Laparoscopy and Robotic Surgery

Laparoscopic Dismembered Pyeloplastyfor Ureteropelvic Junction Obstruction:

Experience with 142 Cases in a High-Volume Center

Onkar Singh, MBBS, M.S.,1 Shilpi Singh Gupta, MBBS, M.S.,1

Ankur Hastir, MBBS, M.S.,2 and Nand Kishore Arvind, M.S., M.Ch., D.N.B.1,3

Abstract

Background and Purpose: Laparoscopic dismembered pyeloplasty (LDP) is a minimally invasive approach thatis becoming standard management of ureteropelvic junction obstruction (UPJO). It provides similar results whencompared with open surgery. The main goal of LDP is to meet the standard of open dismembered pyeloplastywith reduced trauma for the patients. The purpose of the study was to evaluate the postoperative and functionalresults of LDP.Patients and Methods: We retrospectively reviewed and analyzed 142 cases of LDP performed at our center overa period of 7 years ( January 2003 to December 2009) for UPJO with dilatation of the renal pelvis. Patients’profiles and perioperative, intraoperative, and postoperative parameters, such as time of surgery, blood loss,complications, duration of hospital stay, and outcomes of the procedure, were all evaluated and analyzed.Results: The mean operative time for LDP was 145 minutes (range 110–180 min), and the mean estimated bloodloss was negligible in all patients. The mean hospital stay was 3.5 days (3–6 d). Two conversions to open surgeryoccurred because of difficulty to complete the anastomosis. In one patient, shock caused by bleeding frominferior epigastric vessels near the port site developed and had to be explored. The success rate was 96.8%.Conclusion: When performed by expert surgeons, LDP can safely achieve success rates that are comparable tothose of open surgery described in the literature, with fewer complications and less morbidity to the patients.The few important difficulties with their management that we encountered are discussed.

Introduction

Laparoscopic dismembered pyeloplasty (LDP) was de-veloped during the early 1990s, and since then, it has been

widely accepted rapidly as standard treatment for ureteropelvicjunction obstruction (UPJO). LDP has stood the test of time interms of results, safety, efficacy, and complications. Recent re-ports show that LDP performed by experienced laparoscopicsurgeons has provided success rates of more than 90%.1–14

We present our technique and results of LDP for UPJO in142 patients.

Patients and Methods

From January 2003 to December 2009, 142 LDP were per-formed by the same surgeon (NKA). All patients had primaryUPJO with a dilated renal pelvis (secondary UPJO excluded).The diagnosis was made and confirmed by ultrasonography

(US), intravenous urography (IVU), and renal scintigraphy inall aptients. Patients’ profiles (age, sex) and perioperative,intraoperative, and postoperative parameters, such as time ofsurgery, blood loss, complications, duration of hospital stay,and outcomes of the procedure were all evaluated and analyzed.Patients with previous abdominal surgeries were not included.

Surgical technique

To start, we used to perform cystoscopy and ureteralcatheterization with a 6F ureteral catheter (UC), followed byretrograde pyelography, and leave the UC in situ in everypatient (first 37 cases). The UC was tied to a Foley catheter thatwas inserted in the bladder to avoid displacement. Then thepatients were placed in a 45-degree flank position. We usedthe transperitoneal approach in all cases.

First, a 12-mm port was placed by open technique at thelevel of the umbilicus and about two fingers toward the side to

1Department of Urology, Bhopal Memorial Hospital and Research Centre, Bhopal, India.2Department of Surgery, MGM Medical College and Hospital, Navi Mumbai, Kamothe, India.3Department of Urology, BGS Apollo Hospital, Kuvempu Nagar, Mysoor, Karnataka, India.

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be operated. The peritoneal cavity was inspected by a 30-degree telescope, followed by placement of two other ports: A12-mm port in the ipsilateral midclavicular line in the iliac fossa,and a 5-mm port between the xyphoid and the umbilicus.

Bowel was reflected by giving an incision along the line oftoldt. The ureter was identified in the retroperitoneum. Theproximal ureter, ureteropelvic junction (UPJ) and the renalpelvis were completely freed. The renal pelvis was eitherdismembered completely and the redundant portion excisedor the dismembering incision was extended to the lateral as-pect of the ureter to spatulate it before complete dismember-ing. The cephalad aspect of the pelvis was closed verticallyfrom above-downward with interrupted=continuous poly-glactin 4-0 sutures, leaving about a 1.5–2 cm portion unclosedin the dependent part. After excising the stenotic portion, theureter was spatulated medial to lateral (above-downward)according to the left-open portion of the pelvis.

The anastomosis was started by taking full-thickness bites(polyglactin 4-0) from the lowermost point of the spatulatedureter to the lowermost point of the pelvis. Withinterrupted=continuous suturing technique, the posteriorlayer was completed so that the uppermost point of the ureterwas approximated watertight to the uppermost point of theleft-open pelvis. In case crossing vessels were the cause, theureter and the renal pelvis were transposed anteriorly beforethe anastomosis.

Just before the anastomosis was completed, a guidewirewas passed through the UC (already left in) and the UC re-moved. A 6F Double-J stent was passed over the guidewireand placed in the pelvis and the ureter across the anastomosis.The anastomosis was then completed.

An additional fourth 5-mm port was necessary in the an-terior axillary line at the level of the umbilicus to facilitate thedissection and anastomosis in 39 cases.

After the initial 37 cases, our surgeon tried antegrade stentplacement laparoscopically by introducing a UC loaded overa guidewire through a 5-mm port. The guidewire was passedinto the bladder through the partially completed ureter-opelvic anastomosis, the UC removed, and the Double-J stentinserted. In the rest of the cases (105), we did antegrade stentplacement laparoscopically.

A 14F closed suction drain was placed through the 5 mmport in the operative area away from the anastomosis. Theport sites were closed with interrupted absorbable sutures.The Foley catheter was removed on the morning of postop-erative day 2.

Follow-up

The Double-J stent was removed after 4 weeks. The meanfollow-up was 30 months (range 4–56 mos). Our protocol wasto obtain an IVU at 3 months and a diuretic renal scan in allcases at 6 months of follow-up. The outcome was consideredsuccessful if there was complete resolution of flank pain (clini-cal), adequate renal excretion of contrast on IVU (radiographic),and preserved or improved renal function on the renal scan.

Results

The mean age of patients who underwent LDP was 39 years(18–60). Of these, 78 were men and 64 were women. Crossingvessels with an anterior course to the UPJ were found in 60.5%(86=142) cases. Two patients with retrocaval ureter alsounderwent LDP without excision of the retrocaval portion.The mean operative time was 145 min (110–180 min), and themean estimated blood loss was minimal (<20 mL) (Table 1).Two conversions to open surgery occurred because of diffi-culty to complete the anastomosis. Injury to the crossingvessels did not occur in any case. The mean hospital stay was3.5 days (3–6).

We started the operation with a standard three-port tech-nique in all cases. In 39 (27.5%) patients, a fourth port wasneeded to facilitate either the mobilization of the renal pelvisor the ureteropelvic anastomosis. A fourth port was neededfor LDP in both patients with retrocaval ureter.

Retrograde stent placement (preopertive) was performedin the first 37 cases and antegrade stent placement in 104. Onepatient needed postoperative retrograde stent placement,because the stent could not be passed down beyond the ve-sicoureteral junction. We found antegrade stent placementsimpler, easier, and quicker than use of the retrograde tech-nique. The mean operative time of cases in which retrograde(37) and antegrade (104) stent placement was performed was162 minutes and 124 minutes (P¼ 0.002), respectively.

Prolonged postoperative ileus was noted in five (3.5%)patients. We removed the drain few hours after catheter re-moval. Three patients (2.1%) needed recatheterization foranother 2 days because of increased urinary drainage from thedrain after catheter removal. Postoperative hematoma de-veloped in three patients, all of whom also had prolongedileus. None of them needed an intervention. Urinoma devel-oped in seven patients (4.9%), and a percutaneous pigtailcatheter was placed under US guidance. Insix patients, theurinoma resolved, while one patient needed laparoscopic re-suturing of a rent in the anastomosis.

Shock occurred in one patient 8 hours after uneventfulLDP, and the patient needed emergency exploration. Severed

Table 1. Intraoperative and Postoperative Records

Mean operating time All cases: 145 min (110–180)First 37 cases with retrograde

stenting: 162 minFirst 37 cases with antegrade

stenting: 124 min

Mean estimated blood loss <20 ml

Crossing vessels present 86=142 (60.5%)

Fourth port needed 39=142 (27.5%)

Hospital stay (days) 3.5 (3–6)

Postoperative hematoma 3 (2.1%)

Postoperative urinoma 7 (4.9%)Resolved with percutaneous

drainage: 6Needed laproscopic repair of

anastomotic rent: 1

Others:-Injury to inferior epigastric

vessels (after 8 hour postop)1

leading to exploration-Loss of needle 2

Recurrence 4 (3%)Balloon dilatation successful:

2 Needed open surgery: 2Overall success rate 96.8%

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inferior epigastic vessels near the port site were the cause ofbleeding and were ligated. Another problem was accidentalloss of the suture needle in two cases; the needle was recov-ered using fluoroscopy.

The mean follow-up was 30 months (range 4–56 mos).Eleven patients were lost to follow-up after Double-J stentremoval. During follow-up, all patients underwent IVU at3 months. A total of 128 patients underwent a diuretic renalscan at 6 months, and 1 patient at 5 months (11 patients lost infollow-up). The renal scan could not be performed in twopatients who did not come for further follow-up after initialevaluation with IVU. If these two are also excluded, theoverall success rate is 96.8% (125=129). Four (3%) came withrecurrence after 6, 8, 11, and 12 months of operation. All fourunderwent balloon dilatation, but two patients ultimatelyneeded open surgery.

Discussion

LDP, developed in the early 1990s, is rapidly becomingthe standard of care for the management of UPJO. This min-imally invasive approach has led to equivalent resultscompared with open surgery, with decreased convalescenceand analgesic requirements.15,16 The other minimally invasivemanagement options for UPJO include percutaneous andureteroscopic endopyelotomy and cutting transvesical bal-loon dilatation.17 The main goal of these minimally invasiveprocedures, including LDP, is to meet the standard of opendismembered pyeloplasty with reduced morbidity for thepatients.1

LDP has been shown to provide high success rates simi-lar to those achieved with open pyeloplasty, with similar orlesser overall complication rates, when performed by expertsin centers with high laparoscopic expertise.2–4,17 The reportedsuccess rate of LDP is 73% to 100%.1–14,17 LDP provides bettervisualization of anatomy and more workspace to performanastomosis in addition to a good track record of performedcases.11 Our surgeon also reported that improved visualiza-tion resulted in better dissection in the UPJ area. Furthermore,Eden11 in 2007 reviewed the results of minimally invasivetreatment of UPJO and concluded that patients undergoingLDP rarely needed transfusion while the transfusion rate withendourologic UPJO incision was 3% to 11%.

Recently, Wagner and associates17 published the resultsof LDP in 105 patients. The mean operative time was 150minutes, and they reported no conversion to open surgery,minimal blood loss, and a success rate of 96.2% with very fewcomplications. In the present series, the mean operative timewas 145 minutes, which is on the lower side of the rangereported in the literature.1–14,17 The mean estimated blood losswas minimal in all patients, and no conversion to open sur-gery occurred. Our surgeon attributed the zero incidence ofinjury to the crossing vessels to better visualization of thenormal and anomalous anatomy in LDP.

In the study by Wagner and colleagues,17 the surgeonsperforming LDP had already performed at least 40 LDPs eachbefore the beginning of the study. They used a four-porttechnique and occasionally used a fifth port. Our surgeon hadcompleted 25 LDPs before inclusion of his case records intothe present study. We used the standard three ports andneeded a fourth port in little more than one quarter (39=142) ofthe cases. Among these, the first 13 fourth-port insertions

were needed in the first 26 cases, while the last 13 were in thelast 69 cases. According to our team’s experience, the learningcurve for LDP tapers at about 45 cases.

In our initial cases, we experienced a problem in spa-tulating the ureter, because it became difficult to handleafter complete dismembering. In comparison, extendingthe dismembering incision on to the lateral aspect of theureter to spatulate it before complete dismemberingreally proved helpful by providing traction and stabili-zation.18

Also, initially we used to perform anastomosis using aninterrupted suturing technique, but with increasing experi-ence, we now prefer a continuous suturing technique becauseit avoids hindrance caused by multiple intracorporeal knots.Thus, it is time saving.19

Last, we found antegrade stent placement really simple andquicker than using the retrograde method. Moreover, thesurgical area remains free of any hindrance caused byUC=Double-J stent placement in a retrograde manner. Thisactually makes spatulation of the ureter and subsequentanastomosis easier. Also, it avoids one more procedure andneed to change the position of the patient, and obviouslyreduces the operative time.20

Conclusion

Although LDP requires great expertise, with increasingexperience in laparoscopy, it should be the procedure ofchoice for primary UPJO in terms of high success rates, fewercomplication rates, and decreased surgical morbidity for thepatients. Laparoscopic antegrade stent placement, spatulatingthe ureter before complete renal pelvic dismemberance, andusing a continuous suturing technique for anastomosis are afew tips that may prove helpful to increase efficiency andreduce the learning curve.

Disclosure Statement

No competing financial interests exist.

References

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Address correspondence to:Onkar Singh, MBBS, M.S.

Department of UrologyBhopal Memorial Hospital and Research Centre

Bhopal 462038India

E-mail: dronkarsingh@gmail.com

Abbreviations Used

IVU¼ intravenous urographyLDP¼ laparoscopic dismembered pyeloplastyUPJ¼ureteropelvic junction

UPJO¼ureteropelvic junction obstructionUC¼ureteral catheterUS¼ultrasonography

1434 SINGH ET AL.