Laparoscopic pyeloplasty. What is changed after more than 300 surgical procedures and 10 year of experience
Purpose of the study: to describe and analyze a single surgical team's experience of the Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) procedure in the treatment of UPJO. We analyze what is changed after more than 300 surgical procedures and 10 year of experience.
Materials and Methods
316 consecutive patients whose underwent transperitoneal (LP) over a period of 11 years (january 2004-february 2015) were retrospectively analyzed for intraoperative complications. 301 consecutive patients were analyzed for postoperative complications because 15 patients underwent pyeloplasty from September 2014 to February 2015). In 297 cases surgical indication was primary uretero-pelvic junction obstruction (UPJO) and in 19 cases recurrent obstruction. Two hundred and ninety patients (91%) were symptomatic. All procedures described here were performed by a single experienced laparoscopic team. In all cases pyeloplasty using the Anderson-Hynes technique was performed. A transperitoneal approach was used in all cases. Ventrally crossing vessels were found in 126 patients (40%). 3 cases consisted of a horseshoe kidney. A retrocaval ureter was diagnosed in one case while in 7patients a large parapyelic cyst was associated with UPJO. Treatment success was defined by imaging (partial or complete resolution of hydronephrosis), functional assessment (improvement at renal scan) and on the basis of clinical findings. Renal ultrasonography and IVU were performed 6, 12 and 18 months postoperatively and a yearly follow-up with either IVU or renal ultrasonography thereafter was indicated. Intraoperative incidents were analyzed1. The patients were positioned in lateral decubitus after placement of the ureteral catheter and ureteropyelography. Initial transperitoneal access was performed through an open Hasson approach. A 0° telescopic and 2 multi-disposal metal trocars were used. Dissection was performed by using monopolar scissors and bipolar forceps. The proximal ureter was spatuled with a lateral incision after resection and removal of the stenotic ureteropelvic junction. Ventrally crossing vessels were generally transposed only in cases of real obstruction. The anastomosis was performed using a running 5-0 absorbable suture. A double-J stent was routinely inserted in retrograde fashion but in male patients this step was completed at the end of the laparoscopic intervention under fluoroscopic and cistoscopic control2.
Mean operating time at 94.5 minutes (range 40 to 360). The mean blood loss was 20 mL (range 5 to 500 mL) and no blood transfusions were necessary. All operations were successfully performed laparoscopically without conversion to open surgery. The overall success rate was 99% (298 patients) with a mean follow-up of 38 months (range 6 – 84 months).
We didn’t report intra or postoperative complications in the patients with anomalous crossing vessel not transposed and the surgical procedures resolved the UPJO in all these cases. The mean postoperative hospital stay was 4.1 days (range 3 to 14). All 290 preoperative symptomatic patients reported a complete resolution of symptoms following the procedure. The radiologic follow-up showed a normal UPJ and a significant reduction in preoperative hydronephrosis in all patients with the exception of 15 (5%) for whom persistence of a partial UPJO and moderate-to-severe hydronephrosis was detected at first post-operative follow-up visit at month 6. All cases were initially conservatively treated by retrograde insertion of a double-J stent left in place for 3 months and this treatment resulted in a definitive resolution of persistent UPJO in 8 cases3. The remaining 7 patients underwent a successful second laparoscopic dismembered pyeloplasty. Intraoperative incidents occurred in 9 patients (2.8%). The most frequent intraoperative incident was retrograde stent migration to distal ureter and all cases occurred with female patients. The most frequent postoperative complication was urine leakage (2%)4.
From first pyeloplasty ten years ago, we have reduced operating time from about 5 hours to about 1 hour. The overall success rate is reaching 100% with a progressive reduction of complications. During these years we have improved our technique and we have discovered some important strategies that could help to improve the success of procedure. First of all we consider that the isolation of the ureteropelvic junction should be much more "in situ". Moreover you should coagulate sections margins as less as possible, in particular ureteral margins in order to make ureteropelvic anastomosis more vital. Pay attention to perform a "tension free" anastomosis, in the correct position (as more anatomical as possible) and without make it twisted. In our experience the most delicate surgical step is the insertion of the ureteral stent because, if inserted incorrectly it can cause time-consuming intraoperative complications or induce moderate to severe postoperative complications. For this reason we refined our technique and started to routinely perform some modifications such as retrograde insertion in female patients and insertion under fluoroscopic and cistoscopic control at the end of the operation in male patients. Our future target will be the intraoperative stent placement, also in male patients, using a flexible cistoscopy, before anterior hemisuture. Particular attention should be given to the early postoperative phase so as to monitor for eventual urine leakage which could lead to a severe complication that which would require active management. Improving our overall success, we have increased follow-up period. Although we never undervalue the importance of follow-up. It's important to inform patient and his family about results and expectations, without consider laparoscopic pyeloplasty a simple procedure. In this period we have improved our surgical experience in with important functional results. By our experience we think that new "barbed suture" will not improve success rate, robotical surgery is too much expensive without improving success rate (at least in the centers with an important laparoscopical experience). Also 3D laparoscopy and minilaparoscopy don't improve success rate.
Our retrospective analysis confirms that the Anderson-Hynes transperitoneal laparoscopic pyeloplasty (LP) procedure is a efficacious and safe in the treatment of UPJO, resulting in a reported success rate of 99% and a concomitant low level of intraoperative and postoperative complications. The most frequent and severe intraoperative complications are related to the double J stent insertion. The most common postoperative complication is urine leakage that in the case of a transperitoneal approach requires an early active management in order to avoid potentially severe consequences. New technologies as robotic devices, 3D laparoscopy and minilaparoscopy can help surgeon to perform important step during pyeloplasty, but they are not necessary, above all in hospitals with a big surgical volume.
1-Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R,Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009 Aug; 250 (2): 187-96.
2-Fedelini P. et all, Intraoperative and postoperative complications of laparoscopic pyeloplasty: a single surgical team experience with 236 cases. J Endourol. 2013 Oct;27(10):1224-9.
3- Jens J. Rassweiler, Dogu Teber, Thomas Frede, Complications of laparoscopic pyeloplasty. World J Urol (2008) 26:539–547.
4- Satava RM. Identification and reduction of surgical error using simulation. Minim Invasive Ther Allied Technol. 2005; 14 (4): 257-61.