Novel Method for Double-J Stenting in Retroperitoneal Laparoscopic Dismembered Pyeloplasty

A very easy technique of stenting for laparoscopic pyeloplasty: penbegul intravenous cannula (PICA) technique

INTRODUCTION

Double-J stent insertion during laparoscopic pyeloplasty is a difficult and time-consuming process and several techniques were defined to perform a double-J stent with an antegrade approach. In this study we present the technique (PICA) of antegrade double-J placement during laparoscopic pyeloplasty by using 14 gauge intravenous cannula. Surgıcal technıque: After we complete the suturing of the posterior wall of the anastomosis during laparoscopic pyeloplasty, we first puncture the abdominal wall with a 14-gauge "intravenous cannula" from a location that provides most suitable angle for inserting the double-J stent into the ureter. We remove the metal needle of the cannula, and the sheath which has an inner diameter of 5.2F remains over the abdominal wall. The double J stent is then advanced from inside the cannula sheath to the intraperitoneal area; under laparoscopic imaging the stent is gently grasped at its distal end using an atraumatic laparoscopic forceps to insert it into the ureter. The stent is then pulled down to its proximal end, and after the guidewire is removed, the proximal end of the double-J stent is placed inside the renal pelvis with an atraumatic forceps. With this technique we can apply the double-J stent in just one step. Additionaly we can use a 14-gauge IV cannula sheath as a trocar when needed during laparoscopic pyeloplasty to retract an organ or reveal an anastomosis line.

COMMENTS

Our new technique of antegrade double-J placement during laparoscopic pyeloplasty by 14 gauge intravenous cannula sheath, is very easy and quick to perform.

An up-to-date overview of minimally invasive treatment methods in ureteropelvic junction obstruction

Introduction

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction have been developed and are bcoming more popular. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, for both the transperitoneal and retroperitoneal approaches. In this review, we aimed to analyze the current status of minimally invasive therapy of ureteropelvic junction obstruction.

Material and methods

A PubMed database search was conducted to examine minimally invasive treatments of ureteropelvic junction obstruction.

Results

A large number of cases have been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric populations. A clear advantage, in terms of hospital stay, of minimally invasive over open pyeloplasty was observed only in the adult population.

Conclusions

Studies have shown that minimally invasive pyeloplasty techniques are a safe, effective, and feasible in adult and pediatric populations.

Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis

CONTEXT

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized.

OBJECTIVE

To critically analyze the current status of laparoscopic and robotic repair of UPJO.

EVIDENCE ACQUISITION

A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria.

EVIDENCE SYNTHESIS

Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population.

CONCLUSIONS

Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.

Intracorporeal Double-J stent placement during robot-assisted urinary tract reconstruction: technical considerations

BACKGROUND AND PURPOSE

An integral component of many urologic reconstructive surgical procedures is the positioning of a Double-J stent to span the anastomosis. Some surgeons prefer to place a retrograde stent during cystoscopy, either during or after the reconstruction. In this communication, we describe our straightforward and effective approach of performing this critical step intracorporeally using robotic assistance in a variety of upper tract urologic reconstructive procedures.

PATIENTS AND METHODS

We examined our Institutional Review Board-approved database of robotic surgeries to identify reconstructive operations that included the intracorporeal placement of a Double-J stent since 2008. Our step-by-step method for stent placement during various robotic urologic reconstructions is detailed, including procedures involving the proximal, mid, and distal ureter. With the aid of a bedside assistant-surgeon, we delineate how the console surgeon is able to perform this step of the procedure completely intracorporeally, without the need for repositioning or cystoscopy.

RESULTS

Since the inception of our robotic surgical program in 2008, we have used these robotic stent placement techniques in 150 patients. The average time of robotic intracorporeal stent placement across the anastomosis was 3.5 minutes. Three patients did experience proximal stent migration, as documented on postoperative radiographs, but all were treated with conservative measures, because their anastomosis was not affected and severe symptoms did not develop. No patient needed stent replacement, and each stent was subsequently removed ureteroscopically without sequelae.

CONCLUSIONS

Our robotic intracorporeal Double-J stent placement approach is simple and effective, avoids the need for cystoscopy and fluoroscopy, and can be used in any type of upper urinary tract urologic reconstruction.

Transmesocolic approach for left side laparoscopic pyeloplasty: comparison with laterocolic approach in the initial learning period

PURPOSE

To evaluate the outcome of transmesocolic (TMC) laparoscopic pyeloplasty compared with conventional laterocolic procedure for surgeons with limited experience.

MATERIALS AND METHODS

We started laparoscopic pyeloplasty for ureteropelvic junction obstruction in 2009. Since then, 21 patients of left side disease have undergone this surgery in our institution. To access the left ureteropelvic junction, we used the conventional laterocolic approach in 9 patients, while the transmesocolic approach was used in the remaining 12 patients, and perioperative results and follow-up data were then compared.

RESULTS

The mean operative time using the transmesocolic approach was significantly shorter than the conventional laterocolic approach (242 vs. 308 min, p=0.022). Furthermore, there was no complication or open conversion. Postoperative pain was significantly decreased in the TMC group (2.8 vs. 4.0 points, measured using the visual analogue scale on the first postoperative day, p=0.009). Postoperative complications were encountered in two patients. All patients were symptom-free after 1 year of follow-up, and radiologic success rates for each group were 92 and 89%, respectively.

CONCLUSION

Direct exposure of the ureteropelvic junction via the mesocolon saves time during the colon mobilization procedure. The approach is safe and feasible even for surgeons with limited experience, and has success rates similar to those of the conventional laterocolic approach.

Technical modifications of double-J stenting for retroperitoneal laparoscopic dismembered pyeloplasty in children under 5 years old

Both antegrade stenting and retrograde stenting for retroperitoneal laparoscopic dismembered pyeloplasty in children have many disadvantages. In this work, we tried using an alternative technique of modified antegrade (MAG) double-J stenting for retroperitoneal laparoscopic dismembered pyeloplasty in children under 5 years old, analyzed our results using the conventional antegrade (CAG) and the MAG techniques of stent insertion for this procedure, and reported our experience with these techniques. Between December 2002 and July 2010, 77 children under 5 years old with ureteropelvic junction obstruction underwent retroperitoneal laparoscopic dismembered pyeloplasty. CAG and MAG double-J stenting were attempted, in the first 36 cases (mean age 27.1 months) and the following 41 cases (mean age 25.4 months), respectively. The stents were removed 4–6 weeks later via cystoscopy. Follow-up studies were performed with ultrasonography and intravenous urography at 3 and 12 months postoperatively. The results showed that successful stent placement without malpositioning was achieved in 31 of 36 (86%) and all 41 (100%) cases, in the CAG and MAG groups, respectively. The common factor of unsuccessful stent was the inability to across the ureterovesical junction. The mean stent insertion time was 10 min 54 s and 12 min 46 s in the CAG and MAG groups, respectively. The mean operating time was 176 min and 185 min in the CAG and MAG groups, respectively. No stent malpositioning occurred in the MAG group; in the CAG group, two children had a malpositioned stent in the distal ureter and one child presented with a severe hematuria. Twelve months follow-up showed no new onset of hydroureteronephrosis and hydronephrosis. Thus we concluded that the MAG double-J stenting seems more reliable than CAG stenting for retroperitoneal laparoscopic dismembered pyeloplasty in children under 5 years old, with greater success and lower complication rates.