- Email: [email protected]
The 3-Port Laparoscopic Pyeloplasty
0022-5347/04/1713-1050/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 171, 1050 –1053, March 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000112701.81071.20
THE 3-PORT LAPAROSCOPIC PYELOPLASTY ERIC S. CHENVEN, DAVID McGINNIS
AND
STEPHEN E. STRUP*
From the Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, and Division of Urology, University of Kentucky (SES), Lexington, Kentucky
ABSTRACT
Purpose: We describe our technique of a 3 port approach for transperitoneal laparoscopic pyeloplasty and its evolution. Materials and Methods: Between August 1999 and February 2003, 56 patients underwent laparoscopic transperitoneal pyeloplasty. The operative procedure, including patient positioning, surgical technique and postoperative care, is described in detail. For analysis patients were divided into 2 groups, namely an initial 4 port approach and a later 3 port approach. The number of additional ports placed and the reasons why were determined. Results: In the initial 14 patients a 4 port plan was used and 1 (7.2%) required a fifth port. In the subsequent 42 patients surgery was initiated with a 3 port plan and 8 (19%) required 1 additional port, while 2 (4.8%) required 2 additional ports. Of the extra ports used 50% were necessary for liver retraction in procedures on the right side. In patients with greater than 10 renal calculi a retrieval pouch was used, necessitating an additional port. A planned 3 port approach was feasible in 32 of the 42 cases (76.2%) and even initially a 4 port approach was sufficient in 13 of 14 (92.9%). Conclusions: We believe that our 3 port, transabdominal laparoscopic pyeloplasty technique is an efficient one with the least number of incisions and morbidity to the patient. It has proved to be feasible in more than 75% of our cases. Additional ports can easily be added but usually they are not required. KEY WORDS: ureteral obstruction, kidney, laparoscopy, hydronephrosis
The obstructed ureteropelvic junction (UPJ) has traditionally been managed by the gold standard of open AndersonHynes dismembered pyeloplasty. Contemporary series report success rates of more than 90% with this procedure.1–3 With advancements in technology less invasive treatment techniques have been developed. They include balloon dilation alone, the Acusize cutting balloon catheter (Applied Urology, Laguna Hills, California), antegrade percutaneous endopyelotomy and retrograde ureteroscopic endopyelotomy. In 1993 Kavoussi and Peters,4 and Schuessler et al5 first described laparoscopic transperitoneal pyeloplasty.4, 5 Initially this procedure was described using 4 or 5 ports. Since that time, the procedure was revised by a number of others and newer approaches now use 3 or 4 ports. It has also been performed via a retroperitoneal approach.6 – 8 The primary goal is to perform successful UPJ repair. Also, cosmesis is often of significant importance in this generally younger patient population. We describe our technique, a transperitoneal approach, using as few as 3 ports, which we believe is the least invasive while still being highly efficient. MATERIALS AND METHODS
Between August 1999 and February 2003, 56 patients underwent laparoscopic transperitoneal pyeloplasty. Table 1 lists mean demographic information. A planned 4-port approach was used in the initial 14 cases. However, after achieving sufficient proficiency with the procedure a 3 port approach was developed in the subsequent 42 patients. Data were collected in retrospective fashion, to examine technique, port placement and reasons for additional port placement.
TECHNIQUE
Preoperative preparation and patient positioning. Light mechanical bowel preparation is given at home 1 day preoperatively. Cefazolin (1 gm) is administered intravenously prior to skin incision for antibiotic prophylaxis. The patient is placed in a modified flank position with access to the urethra with women frog-legged and men supine, and secured to the table. The ipsilateral arm is secured to an over-the-head type arm board, such that it does not impede mobility when suturing the anastomosis (fig. 1). We use an AESOP (Computer Motion, Goleta, California) robotic arm to hold the camera because it provides superior image stabilization to that of human assistance. It is attached to the table ipsilateral to the surgical side at shoulder level. An orogastric tube is placed prior to insufflation. Surgical technique. The appropriate flank abdomen, and genitalia are prepared and draped. A 16Fr Foley catheter is placed on the sterile field. The table is then rotated to bring the abdomen parallel with the floor. A semilunar 1 cm incision is made at the superior aspect of the umbilicus. Pneumoperitoneum is established with a Veress needle and set to a pressure of 15 mm Hg. A 12 mm visualizing trocar is then placed through this incision. An open Hassan approach through a similarly small umbilical incision is used if there is a history of intra-abdominal surgery. The abdominal cavity is then inspected with a 5 mm 0-degree lens. The table is now returned to an ipsilateral modified flank position to allow the colon to be drawn medial. A second port is placed through a upper midline incision about 2 cm caudal to the xiphoid process. A 5 mm bladeless port is usually used here but a 12 mm port should be used if there are renal calculi to be addressed simultaneously. A third port (always 5 mm) is then placed off of the tip of the 12th rib just slightly medial to the underlying UPJ. The 3 ports should form a fairly isosce-
Accepted for publication October 24, 2003. Data were collected with institutional review board approval. * Correspondence: University of Kentucky, 800 Rose St., MS-273, Lexington, Kentucky 40536 (telephone: 859-323-6679; FAX: 859-3231944; e-mail: [email protected]). 1050
1051
3-PORT LAPAROSCOPIC PYELOPLASTY TABLE 1. Demographic data Mean age No. men/women No. lt/rt side No. primary/secondary
36.4 22/34 26/30 30/26
FIG. 1. Patient position and operating room setup
les triangle. When operating on the right side, a fourth 5 mm port may be necessary for liver retraction. The camera is moved to the lateral port and attached to the robotic arm. The lateral port position of the camera provides an overhead view of the UPJ and, thus, a head on orientation for the operation. Pneumoperitoneum is typically maintained at a working pressure of 15 mm Hg. The surgeon stands on the contralateral side of the table. The white line of Toldt is incised and the colon is reflected medial. An assistant places an open ended ureteral catheter over a 0.038-inch polytetrafluoraethylene coated guide wire using a flexible cystoscope. Each is left in place at this time to allow better identification of the ureter. If the patient already has an indwelling ureteral stent, the stent is removed and the open ended catheter is placed. The ureter is identified by elevating the lower pole of the kidney with the grasper and using gentle, blunt craniocaudal dissection at the UPJ level. Dissection should also proceed with caution at the UPJ because crossing vessels as well as the gonadal vein may be encountered. After the UPJ has been circumferentially dissected free a 10 cm segment of a vessel loop is passed beneath it and the ends are clipped together with a 5 mm clip applier. The vessel loop is used as a retractor to elevate the UPJ in atraumatic fashion. Dissection is then carried superior onto renal pelvis only for as much length as is necessary to excise any redundant pelvis and perform a tension-free anastomosis. Rarely an additional 5 mm port may be required at this time for increased exposure of the highly inserted ureter or continued elevation of the ureter. Classic Anderson-Hynes dismembered pyeloplasty is most commonly performed and for brevity it is the only technique described. After pulling the ureteral catheter and wire to a position below the line of incision nondiathermy laparoscopic scissors are used to transect the ureteral end just distal to the UPJ obstruction in medial to lateral, angled fashion. Attaining the superior to inferior angle is ideally achieved from the subxiphoid port. If the patient has an indwelling stent, care must be taken not to cut the stent. If present, the stent should be brought out of the renal pelvis at this time. The ureter is then spatulated on its lateral aspect for 15 to 20 mm. Using the UPJ for retraction the proximal incision in the renal pelvis is made, although not completed at its most lateral extent. Instead it is left in place as a handle until the
first apical stitch is placed. Reduction pyeloplasty is performed at the discretion of the surgeon. Any anterior crossing vessels are transposed to a posterior position and then the anastomosis is performed. If renal calculi are present, a flexible cystonephroscope is passed down the 12 mm upper midline port and into the renal collecting system. For upper pole calculi the umbilical port offers an excellent angle. Using saline irrigation stones are grasped with a basket or 3 pronged grasper and removed. Alternatively if multiple calculi are present, a retrieval pouch, such as an EndoCatch (Ethicon Endosurgery, Cincinnati, Ohio) bag, may be used for rapid collection with removal from the umbilical port at the end of the procedure. A 4-zero polyglactin suture on an SH needle is introduced via the 12 mm port. It is used to perform a freehand intracorporeal anastomosis in interrupted fashion. Advancing the ureteral guide wire may help in placing the initial stitch at the inferolateral apex. After the first stitch is tied the remaining attachment of the UPJ is excised and sent for permanent pathological review. The posterior anastomosis is performed first. After 2 or 3 anterior stitches are placed the guide wire or preexisting indwelling stent is passed into the renal pelvis. We usually place an 8Fr double pigtail ureteral stent over the wire with visual confirmation of its proximal curl in the renal pelvis. After the wire is removed flexible cystoscopy confirms the proper position of the distal curl. The remaining anastomosis is then completed. If renal pelvis reduction is required, the excess pelvis is closed with a running 4-zero polyglactin suture. All 12 mm port sites are closed at the fascial level using zero polyglactin suture and a Carter Thomason closure device. Insufflation pressure may now be decreased to 5 mm Hg and the operative field is inspected for hemostasis. A round 19Fr Jackson-Pratt drain is passed down a 12 mm port and externalized through the lateral 5 mm port. The drain is positioned in the retroperitoneum close to but not directly over the anastomosis. It is secured to the skin with a nonabsorbable stitch. The table is then rotated back to a supine position and the colon is situated back into its normal anatomical position, thereby, covering the UPJ. The abdomen is then desufflated and all ports are removed. Time should be taken to express any remaining intraperitoneal CO2. All skin incisions are infiltrated with 0.25% bupivacaine solution, irrigated with saline and closed with 4-zero polyglecaprone suture, followed by sterile strips. A 16Fr Foley catheter is left in place and connected to straight drainage. Postoperative care. The orogastric tube is removed prior to extubation. A creatinine level on the drain fluid is obtained on postoperative day 1. Intravenous antibiotics are continued for 24 hours and then changed to an oral agent, which is maintained for 1 to 2 weeks postoperatively. The drain and Foley catheter are removed that day if the fluid proves to be serum, and the patient is usually discharged home. The ureteral stent is removed after a minimum of 6 weeks. Renal ultrasound is performed just after stent removal to evaluate baseline postoperative pelvicaliectasis compared to that preoperatively. Radiographic followup is continued at 3 months with renal ultrasound and at 4 months with a diuretic renal scan. RESULTS
Of the 42 cases that were started with a 3 port technique 19% required 1 additional port, while 4.8% required 2 additional ports (table 2). Table 3 lists the number of additional ports used in the latter 42 patients and reasons for placement. Table 4 shows mean operative time for each procedure plan. Therefore, a planned 3 port approach was feasible in 76.2% of cases and even initially a 4 port approach was adequate in 92.9%. Overall 8 patients also underwent pyelolithotomy at lapa-
1052
3-PORT LAPAROSCOPIC PYELOPLASTY TABLE 2. Operative data Planned 3 Port
No. No. No. 1 2 No.
pts lt/rt side additional ports (%): initial planned no. ports feasibility (%)
Planned 4 Port
42 20/22
14 6/8
8 (19) 2 (4.8) 32 (76.2)
— 1 (7.2) 13 (92.9)
TABLE 3. Reason for additional port placement No. Ports Initial Plan
No. Extra Ports
Reason
4 3 3 3 3 3 3 3 3 3 3
1 1 1 1 1 1 1 1 2 1 2
Poor port position for suturing Liver retraction Liver retraction Liver retraction Upper port angle too superior for suturing Exuberant colonic mesentery retraction in obese pt Liver retraction Liver retraction Renal retraction for high insertion renal pelvis Multiple calculi Retraction of adhesed kidney and multiple calculi
TABLE 4. Mean operative time per port plan Operative Time (mins) 4 4 3 3
Port plan to 5 Port conversion Port plan to 4 or 5 Port conversion
was visualized but it was buried in the renal papilla and could not be extracted.
275.8 390.0 233.3 288.4
roscopic pyeloplasty. While 4 of 8 cases (50%) had more than 3 ports placed, only 2 of these cases required additional ports specifically to assist in stone removal. These 2 cases had greater than 10 calculi each. A 10 mm EndoCatch was used in these cases to store the calculi until completion of the repair. None of the patients with associated calculi underwent lithotripsy at pyeloplasty. The postoperative stone-free rate was 78% (7 of 9 patients stone-free on postoperative imaging). In the 2 failures 1 lower pole stone was inaccessible. In the other patient 1 stone was removed and another
DISCUSSION
Since its introduction in 1993, laparoscopic pyeloplasty has proved to be an equally effective alternative to open pyeloplasty. Variations in surgical technique exist among different centers. We believe that the 4 or 5 port approach initially described can easily be restricted to 3 ports in the majority of cases. While other reports illustrated a 3 port technique,9, 10 we believe that our port placement allows more facile intracorporeal suturing because of the head on orientation with the anastomosis. Use of a robotic arm further aids in image stabilization, which is especially appreciated during suturing. In our initial experience with a 4 port approach the fourth port did not serve an integral role in the majority of cases. In addition, we found that only 14% of these procedures required an additional port (table 2). From there we attempted to limit the initial number of ports to 3 since the fourth port had only been necessary for liver retraction and in patients with multiple (greater than 10) renal calculi (table 3). When a planned three port approach was implemented, the subxiphoid, umbilical, and subcostal port sites remained constant. Additional ports were placed based on the particular patient’s anatomy. Limitation to three operative port sites proved feasible in 76% (32/42) of such planned cases. Excellent cosmetic results were obtained with zero incidences of port site hernias or other wound related complications (fig. 2). In the 10 patients needing at least 1 additional port 50% were placed for liver retraction during procedures on the right side. It is certainly not to say that all right pyeloplasties require liver retraction. In our latter 42 cases 22 were on the right side and only (22.7%) needed an extra port for such retraction. Therefore, a procedure on the right side should not always warrant an initial plan of more than 3 ports. In 2 of the 10 patients requiring at least 1 additional port an extra port was placed to use a retrieval pouch for efficient capture of multiple renal calculi. In the other cases with fewer than 10 calculi endoscopic retrieval using a cystonephroscope and a calculous retrieval basket or 3 pronged grasper was sufficient. With multiple calculi (our limit was greater than 10)
FIG. 2. Evaluation 6 weeks postoperatively
1053
3-PORT LAPAROSCOPIC PYELOPLASTY
performing multiple individual retrievals has potential drawbacks. This approach can be time-consuming. Also, with each retrieval there is a slight chance of unintended release of the stone into the abdominal cavity or stone impaction within the port. Multiple retrievals would increase this likelihood. The retrieval pouch allows efficient, safe collection of multiple calculi. Mean operative time was shorter when an initial 3 port approach was used (table 4). Such differences are probably multifactorial. With increasing experience, especially with intracorporeal suturing, we saw a decrease in our surgical time. In addition, cases requiring additional ports were usually more complex. In general, since bleeding is usually minimal, performing the anastomosis should only require 2 ports for each needle driver. Fewer port sites result in improved cosmesis and theoretically in fewer port site complications. The position and closure of each port has further significance. Recently Siqueira et al described their technique and results.9 While a 3 port approach was used, they placed the 12 mm port at the lateral border of the rectus muscle. Our positioning of this port at the umbilicus allows the incision to be better concealed and, therefore, more cosmetically pleasing. In the study of Siquiera et al fascial closure of the trocar sites was not performed.9 While 5 mm port sites are usually free of complications, 10 and 12 mm port sites can be more problematic. Port site hernias have been reported to occur in 0.23% of cases with a 10 mm trocar and in 3.1% with a 12 mm trocar.11 Also, bowel may herniate into the site and potentially result in mechanical obstruction. A problem that we noted with our technique is application to the obese patient. In this case the umbilical port may be too far from the operative field. In such patients paramedian placement of this port is necessary. CONCLUSIONS
We believe that our 3 port transabdominal laparoscopic pyeloplasty technique is an efficient one with the least num-
ber of incisions and morbidity to the patient. It has proved to be feasible in more than 75% of our cases. Additional ports can easily be added but usually they are not required.
REFERENCES
1. Kelalis, P. P., Culp, O. S., Stickler, G. B. and Burke, E. C.: Ureteropelvic obstruction in children: experiences with 109 cases. J Urol, 106: 418, 1971 2. Notley, R. G. and Beaugie, J. M.: The long-term follow-up of Anderson-Hynes pyeloplasty for hydronephrosis. Br J Urol, 45: 464, 1973 3. Persky, L., Krause, J. R. and Boltuch, R. L.: Initial complications and late results in dismembered pyeloplasty. J Urol, 118: 162, 1977 4. Kavoussi, L. R. and Peters, C. A.: Laparoscopic pyeloplasty. J Urol, 150: 1891, 1993 5. Schuessler, W. W., Grune, M. T., Tecuanhuey, L. V. and Preminger, G. M.: Laparoscopic dismembered pyeloplasty. J Urol, 150: 1795, 1993 6. Janetschek, G., Peschel, R., Altarac, S. and Bartsch, G.: Laparoscopic and retroperitoneoscopic repair of ureteropelvic junction obstruction. Urology, 47: 311, 1996 7. Ben Slama, M. R., Salomon, L., Hoznek, A., Cicco, A., Saint, F., Alame, W. et al: Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases. Urology, 56: 45, 2000 8. Soulie, M., Thoulouzan, M., Seguin, P., Mouly, P., Vazzoler, N., Pontonnier, F. et al: Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches. Urology, 57: 443, 2001 9. Siqueira, T. M., Jr., Nadu, A., Kuo, R. L., Paterson, R. F., Lingeman, J. E. and Shalhav, A. L.: Laparoscopic treatment for ureteropelvic junction obstruction. Urology, 60: 973, 2002 10. Chen, R. N., Moore, R. G. and Kavoussi, L. R.: Laparoscopic pyeloplasty. Indications, technique, and long-term outcome. Urol Clin North Am, 24: 323, 1998 11. Kadar, N., Reich, H., Liu, C. Y., Manko, G. T. and Gimpelson, R.: Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol, 168: 1493, 1993
Vol. 171, 1050 –1053, March 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000112701.81071.20
THE 3-PORT LAPAROSCOPIC PYELOPLASTY ERIC S. CHENVEN, DAVID McGINNIS
AND
STEPHEN E. STRUP*
From the Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, and Division of Urology, University of Kentucky (SES), Lexington, Kentucky
ABSTRACT
Purpose: We describe our technique of a 3 port approach for transperitoneal laparoscopic pyeloplasty and its evolution. Materials and Methods: Between August 1999 and February 2003, 56 patients underwent laparoscopic transperitoneal pyeloplasty. The operative procedure, including patient positioning, surgical technique and postoperative care, is described in detail. For analysis patients were divided into 2 groups, namely an initial 4 port approach and a later 3 port approach. The number of additional ports placed and the reasons why were determined. Results: In the initial 14 patients a 4 port plan was used and 1 (7.2%) required a fifth port. In the subsequent 42 patients surgery was initiated with a 3 port plan and 8 (19%) required 1 additional port, while 2 (4.8%) required 2 additional ports. Of the extra ports used 50% were necessary for liver retraction in procedures on the right side. In patients with greater than 10 renal calculi a retrieval pouch was used, necessitating an additional port. A planned 3 port approach was feasible in 32 of the 42 cases (76.2%) and even initially a 4 port approach was sufficient in 13 of 14 (92.9%). Conclusions: We believe that our 3 port, transabdominal laparoscopic pyeloplasty technique is an efficient one with the least number of incisions and morbidity to the patient. It has proved to be feasible in more than 75% of our cases. Additional ports can easily be added but usually they are not required. KEY WORDS: ureteral obstruction, kidney, laparoscopy, hydronephrosis
The obstructed ureteropelvic junction (UPJ) has traditionally been managed by the gold standard of open AndersonHynes dismembered pyeloplasty. Contemporary series report success rates of more than 90% with this procedure.1–3 With advancements in technology less invasive treatment techniques have been developed. They include balloon dilation alone, the Acusize cutting balloon catheter (Applied Urology, Laguna Hills, California), antegrade percutaneous endopyelotomy and retrograde ureteroscopic endopyelotomy. In 1993 Kavoussi and Peters,4 and Schuessler et al5 first described laparoscopic transperitoneal pyeloplasty.4, 5 Initially this procedure was described using 4 or 5 ports. Since that time, the procedure was revised by a number of others and newer approaches now use 3 or 4 ports. It has also been performed via a retroperitoneal approach.6 – 8 The primary goal is to perform successful UPJ repair. Also, cosmesis is often of significant importance in this generally younger patient population. We describe our technique, a transperitoneal approach, using as few as 3 ports, which we believe is the least invasive while still being highly efficient. MATERIALS AND METHODS
Between August 1999 and February 2003, 56 patients underwent laparoscopic transperitoneal pyeloplasty. Table 1 lists mean demographic information. A planned 4-port approach was used in the initial 14 cases. However, after achieving sufficient proficiency with the procedure a 3 port approach was developed in the subsequent 42 patients. Data were collected in retrospective fashion, to examine technique, port placement and reasons for additional port placement.
TECHNIQUE
Preoperative preparation and patient positioning. Light mechanical bowel preparation is given at home 1 day preoperatively. Cefazolin (1 gm) is administered intravenously prior to skin incision for antibiotic prophylaxis. The patient is placed in a modified flank position with access to the urethra with women frog-legged and men supine, and secured to the table. The ipsilateral arm is secured to an over-the-head type arm board, such that it does not impede mobility when suturing the anastomosis (fig. 1). We use an AESOP (Computer Motion, Goleta, California) robotic arm to hold the camera because it provides superior image stabilization to that of human assistance. It is attached to the table ipsilateral to the surgical side at shoulder level. An orogastric tube is placed prior to insufflation. Surgical technique. The appropriate flank abdomen, and genitalia are prepared and draped. A 16Fr Foley catheter is placed on the sterile field. The table is then rotated to bring the abdomen parallel with the floor. A semilunar 1 cm incision is made at the superior aspect of the umbilicus. Pneumoperitoneum is established with a Veress needle and set to a pressure of 15 mm Hg. A 12 mm visualizing trocar is then placed through this incision. An open Hassan approach through a similarly small umbilical incision is used if there is a history of intra-abdominal surgery. The abdominal cavity is then inspected with a 5 mm 0-degree lens. The table is now returned to an ipsilateral modified flank position to allow the colon to be drawn medial. A second port is placed through a upper midline incision about 2 cm caudal to the xiphoid process. A 5 mm bladeless port is usually used here but a 12 mm port should be used if there are renal calculi to be addressed simultaneously. A third port (always 5 mm) is then placed off of the tip of the 12th rib just slightly medial to the underlying UPJ. The 3 ports should form a fairly isosce-
Accepted for publication October 24, 2003. Data were collected with institutional review board approval. * Correspondence: University of Kentucky, 800 Rose St., MS-273, Lexington, Kentucky 40536 (telephone: 859-323-6679; FAX: 859-3231944; e-mail: [email protected]). 1050
1051
3-PORT LAPAROSCOPIC PYELOPLASTY TABLE 1. Demographic data Mean age No. men/women No. lt/rt side No. primary/secondary
36.4 22/34 26/30 30/26
FIG. 1. Patient position and operating room setup
les triangle. When operating on the right side, a fourth 5 mm port may be necessary for liver retraction. The camera is moved to the lateral port and attached to the robotic arm. The lateral port position of the camera provides an overhead view of the UPJ and, thus, a head on orientation for the operation. Pneumoperitoneum is typically maintained at a working pressure of 15 mm Hg. The surgeon stands on the contralateral side of the table. The white line of Toldt is incised and the colon is reflected medial. An assistant places an open ended ureteral catheter over a 0.038-inch polytetrafluoraethylene coated guide wire using a flexible cystoscope. Each is left in place at this time to allow better identification of the ureter. If the patient already has an indwelling ureteral stent, the stent is removed and the open ended catheter is placed. The ureter is identified by elevating the lower pole of the kidney with the grasper and using gentle, blunt craniocaudal dissection at the UPJ level. Dissection should also proceed with caution at the UPJ because crossing vessels as well as the gonadal vein may be encountered. After the UPJ has been circumferentially dissected free a 10 cm segment of a vessel loop is passed beneath it and the ends are clipped together with a 5 mm clip applier. The vessel loop is used as a retractor to elevate the UPJ in atraumatic fashion. Dissection is then carried superior onto renal pelvis only for as much length as is necessary to excise any redundant pelvis and perform a tension-free anastomosis. Rarely an additional 5 mm port may be required at this time for increased exposure of the highly inserted ureter or continued elevation of the ureter. Classic Anderson-Hynes dismembered pyeloplasty is most commonly performed and for brevity it is the only technique described. After pulling the ureteral catheter and wire to a position below the line of incision nondiathermy laparoscopic scissors are used to transect the ureteral end just distal to the UPJ obstruction in medial to lateral, angled fashion. Attaining the superior to inferior angle is ideally achieved from the subxiphoid port. If the patient has an indwelling stent, care must be taken not to cut the stent. If present, the stent should be brought out of the renal pelvis at this time. The ureter is then spatulated on its lateral aspect for 15 to 20 mm. Using the UPJ for retraction the proximal incision in the renal pelvis is made, although not completed at its most lateral extent. Instead it is left in place as a handle until the
first apical stitch is placed. Reduction pyeloplasty is performed at the discretion of the surgeon. Any anterior crossing vessels are transposed to a posterior position and then the anastomosis is performed. If renal calculi are present, a flexible cystonephroscope is passed down the 12 mm upper midline port and into the renal collecting system. For upper pole calculi the umbilical port offers an excellent angle. Using saline irrigation stones are grasped with a basket or 3 pronged grasper and removed. Alternatively if multiple calculi are present, a retrieval pouch, such as an EndoCatch (Ethicon Endosurgery, Cincinnati, Ohio) bag, may be used for rapid collection with removal from the umbilical port at the end of the procedure. A 4-zero polyglactin suture on an SH needle is introduced via the 12 mm port. It is used to perform a freehand intracorporeal anastomosis in interrupted fashion. Advancing the ureteral guide wire may help in placing the initial stitch at the inferolateral apex. After the first stitch is tied the remaining attachment of the UPJ is excised and sent for permanent pathological review. The posterior anastomosis is performed first. After 2 or 3 anterior stitches are placed the guide wire or preexisting indwelling stent is passed into the renal pelvis. We usually place an 8Fr double pigtail ureteral stent over the wire with visual confirmation of its proximal curl in the renal pelvis. After the wire is removed flexible cystoscopy confirms the proper position of the distal curl. The remaining anastomosis is then completed. If renal pelvis reduction is required, the excess pelvis is closed with a running 4-zero polyglactin suture. All 12 mm port sites are closed at the fascial level using zero polyglactin suture and a Carter Thomason closure device. Insufflation pressure may now be decreased to 5 mm Hg and the operative field is inspected for hemostasis. A round 19Fr Jackson-Pratt drain is passed down a 12 mm port and externalized through the lateral 5 mm port. The drain is positioned in the retroperitoneum close to but not directly over the anastomosis. It is secured to the skin with a nonabsorbable stitch. The table is then rotated back to a supine position and the colon is situated back into its normal anatomical position, thereby, covering the UPJ. The abdomen is then desufflated and all ports are removed. Time should be taken to express any remaining intraperitoneal CO2. All skin incisions are infiltrated with 0.25% bupivacaine solution, irrigated with saline and closed with 4-zero polyglecaprone suture, followed by sterile strips. A 16Fr Foley catheter is left in place and connected to straight drainage. Postoperative care. The orogastric tube is removed prior to extubation. A creatinine level on the drain fluid is obtained on postoperative day 1. Intravenous antibiotics are continued for 24 hours and then changed to an oral agent, which is maintained for 1 to 2 weeks postoperatively. The drain and Foley catheter are removed that day if the fluid proves to be serum, and the patient is usually discharged home. The ureteral stent is removed after a minimum of 6 weeks. Renal ultrasound is performed just after stent removal to evaluate baseline postoperative pelvicaliectasis compared to that preoperatively. Radiographic followup is continued at 3 months with renal ultrasound and at 4 months with a diuretic renal scan. RESULTS
Of the 42 cases that were started with a 3 port technique 19% required 1 additional port, while 4.8% required 2 additional ports (table 2). Table 3 lists the number of additional ports used in the latter 42 patients and reasons for placement. Table 4 shows mean operative time for each procedure plan. Therefore, a planned 3 port approach was feasible in 76.2% of cases and even initially a 4 port approach was adequate in 92.9%. Overall 8 patients also underwent pyelolithotomy at lapa-
1052
3-PORT LAPAROSCOPIC PYELOPLASTY TABLE 2. Operative data Planned 3 Port
No. No. No. 1 2 No.
pts lt/rt side additional ports (%): initial planned no. ports feasibility (%)
Planned 4 Port
42 20/22
14 6/8
8 (19) 2 (4.8) 32 (76.2)
— 1 (7.2) 13 (92.9)
TABLE 3. Reason for additional port placement No. Ports Initial Plan
No. Extra Ports
Reason
4 3 3 3 3 3 3 3 3 3 3
1 1 1 1 1 1 1 1 2 1 2
Poor port position for suturing Liver retraction Liver retraction Liver retraction Upper port angle too superior for suturing Exuberant colonic mesentery retraction in obese pt Liver retraction Liver retraction Renal retraction for high insertion renal pelvis Multiple calculi Retraction of adhesed kidney and multiple calculi
TABLE 4. Mean operative time per port plan Operative Time (mins) 4 4 3 3
Port plan to 5 Port conversion Port plan to 4 or 5 Port conversion
was visualized but it was buried in the renal papilla and could not be extracted.
275.8 390.0 233.3 288.4
roscopic pyeloplasty. While 4 of 8 cases (50%) had more than 3 ports placed, only 2 of these cases required additional ports specifically to assist in stone removal. These 2 cases had greater than 10 calculi each. A 10 mm EndoCatch was used in these cases to store the calculi until completion of the repair. None of the patients with associated calculi underwent lithotripsy at pyeloplasty. The postoperative stone-free rate was 78% (7 of 9 patients stone-free on postoperative imaging). In the 2 failures 1 lower pole stone was inaccessible. In the other patient 1 stone was removed and another
DISCUSSION
Since its introduction in 1993, laparoscopic pyeloplasty has proved to be an equally effective alternative to open pyeloplasty. Variations in surgical technique exist among different centers. We believe that the 4 or 5 port approach initially described can easily be restricted to 3 ports in the majority of cases. While other reports illustrated a 3 port technique,9, 10 we believe that our port placement allows more facile intracorporeal suturing because of the head on orientation with the anastomosis. Use of a robotic arm further aids in image stabilization, which is especially appreciated during suturing. In our initial experience with a 4 port approach the fourth port did not serve an integral role in the majority of cases. In addition, we found that only 14% of these procedures required an additional port (table 2). From there we attempted to limit the initial number of ports to 3 since the fourth port had only been necessary for liver retraction and in patients with multiple (greater than 10) renal calculi (table 3). When a planned three port approach was implemented, the subxiphoid, umbilical, and subcostal port sites remained constant. Additional ports were placed based on the particular patient’s anatomy. Limitation to three operative port sites proved feasible in 76% (32/42) of such planned cases. Excellent cosmetic results were obtained with zero incidences of port site hernias or other wound related complications (fig. 2). In the 10 patients needing at least 1 additional port 50% were placed for liver retraction during procedures on the right side. It is certainly not to say that all right pyeloplasties require liver retraction. In our latter 42 cases 22 were on the right side and only (22.7%) needed an extra port for such retraction. Therefore, a procedure on the right side should not always warrant an initial plan of more than 3 ports. In 2 of the 10 patients requiring at least 1 additional port an extra port was placed to use a retrieval pouch for efficient capture of multiple renal calculi. In the other cases with fewer than 10 calculi endoscopic retrieval using a cystonephroscope and a calculous retrieval basket or 3 pronged grasper was sufficient. With multiple calculi (our limit was greater than 10)
FIG. 2. Evaluation 6 weeks postoperatively
1053
3-PORT LAPAROSCOPIC PYELOPLASTY
performing multiple individual retrievals has potential drawbacks. This approach can be time-consuming. Also, with each retrieval there is a slight chance of unintended release of the stone into the abdominal cavity or stone impaction within the port. Multiple retrievals would increase this likelihood. The retrieval pouch allows efficient, safe collection of multiple calculi. Mean operative time was shorter when an initial 3 port approach was used (table 4). Such differences are probably multifactorial. With increasing experience, especially with intracorporeal suturing, we saw a decrease in our surgical time. In addition, cases requiring additional ports were usually more complex. In general, since bleeding is usually minimal, performing the anastomosis should only require 2 ports for each needle driver. Fewer port sites result in improved cosmesis and theoretically in fewer port site complications. The position and closure of each port has further significance. Recently Siqueira et al described their technique and results.9 While a 3 port approach was used, they placed the 12 mm port at the lateral border of the rectus muscle. Our positioning of this port at the umbilicus allows the incision to be better concealed and, therefore, more cosmetically pleasing. In the study of Siquiera et al fascial closure of the trocar sites was not performed.9 While 5 mm port sites are usually free of complications, 10 and 12 mm port sites can be more problematic. Port site hernias have been reported to occur in 0.23% of cases with a 10 mm trocar and in 3.1% with a 12 mm trocar.11 Also, bowel may herniate into the site and potentially result in mechanical obstruction. A problem that we noted with our technique is application to the obese patient. In this case the umbilical port may be too far from the operative field. In such patients paramedian placement of this port is necessary. CONCLUSIONS
We believe that our 3 port transabdominal laparoscopic pyeloplasty technique is an efficient one with the least num-
ber of incisions and morbidity to the patient. It has proved to be feasible in more than 75% of our cases. Additional ports can easily be added but usually they are not required.
REFERENCES
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