Laparoscopic dismembered pyeloplasty: 50 consecutive cases

The influence of interstitial cells of Cajal density in the outcomes of pyeloplasty in adults: A prospective analysis

Purpose:

To evaluate if the density of interstitial cells of Cajal (ICC) in the ureteropelvic junction (UPJ) influences the outcomes of pyeloplasty in adults.

Methods:

Twenty-three patients with the diagnosis of ureteropelvic junction obstruction (UPJO) that underwent laparoscopic dismembered pyeloplasty were included. ICC density was measured using immunohistochemistry reaction for c-KIT expression in the resected UPJ segment. Pyeloplasty outcome was evaluated by patient self-report pain, urinary outflow using DTPA renogram and hydronephrosis assessment using ultrasound (US) at 12 months of follow-up. A logistic regression analysis was performed to assess the association of pyeloplasty outcomes and ICC density.

Results:

Low, moderate, and high ICC density were present in 17.4%, 30.4%, and 52.2% of the patients, respectively. Complete pain resolution was observed in 100%, 85.7%, and 75% of patients with low, moderate and high ICC density, respectively ( p = 0.791). DTPA renogram improved in 75%, 85.7%, and 91.7% of patients with low, moderate and high ICC density, respectively ( p = 0.739). Hydronephrosis improved in 25%, 85.7%, and 91.7% of patients with low, moderate and high ICC density, respectively ( p = 0.032).

Conclusions:

Patients with high ICC density have a significant amelioration of hydronephrosis after pyeloplasty. However, ICC density is not associated with functional outcomes.

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

OBJECTIVE

To compare laparoscopic Anderson-Hynes pyeloplasty (LAHP) and retroperitoneal laparoscopic YV-pyeloplasty (LRYVP) in ureteropelvic junction obstruction (UPJ) in presence of a crossing vessels (CV).

METHODS

Our database showed 380 UPJO-cases,who underwent laparoscopic retroperitoneal surgery during the last 2 decades including 206 non-dismembered LRYVP, 157 dismembered pyeloplasties LAHP, and 17 cases of laparoscopic ureterolysis. Among them 198 cases were suitable for a matched-pair (2:1) analysis comparing laparoscopic retroperitoneal non-dismembered LRYVP (Group 1, n = 131) and dismembered LAHP (Group 2, n = 67) in presence of a crossing vessel. Patients were matched according to age, gender, kidney functions, and obstruction grade. Complications were graded according to modified Clavien-classification.

RESULTS

Comparative data were similar between both groups (LRYVP vs. LAHP) including mean operating time (112 min vs. 114 min), complication rates (4.2% vs. 7.3%) mainly Grade 1-2 according to Clavien classification, and success rates (90% vs. 89%). These results reflected in the reviewed literature indicate that LRYVP provides the advantage of minimal dissection in case of CV with similar outcome. However, redundant pelvis and anteriorly crossing vessels still require a dismembered pyeloplasty LAHP.

CONCLUSION

LRYVP has achieved similar results compared with the previous golden standard of open surgery, especially in case of crossing vessels apart from presence of a redundant pelvis or anteriorly crossing vessel. This can be further improved when using the small access retroperitoneoscopic technique respectively mini-laparoscopy.

Does antegrade JJ stenting affect the total operative time during laparoscopic pyeloplasty?

OBJECTIVE

We aimed to show the effect of retrograde JJ stenting and intraoperative antegrade JJ stenting techniques on operative time in patients who underwent laparoscopic pyeloplasty.

MATERIAL AND METHODS

A total of 34 patients were retrospectively investigated (15 male and 19 female) with ureteropelvic junction obstruction. Of the patients stentized under local anesthesia preoperatively, as a part of surgery, 15 were retrogradely stentized at the beginning of the procedure (Group 1), and 19 were antegradely stentized during the procedure (Group 2). A transperitoneal dismembered pyeloplasty technique was performed in all patients. The two groups were retrospectively compared in terms of complications, the mean total operative time, and the mean stenting times.

RESULTS

The mean ages of the patients were 31.5±15.5 and 33.2±15.5 years (p=0.09), and the mean body mass indexes were 25.8±5.6 and 26.2.3±8.4 kg/m2 in Group 1 and Group 2, respectively. The mean total operative times were 128.9±38.9 min and 112.7±21.9 min (p=0.04); the mean stenting times were 12.6±5.4 min and 3.5±2.4 min (p=0.02); and the mean rates of catheterization-to-total surgery times were 0.1 and 0.03 (p=0.01) in Group 1 and 2, respectively. The mean hospital stays and the mean anastomosis times were similar between the two groups (p>0.05).

CONCLUSION

Antegrade JJ stenting during laparoscopic pyeloplasty significantly decreased the total operative time.

Prospective randomized comparison between transperitoneal laparoscopic pyeloplasty and retroperitoneoscopic pyeloplasty for primary ureteropelvic junction obstruction

Background and Objectives:

To compare laparoscopic transperitoneal versus retroperitoneoscopic pyeloplasty for primary ureteropelvic junction obstruction in a prospective randomized manner and assess overall results with long-term follow-up.

Methods:

In this prospective study, from 2008 to 2012, 112 cases of primary ureteropelvic junction obstruction were randomized in a 1:1 ratio into 2 groups. Group I included patients who underwent transperitoneal laparoscopic pyeloplasty, and group II consisted of patients who underwent retroperitoneoscopic laparoscopic pyeloplasty. Demographic and clinical characteristics and postoperative and operative data were collected and analyzed. The statistical analysis was performed with the Fisher exact test, χ² test, and Mann-Whitney U test for independent groups, and P < .05 was considered statistically significant.

Results:

The total operative time and intracorporeal suturing time were significantly higher in group II than in group I (P < .001). The visual analog scale score for pain on postoperative day 1 and the requirement for tramadol were significantly higher in group I than in group II (P = .004). The hospital stay and the rate of temporary ileus were significantly greater (P < .036 and P < .02, respectively) in group I than in group II. The success rate of transperitoneal laparoscopic pyeloplasty versus retroperitoneoscopic laparoscopic pyeloplasty was 96.4% versus 96.6% with a mean follow-up period of 30.75 ± 4.85 months versus 30.99 ± 5.59 months (P < .88).

Conclusion:

Transperitoneal laparoscopic pyeloplasty is associated with significantly greater postoperative pain, a higher tramadol dose, a higher rate of ileus, and a longer hospital stay in comparison with retroperitoneoscopic laparoscopic pyeloplasty. Although the operative time for retroperitoneoscopic laparoscopic pyeloplasty is significantly longer, the success rate remains the same for both procedures.

Comparison of surgical and functional outcomes of open, laparoscopic and robotic pyeloplasty for the treatment of ureteropelvic junction obstruction

OBJECTIVE

To compare the surgical and functional outcomes of open, laparoscopic and robotic dismembered pyeloplasty for the treatment of patients with ureteropelvic junction obstruction (UPJO).

MATERIAL AND METHODS

Between 2007 and 2012, a total of 56 patients underwent conventional open (Group 1; n=25), laparoscopic (Group 2; n=16), and robotic (Group 3; n=15) dismembered pyeloplasty operations. Preoperative evaluation was performed using urinalysis, urine culture, blood biochemistry, urinary ultra-sound, intravenous pyelogram (IVP) (optional) and Mercaptoacetyltriglycine (MAG-3) renal scan. The mean operation time, estimated blood loss, drain removal time, narcotic analgesic requirements, length of hospital stay and functional outcomes were compared among groups. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) v. 20 (IBM, Armonk, NY, USA) software, and statistically significant differences were determined using a p value <0.05.

RESULTS

The mean age of the patients was 30 years in Group 1, 34.3 years in Group 2 and 32.9 years in Group 3. The mean operation time was 127, 130 and 114 min (p=0.32), and the estimated blood loss was 105, 31 and 28 mL, respectively (p=0.001). The drain was removed after 4.36 (±1.3), 2.33 (±0.6) and 1.8 (±0.6) days after surgery (p<0.001), and the mean hospital stay was 4.14 (±1.8), 2.8 (±0.75) and 2 (±1) days, respectively (p<0.001). Narcotic analgesic requirement was significantly higher in Group 1 compared with Groups 2 and 3 (p=0.02). The radiographic and symptomatic success rates were 96% in Group 1, 93.75% in Group 2 and 93.3% in Group 3.

CONCLUSION

Laparoscopic and robotic pyeloplasty are feasible, effective, reliable and minimally invasive treatment approaches for the treatment of UPJO as compared with open dismembered pyeloplasty.

A modified suture technique for transperitoneal laparoscopic dismembered pyeloplasty of pelviureteric junction obstruction

OBJECTIVE

To describe a modified suture technique for transperitoneal laparoscopic dismembered pyeloplasty (TPLDP) that can be consistently replicated.

METHODS

Between June 2010 and April 2014, 21 men and 7 women with primary pelviureteric junction obstruction underwent our modified TPLDP suture technique performed by the same surgeon. In our method, the dismembering should be performed after performing half of anastomosis to achieve the maintenance of correct orientation and the prevention of torsion of anastomosis. We defined the success criteria as complete clinical resolution of flank pain for the patients with flank pain and complete radiologic resolution for the asymptomatic patients.

RESULTS

The mean overall operative time for our technique was 137.3 minutes. The mean operative time for procedures on the left side was longer than on the right side (P = .02). The mean suture time was 37.2 minutes. The mean estimated blood loss was 29.4 mL, and the crossing vessel was found in 7 of 28 patients (25.0%). No open conversion was required. The mean follow-up time was 21.0 months. Only 1 patient still had frequent and intolerable flank pain after surgery whose treatment was unsuccessful. The rest of the patients got complete clinical or radiologic resolution. The success rate was 27 of 28 (96.4%).

CONCLUSION

Our modified TPLDP suture technique is feasible and seems to be safe and to allow high success rate for the treatment of pelviureteric junction obstruction. Sizable sample and further analysis about technique will be completed in the future.

Laparoscopic stepwise-cut double initial stay suture pyeloplasty: our novel surgical technique

OBJECTIVE

To describe a novel surgical technique, laparoscopic stepwise-cut double initial stay suture (LASDISS) pyeloplasty for ureteropelvic junction obstruction (UPJO). Additionally, we evaluated the safety and short-term results.

MATERIALS AND METHODS

This was a nonrandomized study with a series of 6 patients with UPJO, operated on between March 2012 and August 2013. Perioperative and short-term outcomes were evaluated. In brief, a "T shape cut" was performed from the dilated pelvis to the ureter. The initial stay suture was placed between the lower edge of the pelvis and the distal end of the spatulated anterolateral part of the ureter. The pelvis was closed with a continuous suture starting from the opened upper edge of the pelvis that was secured after leaving enough space for ureteral anastomosis. The second initial stay suture was placed after passing the ureter and pelvis two times. The dilated part of the renal pelvis and the stenotic segment were excised. A double-J stent was inserted. The remaining space between the two initial sutures was closed with these continuous sutures.

RESULTS

We performed the LASDISS pyeloplasty technique in all cases. Median operation time was 177 minutes (range, 100-290 minutes). Mean follow-up was 7.5 months (range, 3-18 months). The mean pre- and postoperative split renal function on diuretic renography was 33% (range, 25%-56%) and 42% (range, 30%-52%), respectively.

CONCLUSIONS

The LASDISS pyeloplasty surgical technique represents a safe and effective option in surgical treatment of UPJO.

Prospective randomized study to evaluate the feasibility and outcome of transmesocolic laparoscopic pyeloplasty and compare it with retrocolic laparoscopic pyeloplasty in pediatric and adolescent patients

OBJECTIVE

This prospective randomized study was designed to evaluate the feasibility and outcome of transmesocolic laparoscopic pyeloplasty (TMP) and compare it with retrocolic laparoscopic pyeloplasty (RLP) in pediatric and adolescent patients.

MATERIALS AND METHODS

Between September 2006 to May 2012, data of pediatric and adolescent patients undergoing laparoscopic pyeloplasty were recorded in a prospective manner. Data included age, pelvic volume, presence of stones, aberrant vessels, operative time, analgesics requirement and time to accept oral feeds and drain removal. Patients with left side pelviureteric junction obstruction with any size of pelvic volume, with or without renal stones and aberrant vessels were included in the study. Patients were assigned into two groups by simple randomization technique. A total of 38 TMP and 41 left sided RLP were performed. Median follow-up period for transmesocolic group was 12.5 months (9.5-62 months) and 14 months (8-66 months) for retro colic group. Outcome for this study was adequate drainage on renal scan, improvement in symptom and or resolution of hydronephrosis on ultrasound. Statistical analysis was performed using the Mann-Whitney test.

RESULTS

The mean patient age was 8.73 years in RLP and 7.73 years in TMP. In RLP group the mean operative time was 75.84 min (time from port insertion to pyeloplasty) and 135.4 min (total operative time) while it was 44.82 min and 104.82 min respectively in TMP group. Compared with classic RLP, TMP cases showed a significant reduction in operative time.

CONCLUSIONS

The transmesocolic approach for left sided pyeloplasty enables a shorter operative time even in the presence of large pelvis, aberrant vessel and stones without increasing morbidity in comparison to RLP approach.

Our experience with open dismembered pyeloplasty for uretero-pelvic junction obstruction

OBJECTIVE

To report our experience with open dismembered pyeloplasty for uretero-pelvic junction obstruction.

METHODS

Retrospective study was conducted in the Department of Urology, Jinnah Postgraduate Medical Centre, Karachi for a period of five and half years from May, 2006 to December, 2011. All patients with uretero-pelvic junction obstruction were entered into a database to record patients clinical features, diagnostic tools, operative and post-operative details and follow-up. Over a five-years period, 13 procedures were performed. After clinical evaluation all patient had extensive haematological and radiological workup for diagnosis of uretero-pelvic junction obstruction. All were subjected to open pyeloplasties, out of these 13 patients; one had an aberrant lower pole vessel compressing uretero-pelvic-junction. All procedures were stented. Repair was done with 3/0 vicryl sutures all patients were catheterized and wound drained.

RESULTS

Mean operating time was 60 - 100 minutes with about 100cc blood loss requiring no transfusion. The mean follow up was one year. One patient developed post-operative haematuria and was managed conservatively. Two patients developed fever secondary to urinary tract infection despite adequate treatment of urinary tract infection according to culture and sensitivity pre-operatively. One patient developed surgical emphysema detected post-operatively, which required tube thoracostomy. Neither patient developed recurrent symptoms nor had any evidence of obstruction on the renogram on follow-up. OBJECTIVEly all patients were followed up by intravenous urogram, stress renogram, Urine C/S. Subjective and objective follow-up revealed success in 100% of patients whereas success is defined as no or minimal holder on DTPA renogram, improving renal function and decreasing dilatation on successive intravenous urogram. All patients had a mean post-operative hospital stay of 02 - 04 days Folley catheter was removed after 10-days, double-j- stents were removed after two to three weeks.

CONCLUSION

Our success rate following open pyeloplasty with limited follow-up was 100%. It is comparable with International data. Recent international trend is toward Uretro-pelvic Junction Obstruction (UPJO) repair with laparoscopic approach, they are claiming success rate of 95%.

Single-stage surgical approach in complicated paediatric ureteral duplication: surgical and functional outcome

PURPOSE

Surgical approach to children with complicated ureteral duplication is discussed controversially. Our aim was to determine the outcome of children with complicated renal duplication undergoing a single-stage surgical approach with laparoscopic partial nephrectomy and open bladder reconstruction.

METHODS

Data of patients from 2004 to 2008 were investigated retrospectively. Outcome was analyzed in terms of postoperative course, renal function, urinary tract infection and functional voiding.

RESULTS

Thirteen patients were treated with laparoscopic partial nephrectomy and reconstruction of the lower urinary tract in a single-stage approach. Median age at operation was 15 months (2-63 m). One girl had a renal triplication. 7/13 patients presented with an ectopic ureterocele, two with an ectopic ureter, severe vesicoureteral reflux occurred in 6 patients. All patients had non-functioning renal moieties. Mean operative time was 239 min (129-309; SD 50). One re-operation was necessary 4 years after primary surgery due to a pole remnant. All patients had uneventful recoveries without evidence of recurrent UTI. Postoperative 99mTc-MAG3 scans showed no significant reduction of partial renal function (p = 0.4), and no signs of obstruction (p = 0.188). During a median follow-up of 60 months (49-86), dysfunctional voiding occurred in one patient.

CONCLUSIONS

In children with complicated ureteral duplication a definitive single-stage procedure is feasible and shows excellent functional results.

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.

Analysis of robotic-assisted laparoscopic pyleloplasty for primary versus secondary repair in 119 consecutive cases

OBJECTIVE

To analyze the outcomes of our robotic-assisted pyeloplasty series for primary ureteropelvic junction obstruction (UPJO) and compare them with our series of robotic-assisted pyeloplasty for secondary UPJO. The repair of secondary UPJO can pose additional challenges to surgeons. Robotic assistance could aid in these repairs.

METHODS

Using an institutional review board-approved database, we reviewed 119 consecutive patients who had undergone robotic-assisted laparoscopic pyeloplasty at our institution during an 8-year period (May 2002 to February 2010). Data were collected in a combined retrospective and prospective manner. The patients were stratified into primary repair and secondary repair for the primary analysis. The patients were also stratified into those with stones and those without stones for the secondary analysis. We compared the demographic, operative, postoperative, and radiographic outcomes. Student's t test and Pearson's chi-square correlation were used for statistical analysis of continuous and categorical variables, respectively.

RESULTS

Of the original 119 patients, data were available for 117. Of the 117 patients, 97 had undergone primary pyeloplasty repair and 20 had undergone secondary pyleloplasty repair. Radiographic data were available for 84 patients with primary repair and 17 patients with secondary repair. The radiographic success rate was 96.1% and 94.1%, respectively. No statistically significant differences were found in the patient demographics, operative data, or postoperative or radiographic outcomes for the primary analysis. Additionally, no differences were found in the outcomes for patients with concomitant stone disease.

CONCLUSION

These data represent the largest single-center report of its kind. These data strongly suggest that robotic-assisted laparoscopic pyeloplasty is a safe and durable option for secondary UPJO repair.

Laparoscopic management of primary pelvi-ureteric junction obstruction: Single-centre experience

Objective

To evaluate the effect and safety of laparoscopic pyeloplasty in the treatment of pelvi-ureteric junction obstruction (PUJO).

Patients and methods

In 34 patients, laparoscopic dismembered pyeloplasty was used to treat primary PUJO. Information was obtained for symptoms, results of a nuclear scan before and after surgery, intraoperative blood loss, operative duration, stenting method, and hospital stay. Under general anaesthesia and in the flank position, a 10 mm trocar was first placed above the umbilicus; three 5 mm working ports were then placed. The ureter and pelvis were freed from surrounding adhesions. The obstructive pelvi-ureteric segment was then excised, and the opened point of the ureter spatulated. Ureteropyeloplasty between the lower pole, pelvis and spatulated ureter was made using a 4-0 polyglactin suture around a JJ stent.

Results

The mean (SD) preoperative nuclear scan result was 23.6 (6.4) mL/min, with retention of tracer. The median operative duration was 200 min, and the median blood loss 120 mL. All patients were stented with a JJ stent. The mean hospital stay was 5 days. The final results were assessed at 6 months after surgery, when the mean (SD) nuclear scan result was 30 (7.4) mL/min.

Conclusion

Laparoscopic pyeloplasty is a safe and effective option which can produce satisfactory results both clinically and radiologically.

Laparoscopic calyceal diverticulectomy: video review of techniques and outcomes

Calyceal diverticula are cystic dilations within renal parenchyma prone to urinary stasis, stone formation, and recurrent infection. Using ICD-9 code 55.39 and CPT code 50549, we identified five women and two men (mean age 42 years) who underwent laparoscopic calyceal diverticulectomy at our center from August 2007 to July 2010. Patient videos that highlight basic and advanced laparoscopic techniques (retroperitoneal approach and partial nephrectomy) were selected from an Institutional Review Board-approved video library. Because few published case series exist in the literature, we include equipment used and outcomes for all patients. Posterior diverticula (4/7) were ablated by balloon-assisted retroperitoneal approach. One patient required concomitant partial nephrectomy for a solid renal mass, and laparoscopic ultrasound probe was required for diverticular identification in two patients. No complications were noted with reasonable mean blood loss (40 mL), operating times (160 minutes), and hospital stay (2 days). All diverticula were resolved at 3-month follow-up computed tomography imaging.

Laparoscopic reconstructive urology

Objective:

Laparoscopic reconstructive urology is undergoing rapid change. We review the current status of laparoscopic reconstructive urology, with particular respect to pyeloplasty and reconstructive ureteric surgery.

Methods:

An extensive Medline search of reconstructive laparoscopic procedures was undertaken. The initial reports and large series reports of a range of procedures was examined and summarised. The most commonly practised procedure within this remit is laparoscopic pyeloplasty. Several series of over 100 patients have been published. Success rates average over 90% for laparoscopic pyeloplasty with a low complication rate. Much less common laparoscopic reconstructive urological procedures include ureteric re-implantation, Boari flap, urinary diversion and transuretero-ureterostomy. The results of these are encouraging.

Conclusions:

Laparoscopic pyeloplasty may be safely performed by either the transperitoneal or retroperitoneal routes with excellent results. It should be considered the “gold standard” for the management of UPJ obstruction, especially in those patients with significant hydronephrosis, renal impairment or a crossing vessel. Laparoscopic ureteric reimplantation, Boari flap, urinary diversion and transuretero-ureterostomy have been performed by experienced laparoscopic urologists with encouraging results.

Laparoscopic pyeloplasty in pediatric patients: the SGPGI experience

Objectives:

To determine the safety, efficacy and long-term outcome of laparoscopic pyeloplasty in pediatric patients.

Materials and Methods:

A prospective analysis of data of pediatric patients under the age of 15 years, who had undergone laparoscopic pyeloplasty from January 2000 to June 2008 was done. The various parameters analyzed were; operative time, blood loss, need for analgesics, intra/postoperative complications, hospital stay and postoperative outcome. Success was defined on the basis of either improvement in the symptoms/or better drainage on postoperative isotope renography.

Results:

A total of 82 patients with a mean age of 7.12 years (four months to 15 years) and male to female ratio of 4.3:1 were included in the study. Dismembered pyeloplasty was done in 70 patients and Foley Y-V plasty in 12 patients via transperitoneal approach using three ports in 79 or four ports in three children. Mean operative time was 151 minutes (78-369); mean blood loss was 88.01 ml (50-250) with a mean hospital stay of 5.05 days (2-11). Conversion to open surgery was required in four (4.87%) patients. Follow-up renograms were available in 74 patients who showed improvement in drainage in 69 patients and obstructed pattern in five; of these two patients had significant deterioration in split function. Two patients among the obstructed group underwent redo pyeloplasty by open technique while the rest three elected for conservative approach. At a mean follow-up of 41.58 months (8-75) the overall success rate was 91.89%.

Conclusion:

Laparoscopic pyeloplasty is effective and safe in children with minimal morbidity and gives excellent long-term results.

Laparoscopic dismembered pyeloplasty in 47 cases

PURPOSE

To evaluate the results of a sequence of 47 laparoscopic Anderson-Hynes pyeloplasties for the treatment of patients with ureteropelvic junction obstruction, independently of the etiology.

MATERIALS AND METHODS

Twenty male and 27 female patients diagnosed with ureteropelvic junction obstruction were treated by Anderson-Hynes transperitoneal laparoscopic dismembered pyeloplasty from April 2002 to January 2006. The age of the patients ranged from four to 75 years, with a mean age of 32.3 years. The follow-up ranged between six and 30 months, with a mean follow-up time of 24 months. The outcomes were evaluated through the assessment of symptoms and imaging studies.

RESULTS

In 44 (93.6%) of the 47 patients, resolution of the pain and a reduction in ureteropelvic dilation were observed. The mean operative time was 157 minutes (ranging from 90 to 270 minutes). Neither blood transfusion nor conversion to open surgery was required. The mean hospital stay was 2.2 days. The presence of crossing vessels over the ureteropelvic junction was verified in 26 patients (55%), and vessel transposition in relation to the urinary tract was performed in 25 of these cases. In one patient, the crossing vessel was mobilized out of the ureteropelvic junction with a perivascular suture to the renal capsule associated with the pyeloplasty.

CONCLUSIONS

The outcome of transperitoneal Anderson-Hynes laparoscopic pyeloplasty used for different causes of pyeloureteral obstruction presented a success rate similar to a previously-published open procedure, with the advantage of being less invasive. This procedure may be considered the first option for the treatment of ureteropelvic junction obstruction.

Two decades of minimally invasive pediatric surgery-taking stock

BACKGROUND

The past 2 decades have seen a rapid integration of minimally invasive surgery (MIS) to pediatric surgical practice. This study endeavored to delineate the current status of MIS in pediatric surgery.

METHODS

Three hundred six pediatric surgeons were invited to participate in an anonymous Web-based survey. Apart from demographic details and opinion regarding robotic surgery, surgeons were asked to choose between "perform MIS," "do not perform MIS but recommend it," and "MIS not indicated" for common pediatric surgical conditions.

RESULTS

Responses were received from 117 pediatric surgeons (38.2%). Sixty-one percent of respondents did more than 10% of their work using MIS, and 85% had more than 5 years experience in MIS. Cholecystectomy, nonpalpable testis, and exploration for abdominal pain scored highest among the positive recommendations for MIS, whereas liver tumors, biliary atresia, Wilms' tumor, and inguinal hernia scored highest among the negative recommendations for MIS. Fifty-one percent of the respondents had more than 20 years experience as a pediatric surgeon and were categorized as "senior" surgeons. Compared with the young surgeons, the senior surgeons were more likely to recommend MIS as a contraindication for simple and complicated appendicitis, reduction of intussusception, gastrostomy, fundoplication, pyloromyotomy, adhesiolysis, splenectomy, adrenalectomy, nephrectomy for dysplastic kidneys, heminephrectomy, pyeloplasty, anorectal malformations, pyeloplasty, achalasia cardia, hiatal hernia repair, lung resection, and diaphragmatic hernia repair. More than half the respondents believed that robotic surgery has a role for children in the future.

CONCLUSIONS

A widespread integration of MIS into the pediatric surgical practice is evident from this study. Current practice and recommendations of the surveyed surgeons have been outlined. Significant differences between the young and senior surgeons reflect the evolving nature of the recommendations.

Laparoscopic pyeloplasty: a prospective randomized comparison between the transperitoneal approach and retroperitoneoscopy

PURPOSE

A prospective randomized study was performed to compare the results of laparoscopic dismembered pyeloplasty using transperitoneal and retroperitoneal approaches.

MATERIALS AND METHODS

A total of 40 patients with primary ureteropelvic junction obstruction were included in the study. The patients were prospectively randomized between transperitoneal (20 patients, group 1) and retroperitoneal (20 patients, group 2) laparoscopic Anderson-Hynes pyeloplasty. All the patients were assessed preoperatively by excretory urography, diuretic isotope renography and computerized tomography angiography. The patients were followed at 3 and 6 months postoperatively, and then every 6 months. Evaluation was performed by excretory urography and diuretic renography. Both approaches were compared regarding operative time, morbidity, hospital stay, convalescence and functional outcome. The preoperative demographic data of the patients and radiological and operative findings were statistically correlated to the operative time.

RESULTS

The preoperative data of both groups were comparable. All the procedures were successfully completed with laparoscopy. Mean operative times were 149 and 189 minutes for the transperitoneal approach and retroperitoneoscopy, respectively (p = 0.02). In groups 1 and 2 there were complications in 3 and 5 patients, respectively. Morbidity, hospital stay, convalescence and success rate had no significant differences between the groups. None of the patient parameters apart from the approach had a significant impact on operative time.

CONCLUSIONS

Laparoscopic dismembered Anderson-Hynes pyeloplasty has a satisfactory functional outcome and low morbidity regardless of the approach. Nevertheless, with early experience retroperitoneoscopy is associated with a longer operative time.

Is Antegrade Endopyelotomy Really Less Invasive than Open Pyeloplasty?

OBJECTIVE

We investigated the invasiveness of antegrade endopyelotomy and open pyeloplasty in two consecutive series of patients with ureteropelvic junction obstruction.

PATIENTS AND METHODS

98 patients were treated by open pyeloplasty from 1980 to 1991, and 137 patients by antegrade endopyelotomy from 1991 to 1999. Diagnosis of ureteropelvic junction obstruction was made by excretory urogram and/or antegrade pyelography, diuretic renography and retrograde pyelography. Invasiveness was evaluated by the postoperative need for analgesics, the complication rate and the residual long-term symptoms after surgery.

RESULTS

The postoperative need for opiate analgesics was significantly higher in patients after open pyeloplasty than after antegrade endopyelotomy. Ten percent of the patients complained of problems with the lumbotomy scar after open pyeloplasty, which was not encountered after endopyelotomy. Complications after open pyeloplasty occurred in 24% and were more severe than the 11% seen after endopyelotomy. The primary success rate after open pyeloplasty was 98 and 89% after antegrade endopyelotomy. The long-term success rate, > or = 24 month postoperatively, was 96% (median follow-up 37 (24-196) months) and 76% (median follow-up 32 (24-73) months), respectively.

CONCLUSION

Open pyeloplasty and endopyelotomy both have a high success rate with better patency results after open pyeloplasty. Open pyeloplasty is more invasive and has a higher morbidity. Endopyelotomy is a minimally invasive procedure with faster recovery, fewer and minor complications, significantly less need for peri- and postoperative analgesics, less residual pain due to the access, and no functional and esthetic sequelae of lumbotomy.

Robotic-Assisted Laparoscopic Ureteropyelostomy for Treatment of Prostatitis Secondary to Ectopic Ureteral Insertion of a Completely Duplicated Collecting System

Symptomatic presentation of a completely duplicated collecting system with upper-pole ectopic ureteral insertion is rare in the adult. We present a case of a 52-year-old man with recurrent prostatitis and hematuria secondary to an ectopic ureteral insertion from a left upper-pole moiety in a completely duplicated collecting system. He underwent a robot-assisted laparoscopic ureteropyelostomy with good results. We describe our technique in this unusual case.

The role of percutaneous endopyelotomy for ureteropelvic junction obstruction

INTRODUCTION

Over the last 20 years, the surgical management of ureteropelvic junction obstruction (UPJO) has been revolutionised by the development of endourological instrumentation and several minimally invasive procedures including: antegrade or retrograde endopyelotomy, retrograde balloon dilatation, and laparoscopic pyeloplasty. Currently, in our department, we offer percutaneous antegrade endopyelotomy (PAE) as primary treatment of UPJO in adults, believing it offers less morbidity, better cosmetic results, and quicker operating time compared with open pyeloplasty.

PATIENTS AND METHODS

We performed a retrospective audit of our results for the 14 patients who underwent percutaneous antegrade endopyelotomy between January 2000 and May 2004.

RESULTS

Mean operative time was 53 min (range, 30-80 min), mean in-patient stay was 3.8 days (range, 2-7 days), and there were no major postoperative complications for this series with mean follow-up of 31.8 months (range, 12-52 months). Eleven out of the 14 patients (79%) showed radiological improvement on their 3-month MAG 3 (mercaptoacetyl-triglycyl) renogram, and 13 out of the 14 (93%) patients reported significant reduction or resolution of pain, compared with their preoperative state.

CONCLUSIONS

The majority of urologists still offer open pyeloplasty as primary treatment for UPJO with laparoscopic pyeloplasty currently an evolving procedure in the UK. Our series reports comparable success rates for PAE compared to other series. Despite these results, we feel that the future role of percutaneous endopyelotomy will be as a salvage procedure following failed open or laparoscopic surgery. However, in patients with concurrent stone disease or requiring antegrade ureteric access, percutaneous endopyelotomy would be suitable as a primary treatment option.

Transmesocolic Pyeloplasty: Experience of a Single Center

PURPOSE

We present our experience with dismembered left-sided pyeloplasty using a transmesocolic technique as a way to reduce operative time and facilitate repair by avoiding colon displacement.

PATIENTS AND METHODS

Between January 2004 and January 2006, a total of 11 transmesocolic laparoscopic pyeloplasties were performed by the same surgeon at our institution. The mean patient age was 41.6 years (range 14-65 years). Operative records and follow-up were reviewed.

RESULTS

A dismembered Anderson-Hynes pyeloplasty was carried out in nine patients (82%), while a Y-V plasty (9%) and a Fengerplasty (9%) were done in one patient each. Crossing vessels were observed in 8 patients (73%). A ureteral stent was left in all patients. The mean operative time was 88.6 minutes (range 60-125 minutes), and blood loss was minimal. Compared with classic transperitoneal laparoscopic left pyeloplasties, transmesocolic cases showed a significant reduction in operative time (88.6 minutes v 117 minutes; P < 0.05). There were no intraoperative complications or open conversions. The mean hospital stay was 2.1 days (range 2-3 days). Only 1 patient (9%) demonstrated narrowing of the anastomosis, which occurred 12 months after a Fengerplasty.

CONCLUSIONS

The transmesocolic approach to a dilated left pelvis enables a shorter operative time without increasing morbidity. More patients and longer follow-up are necessary to determine its effect on convalescence.

Usefulness of Short-Term Retrievable Ureteral Stent in Pediatric Laparoscopic Pyeloplasty

PURPOSE

Methods of stenting after laparoscopic pyeloplasty have included indwelling Double-J stents and percutaneous nephrostomy tubes. The disadvantages of these methods are that they necessitate a second surgery for stent removal or require an external drainage bag. To circumvent these issues, the tolerance, safety and outcomes of using a Double-J ureteral stent with a dangler, permitting early office removal, was investigated in a series of pediatric laparoscopic pyeloplasties.

MATERIALS AND METHODS

Medical records from a consecutive series of pediatric patients undergoing transperitoneal laparoscopic pyeloplasties were reviewed. Indications for surgery included ipsilateral flank pain with severe hydronephrosis (12 patients), recurrent pyelonephritis with severe hydronephrosis (2), and hematuria and flank pain (6). All patients were discharged home within 24 to 48 hours of the procedure with prophylactic oral antibiotics. The stent was removed by postoperative day 18 during a followup office visit. Patient tolerance of the indwelling stent, outpatient removal and success of pyeloplasty were assessed.

RESULTS

A total of 20 patients underwent transperitoneal laparoscopic pyeloplasty by 1 surgeon (LAB) between 2001 and 2005. All patients underwent cystoscopy and retrograde Double-J ureteral stent placement before pyeloplasty under the same anesthesia. Mean patient age at operation was 11.3 years (median 11.3, range 4.6 to 17.2). Stents were left indwelling for a mean of 10.3 days (median 10, range 7 to 18). All patients tolerated the Double-J stent well, with 2 requiring anticholinergic therapy for mild urgency symptoms and 1 demonstrating urinary tract infection. All patients tolerated outpatient stent removal via the dangler at the office without discomfort. One patient was lost to followup. At a mean followup of 1.04 years (range 0.1 to 2.88) 17 of 19 patients (89%) had resolution of flank pain/urinary tract infections, with sonographic improvement in hydronephrosis with or without endoscopic intervention. Six patients (30%) had flank pain with or without continuous hydronephrosis and required re-stenting, and 3 also required balloon dilation. Of these 6 patients 2 (10%) had recurrent ureteropelvic junction obstruction and required open pyeloplasty. All patients are now clinically and radiologically unobstructed and asymptomatic.

CONCLUSIONS

Pediatric transperitoneal laparoscopic pyeloplasty with indwelling Double-J ureteral stent with a dangler is successful and the stent is well tolerated. Whether the duration of ureteral stenting affects the surgical success will require further controlled long-term studies.

Retroperitoneoscopic pyeloplasty: Using reconstructive methods based on intraoperative findings

AIM

Reconstructive laparoscopic procedures have been recognized as a less invasive treatment than conventional open procedures. However, although the laparoscopic pyeloplasty has also been accepted as useful, few findings have been reported relevant to the retroperitoneal approach. To elucidate its effectiveness and safety, laparoscopic surgery via the retroperitoneal approach was examined in our institution. Furthermore, the importance of laparoscopic observation for ureteropelvic junction and urine passage ureteropelvic junction without indwelling ureteral stent.

METHODS

Between July 1998 and December 2004, 13 men and 15 women underwent laparoscopic retroperitoneal surgery for ureteropelvic junction obstruction. The mean patient age was 33.6 years (range: 13-70 years). Methods of repair were determined by intraoperative findings for the relationship between the ureteropelvic junction and surrounding vessels. An indwelling ureteral stent was removed before initiating laparoscopic operation to observe the relationship between ureteropelvic junction and aberrant vessels more precisely.

RESULTS

An aberrant renal vessel was found in 13 patients (46%). Dismembered pyeloplasty was carried out in 21 patients, Y-V plasty in five patients and Hellstrom technique in two patients. Ureteral transposition was not required in dismembered pyeloplasty cases. All patients achieved retroperitoneoscopic pyeloplasty without open conversion. The mean operative time was 272 min (range: 155-490 min). The mean estimated blood loss was 44 mL (range: 10-200 mL). No major complications were observed during the intraoperative period, but urinary tract infection occurred in two patients in the postoperative period. In all patients except one, obstruction was improved or resolved.

CONCLUSIONS

Laparoscopic retroperitoneal surgery is not only able to repair ureteropelvic junction obstruction, but can also be done safety and less invasively. We believe that laparoscopic observation without indwelling stent will contribute to a more appropriate choice of pyeloplasty.

Retroperitoneal dismembered pyeloplasty: Initial experiences

AIM

To review the results of our first 40 cases of retroperitoneal dismembered pyeloplasty and to compare them with series of open and other minimally invasive treatments of pelviureteric junction (PUJ) obstruction. Also to compare our first 20 cases with the second 20 cases to see if there was an improvement in results with experience.

METHODS

A retrospective review of the first 40 laparoscopic pyeloplasties performed by a single lead surgeon at two institutions was performed. The diagnosis of PUJ obstruction was confirmed with an intravenous urogram as well as a renogram prior to surgery. A retroperitoneal, dismembered pyeloplasty was routinely performed with three or four ports. All patients were followed up with an intravenous urogram, renogram and review of symptoms at 4 months and annual renogram after that.

RESULTS

Average operation time was 236 min and this appeared to decrease with experience. Two cases had to be converted to open operations. The mean hospital stay was 3.4 days. Out of the 40 patients, 34 have had successful laparoscopic operations with total symptomatic relief as well as radiologically proven deobstruction. There were four major complications with 3 patients going on to have redo open pyeloplasty operations. There were seven minor complications.

CONCLUSIONS

In our experience, retroperitoneal dismembered pyeloplasty is an effective and safe means of treating PUJ obstruction. Our results seem to be comparable with series of open pyeloplasty and other laparoscopic series and are better than some other minimally invasive techniques.

Minimally Invasive Treatment of Ureteropelvic Junction Obstruction: Optimizing Outcomes with Concomitant Cost Reduction

With the seemingly exponential increase in the use of minimally invasive techniques in urology, cost-benefit comparisons will continue to play a major part in establishing services and in improving those that already exist. The management of ureteropelvic junction obstruction is a focus of significant attention. An effective way of optimizing the economy of management is to understand the implications in terms of the success of each mode of treatment. Subsequently, costing models should be developed and applied in large-scale multicenter studies with the aid of health economists. The long-term benefits can then be assessed by also including patient's perceived quality of life. Economic assessment will not be enough to promote cost-effective practices. The take-up of any techniques will always be influenced not only by patient preference and surgeon expertise but also, perhaps ironically, by the way hospitals and surgeons are remunerated. In addition, the impact of the time taken to train a surgeon to carry out laparoscopic dismembered pyeloplasty competently may play a significant role. Until these issues are resolved, definitive recommendation for the treatment of ureteropelvic junction obstruction will continue to be made on an individual basis.

Laparoscopic pyeloplasty: Evolution of a new gold standard

OBJECTIVES

To report our series of laparoscopic dismembered pyeloplasty for the treatment of primary and secondary ureteropelvic junction obstruction and to review the current status of this procedure.

METHODS

A total of 170 consecutive cases of laparoscopic pyeloplasty (156 for primary and 14 for secondary ureteropelvic junction obstruction) were performed or supervised by a single surgeon (C.G.E). A four-port extraperitoneal approach was used in all but 3 cases, which were performed transperitoneally.

RESULTS

The median operative time was 140 minutes. The complication rate was 7.1%, and the conversion rate was 0.6%, with no conversion in the last 161 cases. The median postoperative hospital stay was 3 nights. Crossing vessels were encountered in 42% of cases, and in 11 patients, coexisting renal calculi were successfully removed. At a median follow-up of 12 months, the success rate was 96.2%.

CONCLUSIONS

Laparoscopic dismembered pyeloplasty produces functional results comparable to that of open surgery with the advantages of a minimally invasive procedure. Our results are consistent with previous series and support the view that laparoscopic pyeloplasty is moving rapidly toward replacing open surgery as the gold standard in the treatment of ureteropelvic junction obstruction.

Laparoscopic urology training in South Africa

BACKGROUND AND PURPOSE

Laparoscopic urologic surgery is not widely practiced in South Africa. After presenting a laparoscopic training course, we evaluated how effectively this training translated into clinical practice.

SUBJECTS AND METHODS

Invitations to the course were sent to all South African urologists. Ten applicants attended the course, which consisted of dry and in-vivo animal surgery. Two questionnaires were sent out after the course. Questionnaire 1 (at course completion) aimed at identifying the precourse laparoscopic experience and expectations of the trainee. Questionnaire 2 (6 months postcourse) assessed how much laparoscopic surgery the participant had performed since the course.

RESULTS

Seventeen percent of all South African urologists responded to the invitation. Prior to the course, 40% of trainees had performed >or=10 laparoscopic cases, 30% had performed <10 cases, and 30% had never performed laparoscopy, whereas 60% expected to be doing one or two cases a month after completing the course. Six months after the course, 60% had performed no laparoscopic cases. Of the three trainees who had never before done laparoscopic procedures, none had started to perform procedures since the course. The commonest procedures performed were varicocelectomy and diagnostic laparoscopy for nonpalpable testis.

CONCLUSIONS

A hands-on laparoscopic training course to introduce laparoscopic urology into South African private urology practice has not translated into a satisfactory number of clinical cases being performed. The causes are likely multifactorial but are greatly influenced by social and economic forces. One possible solution may be to offer a mentor-based training program.