD, Adams JB, et al: Laparoscopic pyeloplasty: experience with the initial 30 cases. J Urol 157: 459 – 462, 1997. 11. Bauer JJ, Bischoff JT, Moore RG, et al: Laparoscopic versus open pyeloplasty: assessment of objective and subjective outcome. J Urol 162: 692– 695, 1999. 12. Jarret TW, Fabrizio MD, Moore RG, et al: Laparoscopic pyeloplasty: five-year experience (abstract). J Urol 161(suppl): 24, 1999. 13. Gasman D, Saint F, Barthelemy Y, et al: Retroperitoneoscopy: a laparoscopic approach for adrenal and renal surgery. Urology 47: 801– 806, 1996. 14. Brooks JD, Kavoussi LR, Preminger GM, et al: Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology 46: 791–795, 1995. 15. Meretyk I, Meretyk S, and Clayman RV: Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques. J Urol 148: 775–783, 1992. 16. Motola JA, Badlani GH, and Smith AD: Results of 212 consecutive endopyelotomies: an 8-year follow-up. J Urol 149: 453– 456, 1993. 17. Nadler B, Rao GS, Pearle MS, et al: Acucise endopyelotomy: assessment of long-term durability. J Urol 156: 1094 –1098, 1996. 18. Van Cangh PJ, Wilmart JF, Opsomer RJ, et al: Longterm results and late recurrence after endoureteropyelotomy: a critical analysis of prognostic factors. J Urol 151: 934 –937, 1994. 19. Rassweiler J, Seemann O, Frede T, et al: Retroperitoneoscopy: experience with 200 cases. J Urol 160: 1265–1269, 1998. 20. Nakada SY, McDougall EM, and Clayman RV: Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: preliminary experience. Urology 46: 257–260, 1995. 21. Abbou CC, Doublet JD, Gaston R, et al: La laparoscopie en urologie: report of the 1999 Congress of the Association Franc¸aise d’Urologie. Prog Urol 5: 918 –925, 1999. 22. Sung GT, Gill I, and Hsu TS: Robotic-assisted laparoscopic pyeloplasty: a pilot study. Urology 53: 1099 –1103, 1999. EDITORIAL COMMENT The clinical management of UPJ obstruction is a passionately debated urologic topic. The OP procedures have endured the test of time, with 95% success rates. Endopyelotomy, using
UROLOGY 57 (3), 2001
the antegrade or retrograde approach, has significantly reduced patients’ postoperative morbidity while providing longterm success rates ranging from 80% to 85%. The recent advocacy of the laparoscopic pyeloplasty proposed reduced patient morbidity while maintaining the higher success rate of OP for management of UPJ obstruction. The issue of morbidity has become a key focus in the comparison of the minimally invasive approaches for correction of UPJ obstruction. The authors are to be commended on their experience with the technically challenging RL pyeloplasty. Their clinical results appear to support other large comparative studies demonstrating the efficacy of laparoscopic pyeloplasty for the correction of UPJ obstruction.1 However, their report has not adequately addressed the issue of reduced morbidity in comparison with the RL and OP groups. The authors admit to a significant bias in the criteria used to select the patients for the two procedures in their study; this was largely determined by surgeon preference. It must be acknowledged that an initial experience with the laparoscopic pyeloplasty technique may not be appropriately compared with an established OP experience. Also, including patients with other renal pathologic findings, such as stones, cysts, and ptosis, in the OP group may further obscure the comparative ability of this study with regard to postoperative morbidity. We have no information regarding the postoperative course of the two patient groups with regard to their analgesic requirement. This would seem to be a key factor in comparing the postoperative morbidity of the two procedures. The outcome results for the management of UPJ obstruction have often tended to be an emotional debate rather than a scientific comparison. It is imperative that objective, rather than subjective, evaluations be used in the comparative study of the potential morbidity of the various surgical techniques. A surgeon-administered postoperative pain assessment is notoriously inaccurate. The use of the pain analog score to compare preoperative and postoperative discomfort is essential to accurately assess these parameters.2 Objective evaluation of the UPJ obstruction is also critical in determining the success of the particular surgical intervention. Although IVU may be satisfactory in many clinical situations, in those patients with residual hydronephrosis, an accurate functional study is necessary, and in this regard, only the diuretic renogram and/or Whitaker test can reliably demonstrate the functional patency of the UPJ. Continued critical and objective clinical evaluation of the new minimally invasive surgical techniques will help to clarify the benefits for patients with regard to the correction of the underlying pathologic finding and improvement of their quality of life. REFERENCES 1. Bauer JJ, Bischoff JT, Moore RG, et al: Laparoscopic versus open pyeloplasty: assessment of objective and subjective outcome. J Urol 162: 62– 65, 1999. 2. Nadler BR, Rao GS, Pearle MS, et al: Acucise endopyelotomy: assessment of long-term durability. J Urol 156: 1094, 1996. Elspeth M. McDougall, M.D. Department of Urologic Surgery Vanderbilt University Medical Center Nashville, Tennessee PII S0090-4295(00)01066-9 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
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RETROPERITONEAL LAPAROSCOPIC VERSUS OPEN PYELOPLASTY WITH A MINIMAL INCISION: COMPARISON OF TWO SURGICAL APPROACHES MICHEL SOULIE´, MATHIEU THOULOUZAN, PHILIPPE SEGUIN, PATRICK MOULY, NICOLAS VAZZOLER, FRANCIS PONTONNIER, AND PIERRE PLANTE
ABSTRACT Objectives. To compare the complications, hospital stay, and functional results of retroperitoneal laparoscopic (RL) pyeloplasty versus open pyeloplasty (OP) with a minimal subcostal incision. Methods. From October 1997 to January 2000, 53 consecutive nonrandomized patients underwent 26 RL pyeloplasties, of which 1 was bilateral (group 1), and 28 OP (group 2). The decision between the two techniques depended on the patient’s anesthetic ability to tolerate RL, previous ureteropelvic junction surgery, associated renal pathologic findings, and the surgeon’s laparoscopic experience. Subjective outcomes as to postoperative pain and convalescence and objective findings on intravenous urography were assessed at 3 months postoperatively in both groups. Results. The mean operating time (165 versus 145 minutes) and mean blood loss (92 versus 84 mL) were similar in both groups. No intraoperative complications occurred in either group; in group 1, 1 patient required open conversion. Postoperative complications occurred in 11.5% of group 1 and 14.3% of group 2. The mean hospital stay was 4.5 days for group 1 and 5.5 days for group 2. At 3 months, 23 patients (92%) in group 1 and 25 (89.2%) in group 2 were pain-free or improved. Intravenous urography showed a patent ureteropelvic junction in all cases and improvement of hydronephrosis in 88.5% of group 1 and 89.3% of group 2. Conclusions. The incidence of complications, hospital stay, and functional results were equivalent for RL pyeloplasty and OP with a minimal incision, but the return to painless activity was more rapid with laparoscopy in younger patients. UROLOGY 57: 443–447, 2001. © 2001, Elsevier Science Inc.
A
mong the current surgical techniques to treat ureteropelvic junction (UPJ) obstruction, open pyeloplasty is the reference standard, with long-term success rates exceeding 90%.1–3 Since 1993, laparoscopic surgeons have continued to use the Anderson-Hynes dismembered pyeloplasty, the Foley Y-V advancement, and Fenger-plasty.4 – 8 Preliminary reports have demonstrated the feasibility of laparoscopic procedures in experienced hands, with a lower morbidity and shorter convalescence, and operative success rates comparable with those of open techniques.3–5,9 –12 In this prospective study, we compared retroperitoneal laparoscopic (RL) pyeloplasty and open pyeloplasty From the Department of Urologic Surgery and Andrology, University Hospital of Rangueil, Toulouse, France Reprint requests: Michel Soulie´, M.D., Service d’Urologie et d’Andrologie, CHU Rangueil, F-31403 Toulouse Cedex 4, France Submitted: August 11, 2000, accepted (with revisions): October 20, 2000 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
(OP) using a minimal subcostal incision with regard to operative complications, length of hospital stay, functional results on postoperative pain and return to normal activity, and radiographic outcome at 3 months. MATERIAL AND METHODS Between October 1997 and January 2000, 53 consecutive nonrandomized patients underwent 54 pyeloplasties for UPJ obstruction in our department. Group 1 consisted of 25 patients (17 women and 8 men, mean age 35.2 years, range 17 to 68) who underwent RL pyeloplasty, with one bilateral procedure. Group 2 consisted of 28 patients (16 women and 12 men, mean age 42.3 years, range 18 to 81) who underwent OP with a minimal subcostal incision. Two patients in group 2 had a secondarily obstructed UPJ after a previous percutaneous endopyelotomy at another institution. The body mass index (BMI) ⫾ SD was 21.6 ⫾ 2.2 kg/m2 in group 1 and 22.4 ⫾ 2.6 in group 2. The decision as to which of the two techniques was used depended on the patient’s anesthesic ability to tolerate RL, previous UPJ surgery, associated renal pathologic findings, 0090-4295/01/$20.00 PII S0090-4295(00)01065-7 443
and the laparoscopic expertise of the four different surgeons during the study period.
PREOPERATIVE EVALUATION All patients were symptomatic and had sterile urine and a normal bleeding profile before surgery. The diagnosis of UPJ obstruction was assessed by intravenous urography (IVU) with diuretic renogram (Lasilix), dating from less than 1 year in all cases. Each renal unit with UPJ obstruction was functional. In the RL group, no patient had associated renal pathologic findings or previous renal surgery. All the renal pelves examined on IVU were extrasinusal and dilated. Fourteen patients had left-sided and 11 had right-sided UPJ obstruction. A young woman 26 years old had bilateral symptomatic UPJ obstruction and underwent two procedures at an interval of 3 months. In the OP group, 2 patients had secondary UPJ obstruction, previously treated by antegrade endopyelotomy. The renal pelvis was dilated on IVU in 25 patients and retracted in 3 patients. Fifteen patients had left-sided and 13 right-sided UPJ obstruction. Nine patients (32%) had associated renal pathologic findings: lithiasis in 4 patients (10 and 12-mm pelvic calculi and 6 and 5-mm middle and inferior caliceal calculi), cortical benign cysts in 3 patients (40, 48, and 60 mm in size), and renal ptosis with major pelvic dilation in 2 young women. In these 2 patients, a retrograde pyelogram confirmed the UPJ obstruction. Furthermore, 5 patients had anesthesic contraindications to RL because of impaired lung function: 2 with recurrent pneumothorax, 2 with chronic obstructive pulmonary disease, and 1 with atelectasia secondary to pulmonary tuberculosis.
SURGICAL TECHNIQUES In group 1, the retroperitoneal approach to the UPJ was similar to the primary description by Gasman et al.13 for renal and adrenal surgery. We always used four trocars: two posterior 10 and 5 mm, one anterior 5 mm, and the lateral opening site 15 mm with a trocar Origin for the lens. In group 2, a short skin incision of 4 to 6 cm (mean 5) was made horizontally along an anterior axillary line below the rib cage. The abdominal muscle aponevrosis was cut, the muscles were split, and the peritoneum was pushed back. We used a Gausset retractor with a flexible blade. This anterior extraperitoneal approach allows direct access to the UPJ with good exposure of the pelvis and renal vessels. In both groups, ureteropelvic anastomosis and pelvic repair were done using 4-0 polyglycolic acid sutures. After completion of the posterior ureteropelvic anastomosis, a double pigtail stent was inserted through the pelvis to the bladder in all patients in group 2 (OP) and in the last 18 patients in group 1 (RL). Fluoroscopy showed the adequate position of the stent in the urinary tract. In the 8 early RL procedures, the stent was inserted before initiating RL pyeloplasty and the operating time included the stent insertion. A 5-mm retroperitoneal drain and Foley catheter were placed, usually for 48 hours. Prophylactic antibiotics (third-generation cephalosporin) were routinely prescribed. A regular diet was resumed on postoperative day 1. The ureteral stent was removed 4 weeks postoperatively, and IVU was performed during the following 2 months.
EVALUATION OF POSTOPERATIVE PAIN AND RADIOLOGIC OUTCOME Postoperative parenteral analgesia consisted of profacetamol and morphine sulfate equivalent during the first postoperative day and paracetamol plus dextropropoxifen from the second day on. Analgesics were discontinued after a mean of 2 444
days (range 1 to 5) according to patient requirements. No medication was prescribed after discharge. All patients were assessed at 3 months with an oral questionnaire by one physician (M.T.). They were asked to comment on their postoperative pain, time to resumption of normal activity at 1 month, and current status. Current pain was assessed in four grades: pain-free, improved, no change, or worse than preoperative pain. Preoperative and postoperative IVU were read by the same physician (M.T.). A good result on the IVU was a patent UPJ with improved hydronephrosis. When there was a persistent dilated renal pelvis or a delayed evacuation of iodine, the result was considered unsatisfactory. Two years of follow-up was planned in both groups with annual clinical examination and urinary tract ultrasound scanning.
STATISTICAL ANALYSIS The characteristics of the two groups were compared using the chi-square test and the Student t test. A P value less than 0.05 was considered statistically significant.
RESULTS In both groups, there was no significant difference in BMI. Dismembered pyeloplasty with excision of the UPJ was performed in 24 patients in group 1 and in 20 patients in group 2. The spatuled ureter was attached to the incised renal pelvis with interrupted or running sutures, as previously described.4,7 Two patients with a high ureteral insertion in group 1 and 8 in group 2 with an intrasinusal renal pelvis underwent Y-V plasty. Crossing vessels were present in 10 patients (38.5%) in group 1 and in 9 (32%) in group 2. The ureter and renal pelvis were displaced to the other side of the vessels before completion of the anastomosis. In group 2, all patients had an adequate exposure of the UPJ and none required an enlarged incision. In this group, extraction of calculi (n ⫽ 4), cyst resection (n ⫽ 3), and nephropexy (n ⫽ 2) were performed uneventfully before anastomosis confection, with a mean operating time of 12 minutes (range 5 to 20), which was included in the analysis. The mean operating time (165 versus 145 minutes), estimated blood loss (92 versus 84 mL), and hospital stay average (4.5 versus 5.5 days) in the two groups are summarized in Table I. The difference in these parameters was not significant between the RL and OP procedures. None of the patients required blood transfusion. INTRAOPERATIVE COMPLICATIONS No intraoperative complications occurred in either group, but open conversion was necessary in 1 patient (3.8%) in group 1 because marked adhesions after pyelonephritis hindered dissection of the ureter and UPJ. He underwent dismembered pyeloplasty. UROLOGY 57 (3), 2001
TABLE I. Comparison of clinical parameters in retroperitoneal laparoscopic and open pyeloplasty procedures (n ⴝ 54)*
Parameter Age (yr) Operating time (min) Blood loss (mL) Hospital stay (days)
Laparoscopic Group* (n ⴝ 26)
Open Pyeloplasty Group (n ⴝ 28)
35.2 (17–68) 165 (120–260)
42.3 (18–81) 145 (80–250)
92 (50–250) 4.5 (3–7)
84 (30–300) 5.5 (4–9)
Numbers in parentheses are the range. No significant differences were found between the two groups. * One patient had a bilateral ureteropelvic junction obstruction.
POSTOPERATIVE COMPLICATIONS In group 1, 1 case of severe pyelonephritis due to pigtail stent obstruction resolved with antibiotics, and the stent had to be removed 3 weeks postoperatively. Anemia (8.5 g/dL) due to a parietal hematoma occurred at postoperative day 6 in 1 young woman. No delayed transfusion or revision procedure was necessary. The main complication was migration of the pigtail stent below the UPJ anastomosis, identified at 3 weeks because the patient had lumbar pain. An established anastomotic stenosis was impassable endoscopically and required open end-to-end anastomosis of the renal pelvis with secondary success. In group 2, 2 cases of delayed pyelonephritis were treated with antibiotics with no need for immediate removal of the pigtail stent. Two wound infections were observed beneath the incision at 1 week and spontaneously resolved after 2 weeks with antibiotics. A comparison of the two groups showed no significant difference in the incidence of postoperative complications, with 11.5% in group 1 and 14.3% in group 2. FUNCTIONAL RESULTS The mean clinical follow-up of the series was 14.3 months (range 6 to 32), but 20 patients in group 1 and 23 in group 2 had at least 1 year of clinical follow-up. Table II summarizes the results of pain assessment in both groups, which were based on the above-mentioned four items of the questionnaire filled out at 3 months. In group 1, 23 patients (92%) were pain-free (n ⫽ 20, 80%) or improved (n ⫽ 3, 12%), and in group 2, 25 patients (89.3%) were pain-free (n ⫽ 19, 67.9%) or improved (n ⫽ 6, 21.4%). The differences between the two groups were not significant. Patients with symptomatic pain in the lumbar area did not require any medication or additional surgery. Pain at the sites of the trocars or subcostal UROLOGY 57 (3), 2001
TABLE II. Comparison of functional results of retroperitoneal laparoscopic and open pyeloplasty in the two groups of patients
Parameter Evaluation of pain Pain-free Improved No change Worse Normal activity At 1 mo At 3 mo IVU at 3 mo Patent UPJ Improved HDN
Laparoscopic Group (n ⴝ 25) 20 3 1 1
(80) (12) (4) (4)
Open Pyeloplasty Group (n ⴝ 28) 19 6 2 1
(67.9) (21.4) (7.2) (3.6)
23 (92) 25 (100)
21 (75) 25 (89.3)
25 (100) 22 (88)
28 (100) 25 (89.3)
KEY: IVU ⫽ intravenous urography; UPJ ⫽ ureteropelvic junction; HDN ⫽ hydronephrosis. Numbers in parentheses are percentages. No significant differences were found between the two groups.
incision was reported by the patient with the poorest results. Normal activity at 1 month was reported by 22 patients (88%) in group 1 and by 21 patients (75%) in group 2. At 3 months, all asymptomatic patients had resumed full activity, even the patient with bilateral UPJ in group 1 who was treated with two procedures. It was interesting to observe that 90% of the younger patients (younger than 40 years old) in group 1 and 70% of those in group 2 were able to resume normal activity (without sports) 15 days postoperatively (P ⫽ 0.14). The radiographic outcome on IVU at 3 months showed a patent UPJ in all patients in both groups, with improvement of hydronephrosis in 22 (88%) of 25 patients in group 1, including the 2 patients later treated by open pyeloplasty, and in 25 (89.3%) of 28 patients in group 2 (P ⫽ 0.7). In the other patients, a dilated renal pelvis or difficulty in evacuation of iodine persisted, but these patients were pain-free and under surveillance, with a second IVU planned during the year. At 12 months, 17 patients in group 1 (68%) and 18 in group 2 (64%) were reassessed, and no patient had an unsuccessful outcome. COMMENT OP is the reference standard for UPJ obstruction repair.1–3,11 Transperitoneal and, recently, RL pyeloplasty were developed to reproduce the success rates achieved with OP, but with lower morbidity, less postoperative pain, and a shorter convalescence.4,5,9 –12 The success rates of minimally invasive endoscopic surgery (antegrade percutaneous endopyelotomy, retrograde endopyelotomy, and 445
Acucise cutting ballon) are approximately 10% to 25% lower than those of OP or laparoscopy, and hemorrhagic complications are more frequent.14 –18 In our experience, we use these endoscopic techniques in older patients and in secondary UPJ stricture after prior pyeloplasty. Our objective was to compare pyeloplasty with RL and open approach. The short anterior incision (mean 5 cm) with muscle splitting reduces the risk of chronic pain and wound herniation. The results of this study revealed no significant difference between the two techniques in terms of morbidity, functional results, postoperative pain, or return to normal activity. Laparoscopic pyeloplasty is classified as a difficult procedure, requiring careful ureteral dissection and considerable familiarity and proficiency in intracorporeal suturing.4,11,19 However, the transperitoneal or RL approach allows UPJ repair under magnified direct vision even with a large dilated renal pelvis and lower pole crossing vessels.4,5,9,10,19 Anterior lower pole crossing vessels were encountered in 38.5% of patients in the RL group and in 32% of the OP group and were uncrossed without difficulty. Crossing vessels are recognized as a cause of failure in endoscopic procedures.5,14,18 Renal calculi can be removed at the same time during laparoscopy and secondary UPJ obstruction can be treated by laparoscopy, especially after failure of endoscopic procedures.9,12,20,21 The operating time (165 minutes) with the extraperitoneal approach was relatively short in group 1, similar to a recent series4 (178 minutes), compared with the longer operating times (mean 240 minutes) with the transperitoneal approach.6 –10 No intraoperative complications occurred and only one conversion (3.8%) was necessary because of a difficult dissection in group 1. The reported conversion rates vary from 0% to 7%.4,5,9,21 The postoperative complication rate was similar in both groups; however, in group 1, another patient required open pyeloplasty because of the delayed stenosis of the ureteropelvic anastomosis. Moore et al.10 had 2 cases of acute obstruction after stent removal, requiring a new stent and nephrostomy. Parietal hematoma and pyelonephritis due to stent obstruction were also encountered in previous reports of laparoscopic pyeloplasty and OP.2–5,14,21 The subjective outcome criterion was the comparison of postoperative pain with preoperative pain. In the present study, RL patients recovered faster and more had resumed normal activity at 3 months. Moore et al.10 and Janetschek et al.5 claimed the complete disappearance of preoperative pain; however, other investigators have been more circumspect in this regard, reporting improvement rates of 85% to 90%.9,11,21 In our 446
study, more patients who were younger than 40 years were active 15 days after RL pyeloplasty (90%) than after OP (70%), which could be expected because of the simpler parietal healing. The objective outcome on IVU at 3 months was based on the quality of the UPJ patency and decreased dilation of the renal pelvis. Despite a nonblind random reading, the results were equivalent for the physician, with a patent UPJ in all patients in both groups and an improvement in hydronephrosis in 88% and 89.3% of patients, respectively, in groups 1 and 2, in agreement with the major series of laparoscopic pyeloplasty and OP.2–5,9 –11,21 Bauer et al.11 found no significant difference in the long-term outcome between 35 OP procedures analyzed retrospectively and 42 transperitoneal laparoscopies, with overall success rates of 94% and 98%, respectively. Transperitoneal laparoscopic pyeloplasty yields a high overall success rate of 97%, with minor complications in 12% for Chen et al.9 Jarret et al.12 reported a 92% and 96% success rate, respectively, in primary and secondary UPJ repair with a 5-year experience. It is necessary to assess the long-term outcome because in rare cases, UPJ obstruction can recur 1 year or more postoperatively.10,21 The suturing technique and the functional results of RL pyeloplasty may be further improved in the future by the extensive use of robotic-assisted technology, which is beginning to be used in several urologic procedures.22 However, these advanced and appealing techniques are costly and should be assessed from the standpoint of their true value to the patients. CONCLUSIONS RL pyeloplasty can reproduce the performance of the reference standard OP, yielding comparable operating time and functional results on postoperative pain and IVU at 3 months. The only advantage of RL pyeloplasty over OP with a minimal incision is a more rapid return to normal activity, particularly in younger patients. RL pyeloplasty requires surgical training specifically in laparoscopic suturing to obtain the same results as OP, for which the morbidity can be dramatically decreased with a shorter incision. However, the long-term outcome of RL pyeloplasty is necessary before complete validation. ACKNOWLEDGMENT. To Nina Crowte for translation of the paper. REFERENCES 1. Notley RG, and Beaugie JM: The long-term follow-up of Anderson-Hynes pyeloplasty for hydronephrosis. Br J Urol 145: 464 – 467, 1973. 2. Persky L, Krause JR, and Boltuch RL: Initial complicaUROLOGY 57 (3), 2001
tions and late results in dismembered pyeloplasty. J Urol 118: 162–165, 1977. 3. Scardino PT, and Scardino PL: Obstruction at the ureteropelvic junction, in Bergman H (Ed): The Ureter. New York, Springer-Verlag, 1981, pp 697–716. 4. Ben Slama RM, Salomon L, Hoznek A, et al: Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases. Urology 56: 45– 48, 2000. 5. Janetschek G, Peschel R, Altarac S, et al: Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction. Urology 47: 311–316, 1996. 6. Kavoussi LR, and Peters CA: Laparoscopic pyeloplasty. J Urol 150: 1891–1894, 1993. 7. Recker F, Subotic B, Goepel M, et al: Laparoscopic dismembered pyeloplasty: preliminary report. J Urol 153: 1601– 1604, 1995. 8. Schuessler WW, Grune MT, Tecuanhuey LV, et al: Laparoscopic dismembered pyeloplasty. J Urol 150: 1795–1799, 1993. 9. Chen RN, Moore RG, and Kavoussi LR: Laparoscopic pyeloplasty: indications, technique and long-term outcome. Urol Clin North Am 25: 323–330, 1998. 10. Moore RG, Averch TD, Adams JB, et al: Laparoscopic pyeloplasty: experience with the initial 30 cases. J Urol 157: 459 – 462, 1997. 11. Bauer JJ, Bischoff JT, Moore RG, et al: Laparoscopic versus open pyeloplasty: assessment of objective and subjective outcome. J Urol 162: 692– 695, 1999. 12. Jarret TW, Fabrizio MD, Moore RG, et al: Laparoscopic pyeloplasty: five-year experience (abstract). J Urol 161(suppl): 24, 1999. 13. Gasman D, Saint F, Barthelemy Y, et al: Retroperitoneoscopy: a laparoscopic approach for adrenal and renal surgery. Urology 47: 801– 806, 1996. 14. Brooks JD, Kavoussi LR, Preminger GM, et al: Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology 46: 791–795, 1995. 15. Meretyk I, Meretyk S, and Clayman RV: Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques. J Urol 148: 775–783, 1992. 16. Motola JA, Badlani GH, and Smith AD: Results of 212 consecutive endopyelotomies: an 8-year follow-up. J Urol 149: 453– 456, 1993. 17. Nadler B, Rao GS, Pearle MS, et al: Acucise endopyelotomy: assessment of long-term durability. J Urol 156: 1094 –1098, 1996. 18. Van Cangh PJ, Wilmart JF, Opsomer RJ, et al: Longterm results and late recurrence after endoureteropyelotomy: a critical analysis of prognostic factors. J Urol 151: 934 –937, 1994. 19. Rassweiler J, Seemann O, Frede T, et al: Retroperitoneoscopy: experience with 200 cases. J Urol 160: 1265–1269, 1998. 20. Nakada SY, McDougall EM, and Clayman RV: Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: preliminary experience. Urology 46: 257–260, 1995. 21. Abbou CC, Doublet JD, Gaston R, et al: La laparoscopie en urologie: report of the 1999 Congress of the Association Franc¸aise d’Urologie. Prog Urol 5: 918 –925, 1999. 22. Sung GT, Gill I, and Hsu TS: Robotic-assisted laparoscopic pyeloplasty: a pilot study. Urology 53: 1099 –1103, 1999. EDITORIAL COMMENT The clinical management of UPJ obstruction is a passionately debated urologic topic. The OP procedures have endured the test of time, with 95% success rates. Endopyelotomy, using
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the antegrade or retrograde approach, has significantly reduced patients’ postoperative morbidity while providing longterm success rates ranging from 80% to 85%. The recent advocacy of the laparoscopic pyeloplasty proposed reduced patient morbidity while maintaining the higher success rate of OP for management of UPJ obstruction. The issue of morbidity has become a key focus in the comparison of the minimally invasive approaches for correction of UPJ obstruction. The authors are to be commended on their experience with the technically challenging RL pyeloplasty. Their clinical results appear to support other large comparative studies demonstrating the efficacy of laparoscopic pyeloplasty for the correction of UPJ obstruction.1 However, their report has not adequately addressed the issue of reduced morbidity in comparison with the RL and OP groups. The authors admit to a significant bias in the criteria used to select the patients for the two procedures in their study; this was largely determined by surgeon preference. It must be acknowledged that an initial experience with the laparoscopic pyeloplasty technique may not be appropriately compared with an established OP experience. Also, including patients with other renal pathologic findings, such as stones, cysts, and ptosis, in the OP group may further obscure the comparative ability of this study with regard to postoperative morbidity. We have no information regarding the postoperative course of the two patient groups with regard to their analgesic requirement. This would seem to be a key factor in comparing the postoperative morbidity of the two procedures. The outcome results for the management of UPJ obstruction have often tended to be an emotional debate rather than a scientific comparison. It is imperative that objective, rather than subjective, evaluations be used in the comparative study of the potential morbidity of the various surgical techniques. A surgeon-administered postoperative pain assessment is notoriously inaccurate. The use of the pain analog score to compare preoperative and postoperative discomfort is essential to accurately assess these parameters.2 Objective evaluation of the UPJ obstruction is also critical in determining the success of the particular surgical intervention. Although IVU may be satisfactory in many clinical situations, in those patients with residual hydronephrosis, an accurate functional study is necessary, and in this regard, only the diuretic renogram and/or Whitaker test can reliably demonstrate the functional patency of the UPJ. Continued critical and objective clinical evaluation of the new minimally invasive surgical techniques will help to clarify the benefits for patients with regard to the correction of the underlying pathologic finding and improvement of their quality of life. REFERENCES 1. Bauer JJ, Bischoff JT, Moore RG, et al: Laparoscopic versus open pyeloplasty: assessment of objective and subjective outcome. J Urol 162: 62– 65, 1999. 2. Nadler BR, Rao GS, Pearle MS, et al: Acucise endopyelotomy: assessment of long-term durability. J Urol 156: 1094, 1996. Elspeth M. McDougall, M.D. Department of Urologic Surgery Vanderbilt University Medical Center Nashville, Tennessee PII S0090-4295(00)01066-9 © 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
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