Retroperitoneal laparoscopic non-dismembered pyeloplasty for uretero-pelvic junction obstruction due to crossing vessels: A matched-paired analysis and review of literature

Retroperitoneoscopic Simple Nondismembered Pyeloplasty with Da Vinci Si Assistance to Prevent Alignment Shift

Aims: Retroperitoneoscopic simple nondismembered pyeloplasty (SNDP) with da Vinci Si assistance was developed because of a possible risk for alignment shift after retroperitoneoscopic diamond-shaped bypass pyeloplasty (Diamond-Bypass; DP). Outcomes of SNDP and DP were compared. Materials and Methods: For SNDP, a small longitudinal incision is made on the border of the dilated pelvis and narrowed ureter at the ureteropelvic junction (UPJ). Extending this incision toward the pelvis allows identification of mucosa while maintaining the integrity of surrounding tissues that are so thin and fragile that they will not influence lumen alignment. Data for DP were obtained from a previously published article. Results: For SNDP (n = 3), mean age at surgery was 2.67 years (range: 1-4), mean operative time was 176 minutes. Mean postoperative Society of Fetal Urology (SFU) grades for hydronephrosis were 1.2, 0.7, and 0.6, 1, 2, and 3 months after stent removal, respectively. Postoperative diethylenetriaminepentaacetic acid (DTPA) was normal (n = 3). For DP (n = 5) mean age at surgery was 4.3 years (range: 1-14), mean operative time was 189 minutes. Mean postoperative SFU grades were 2.8, 2.2, and 1.6, respectively. Postoperative DTPA was normal (n = 4) and delayed (n = 1). All SNDP and DP were asymptomatic by 3 months after stent removal. Conclusion: Both SNDP and DP have favorable outcomes. If the UPJ is located at the lowest end of the renal pelvis, SNDP may improve hydronephrosis more quickly.

Robot-Assisted Retroperitoneoscopic Diamond Bypass Pyeloplasty

AIM

Robot (da Vinci Si; Intuitive Surgical, Sunnyvale, CA) assisted retroperitoneoscopic diamond bypass pyeloplasty (R-RDBP) performed for ureteropelvic junction (UPJ) obstruction (n = 5) is presented.

METHODS

Patients were placed affected side up and the retroperitoneal space accessed conventionally using 3-4 trocars. The diamond-shaped anastomosis involved incising the lowest part of the renal pelvis 12-15 mm transversely and the ureter distal to the obstruction 10-12 mm longitudinally. The first two sutures were placed retroperitoneoscopically; one from the mid-caudal line of the renal pelvis to the apex of the ureteric incision (the apex of the diamond) and the other from the corner of the incision in the renal pelvis to halfway along the ureteric incision. Trocars were replaced and the robot system docked. The first robot suture was placed between these two sutures, and the anastomosis completed by suturing from posterior to ventral applying minimal tension to keep the anastomosis close to the renal pelvis. All sutures were interrupted absorbable 5-0 monofilament.

RESULTS

Mean age at R-RDBP was 4.3 (range: 1-14) years old. Height/weight were average. Preoperative Society for Fetal Urology (SFU) grading was 4.0 in all cases. All repairs were primary and progressed smoothly without perioperative complications; 3/5 had improved appetite postoperatively. Mean SFU grades 1-3 months postoperatively were 2.8, 2.2, and 1.6, respectively. Diuretic renography that was obstructive in all cases preoperatively was normal in four and delayed in one case, postoperatively.

CONCLUSION

R-RDBP prevented rotation/kinking of the ureter, enhanced precision of suturing, and maximized the diameter at the anastomosis, facilitating smooth urine flow.

LEVEL OF EVIDENCE

LEVEL IV.

Comparative evaluation of surgical methods for low invasive surgical treatment of diseases of the kidneys and urinary tract

Background. The rapid development of laparoscopic surgery can significantly reduce trauma during operations in the retroperitoneal space. These goals are also achieved by retroperitoneoscopy (RPS), which has become widespread in the last twenty years. The main difficulties for surgeons were associated with a small workspace and a lack of clear anatomical landmarks. Different access methods have different features, advantages and disadvantages, the analysis of which helps to optimize surgical treatment and accelerate patient rehabilitation.

Aim: to study the advantages and disadvantages of retroperitoneoscopic and transperitoneal laparoscopic surgical methods of treatment.

Materials and methods: We analyzed 305  case histories of patients operated on for various kidney diseases. The patients were divided into 2 groups: Group 1 – patients who underwent surgery using an extraperitoneal retroperitoneoscopic approach, Group 2 – patients who used the transperitoneal laparoscopic approach. A comparison of two methods of surgical treatment of kidney diseases, retroperitoneoscopic and laparoscopic access, was carried out. The following indicators were compared: duration of surgery, length of hospital stay, need for analgesics, frequency of postoperative complications.

Results. The duration of the operation with retroperitoneoscopic surgery was reduced by more than 15 % compared with the laparoscopic approach. Shorter periods of pain relief were required, and the number of complications also decreased. The duration of inpatient treatment did not differ significantly.

Conclusion. Retroperitoneoscopic approach can be used as the method of choice for operations on the retroperitoneal space. 

Ureter-first Approach and Reduction of Pelvis: Standardizing Handling of Ureteropelvic Junction During Pyeloplasty

OBJECTIVE

To present our "ureter-first" approach as a standardized step-wise incision-making technique to deal with all types of uretero-pelvic junction (UPJ) anatomy during pyeloplasty. Pyeloplasty is a common surgery performed for UPJ obstruction, with Anderson-Hynes' pyeloplasty being the commonest. However, there is great variability in handling UPJ and incision-making among the surgeons with no detailed standardized description that can be followed in all cases, notwithstanding broad descriptions of incision lines. We underscore this aspect of pyeloplasty and present our universal technique with a goal to minimize surgical errors.

METHODS

A standardized step-by-step handling of UPJ and sequential incision-making was developed for pyeloplasty. It avoids unwarranted loss of any pelvis tissue before confirming individual UPJ anatomy, emphasizes preservation of lower lip of pelvis and minimizes tension on anastomosis. This standardized technique was uniformly used in all cases over 5 years. The peri-operative and functional outcome results are presented.

RESULTS

Fifty-one consecutive cases were done using ureter-first approach. UPJ was >1 cm in eight cases. Three of these had UPJ >2 cm. Eight other cases had a low-insertion below level of kidney while three had high insertion of ureter. There were no cases which were deemed to be done under tension or unsatisfactory repair by the surgeon. There were no failures requiring any kind of redo repair at mean follow up of 39 months.

CONCLUSION

A uniform standardized approach saves the surgeon from unwarranted or wrongly designed incisions on the pelvis and thus has the potential to reduce surgical mistakes.

Minimal Invasive Treatment in Pelvic-Ureteric Junction Obstruction: A Comprehensive Review

Pelvic-ureteric junction obstruction (PUJO) is a common condition, and one of the lead causes of hydronephrosis in children. Currently, the gold standard treatment of PUJO is open surgery using the Anderson–Hynes-modified dismembered pyeloplasty technique. However, with the advancement of medical technology, several minimal invasive approaches were developed, including endoscopic, laparoscopic, and robotic approach, from which the best choice of surgical technique was yet to be determined. Considering the advantages and disadvantages of these methods, the recommended option is to tailor the best surgical approach to each individual patient, and to the surgeons’ preference and experience. Considering these recent advances, a new algorithm is proposed to choose the best minimal invasive modalities invasive treatment to treat PUJO.

Is secondary robotic pyeloplasty safe and effective as primary robotic pyeloplasty? A systematic review and meta-analysis

Robot-assisted laparoscopic pyeloplasty (RLP) has excellent surgical safety and efficacy in primary pyeloplasty. In recent, the application of robotics has explored to more complex surgical conditions such as failed pyeloplasty. This meta-analysis aimed to evaluate the surgical and clinical outcomes of secondary RLP compared with primary RLP. Following PRISMA guidelines, we carried out an extensive literature search in the PubMed, Web of Science, Cochrane Library, Scopus, and Google Scholar to extract the published articles comparing primary vs. secondary RLP up to April 2019. Interested surgical and clinical outcomes were extracted from each study and then used RevMan 5.3 Software for meta-analysis comparison. Furthermore, the quality of each study was assessed using the Modified Newcastle-Ottawa Scale for cohort studies. Our search has yielded seven studies that met our inclusion criteria. These studies contained 613 vs. 107 patients in primary vs. secondary RLP, respectively. Using random effect model, the analysis showed no statistical difference between the groups in the presence of a crossing vessel, complications, length of hospital stays (LOS), and follow-up period. However, the operative time, estimated blood loss (EBL), and recurrence rate were significantly higher in the secondary RLP compared with primary RLP (p = 0.004), (p = 0.01), and (p = 0.04), respectively. Our results indicate that secondary RLP is associated with significantly increased operative time and EBL and higher recurrence rates compared with primary RLP. We believe that our findings might help surgeon's decision making in patient selection and consultation during redo pyeloplasty surgical planning.