International Journal of Urology (2015) 22, 368–371

doi: 10.1111/iju.12686

Original Article: Clinical Investigation

Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: Long-term results Morihiro Nishi, Mayumi Tsuchida, Masaomi Ikeda, Daisuke Matsuda and Masatsugu Iwamura Department of Urology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan Abbreviations & Acronyms LPP = laparoscopic pyeloplasty UPJ = ureteropelvic junction UPJO = ureteropelvic junction obstruction Correspondence: Morihiro Nishi M.D., Department of Urology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan. Email: uromori2000@yahoo. co.jp Received 7 September 2014; accepted 4 November 2014. Online publication 19 January 2015

Objective: To evaluate the long-term results of laparoscopic pyeloplasty in patients with secondary ureteropelvic junction obstruction after failed primary interventions. Methods: Between August 2000 and October 2012, transperitoneal dismembered laparoscopic pyeloplasty was carried out in 13 patients with a surgical history of failed prior surgical interventions. Perioperative outcomes as well as long-term results were assessed. These outcomes were compared with those of the same procedure carried out for primary ureteropelvic junction obstruction by a single surgeon during the same study period. Results: Laparoscopic transperitoneal pyeloplasty was completed successfully in all cases without converting to open surgery or requiring blood transfusion. The preoperative symptoms in 12 of 13 patients all disappeared soon after the operation. Asymptomatic severe hydronephrosis found in a 2-year-old boy reduced in size postoperatively. When comparing the primary with the secondary laparoscopic pyeloplasty carried out by the same surgeon, the mean operative time was longer (183 vs 241 min, P = 0.002), estimated blood loss was larger (33 vs 66 mL, P = 0.03) and the complication rate was higher (8.8% vs 22.2%, P = 0.01) in the secondary group. Success rates were 97.9% and 100% (P = 0.41) at a mean follow up of 25.9 and 40.0 months (P = 0.14) for the primary and secondary groups, respectively. Conclusions: Laparoscopic pyeloplasty is an excellent option for patients who failed previous surgical management. This approach provides durable long-term outcomes comparable with those of primary treatment for ureteropelvic junction obstruction.

Key words:

laparoscopy, long-term, pyeloplasty, result, secondary.

Introduction For more than 60 years, open dismembered pyeloplasty has been the gold standard for the treatment of UPJO.1–3 Recently, however, surgical management of UPJO has been revolutionized by the introduction and widespread adoption of minimally invasive techniques as alternatives to open procedures. In particular, the popularity of both antegrade and retrograde endopyelotomy has made endourological procedures the primary choices for treatment of UPJO in most adults.4,5 Although these procedures are associated with relatively few complications, brief hospitalization and little disability, the reported success rates of 71–88% have not approached those of open operative intervention.6,7 LPP was first described in 1993 by Schuessler et al.8 This procedure was originally developed in an attempt to duplicate the results of open pyeloplasty while decreasing postoperative morbidity, and many groups have reported favorable results and durable outcomes of LPP for primary UPJO.9–14 However, fewer reports have described salvage LPP in secondary UPJO.15–20 Here, we present our experience with LPP in patients who had failed prior surgical management of UPJO and report their long-term outcomes.

Methods Between August 2000 and October 2012, redo laparoscopic transperitoneal dismembered pyeloplasty was carried out by three surgeons on 13 ureters in 13 patients for whom prior surgical interventions had failed. Patient characteristics are summarized in Table 1. The mean age of the patients was 26.0 years (range 2–47 years). The prior failed procedures were balloon dilation in three patients, antegrade endopyeolotomy in two patients, retrograde endopyelotomy in two patients, open pyeloplasty in four patients and LPP in two patients. All patients except one showed 368

© 2015 The Japanese Urological Association

LPP was feasible treatment for secondary UPJO

Table 1 Characteristics of patients with secondary UPJO Mean age, years (range) Sex (male/female) Disease side (left/right) Prior procedures (n)

Mean time from prior procedures, months (range) Indication of prior procedures (n)

Indication of secondary LPP (n)

26.0 (2–47) 10/3 12/1 Balloon dilation: 3 Antegrade endopyelotomy: 2 Retrograde endopyelotomy: 2 Open pyeloplasty: 4 Laparoscopic pyeloplasty: 2 23 (4–396) Flank pain: 10 Urinary tract infections: 1 Worsening of hydronephrosis: 2 Flank pain: 10 Urinary tract infection: 2 Worsening of hydronephrosis: 1

some clinical symptoms, including flank pain in 10 patients and recurrent urinary infection in two patients. Worsening of hydronephrosis without apparent clinical symptoms was observed in a 2-year-old boy during regular follow up after primary LPP. The mean time from initial treatment to redo LPP was 23 months (range 4–396 months). Among these patients, nine were operated on by a single surgeon who carried out primary laparoscopic transperitoneal dismembered pyeloplasty in 103 cases during the same period. Laparoscopic transperitoneal Anderson–Hynes pyeloplasty was carried out according to the procedure described previously,10 with minor modifications. In brief, after careful dissection of the upper ureter and renal pelvis, a stay suture was placed in the medial edge of the renal pelvis just above the stenotic segment (Fig. 1). This was pulled out through the abdominal wall using Endo-Close (Covidien Japan, Tokyo, Japan) and fixed with appropriate tension. The lower edge of the pelvis was transected on the cross from the upper medial side to the lower lateral side. The lateral aspect of the transected ureter was spatulated longitudinally toward a point 1 cm below the stenotic

segment. A 4-0 polyglycolic acid suture was passed outside-in at the apex of the incised renal pelvis and inside-out at the apex of ureteral spatulation; the suture was then tied. A 6-Fr double pigtail stent was placed in the ureter antegradely. Ureteropelvic anastomosis was carried out in a running manner using 5-0 monofilament sutures with a 1/2 curved 13-mm needle. Running suture was initiated from the caudal to cephalad edge, first on the lateral side, then on the medial side. When anterior crossing vessels were noted, they were preserved and transposed posteriorly, and ureteropelvic anastomosis was carried out at the anterior aspect of crossing vessels. The double pigtail stent remained indwelling for 4–6 weeks. We reviewed the intraoperative records and hospital charts of all patients to evaluate patient characteristics, operative times, hospital courses, and complications. Surgical outcomes of nine redo LPP were compared with 103 primary LPP carried out by the same surgeon during the same period. Complications were categorized according to the Clavien–Dindo classification system.21 All patients were subjectively followed up at office visits or by telephone. Patients followed up by the operating urologist were seen at 4 weeks, 12 weeks, 6 months, every 6 months for 2 years, and yearly thereafter. A diuretic renogram was obtained at 6 months, 1 year and 2 years. Overall success was defined as a combination of symptomatic relief, radiographic evidence of a patent ureteropelvic junction and stable or improved renal function.22 Student’s t-test and Pearson’s χ 2-test were used for statistical analysis of the continuous and categorical variables, respectively. A value of P < 0.05 was considered significant.

Results LPP was completed successfully in all cases, with none converted to open surgery nor requiring blood transfusion. Etiologies of secondary UPJO estimated were based on operative findings and surgical outcomes (Table 2). Intrinsic stricture at the anastomotic site was identified in nine of 13 (69.2%) ureters, whereas the presence of anterior crossing vessels without an obvious narrow segment was noted in four of 13 (30.8%) ureters. The preoperative symptoms observed in 12 patients completely disappeared, except for one patient who had persistent pyuria postoperatively. This patient was confined to bed for a long time because of multiple sclerosis, and had multiple

Table 2 Operative findings and surgical outcomes in patients with secondary UPJO Mean operative time, min (range) Mean volume of bleeding, mL (range) Etiologies (n) Surgical outcomes Disappearance of preoperative symptoms (n) Downgrading of hydronephrosis (n) Complications (n) Figure 1 The pelvis was transected after a stay suture was placed and pulled out through the abdominal wall. The severe adhesion around the thickened pelvic wall is seen. © 2015 The Japanese Urological Association

269 (165–525) 66 (20–230) UPJO: 9 Crossing vessels: 4

11/12 13 Paralytic ileus: 1 Severe hematuria: 1 Metal clip migration: 1

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bilateral renal stones. A 2-year-old boy with asymptomatic severe hydronephrosis showed no newly occurring clinical symptoms postoperatively. The degree of hydronephrosis was downgraded or disappeared in all 13 patients, resulting in a success rate of 100%. Complications were observed in three cases. Paralytic ileus (grade I) and severe hematuria (grade I) recovered spontaneously. In one case, a metal clip used for securing a crossing vein migrated into the renal pelvis (grade IIIb), and subsequently created a renal stone. Therefore, this patient underwent flexible transurethral lithotripsy. Table 3 shows the comparison of patients’ characteristics and surgical outcomes between primary and secondary LPP carried out by a single surgeon. There was no difference in age, sex or body mass index between the two groups. The left side was affected in all of the secondary group (59.2% vs 100%, P = 0.01). Statistically significant differences were seen in operative time (183 vs 241 min, P = 0.002) and estimated blood loss (33 vs 66 mL, P = 0.03) between the primary and secondary groups. The postoperative courses, including the days to ambulation, days to regular diet, days to catheter removal, days to drain removal, days to stent removal (data not shown for all previous) and days of hospital stay (P = 0.27), were similar in the two groups. The success rates were 97.9% and 100% (P = 0.41) at a mean follow up of 25.9 and 40.0 months (P = 0.14) for the primary and secondary groups, respectively. Three cases in the primary group had perioperative complications. Two were urinary tract infections (Clavien grade II) and one was a surgical site infection (Clavien grade I). There was a statistically significant difference in complication rates between the two groups (P = 0.01).

Discussion UPJO is the most common congenital abnormality of the upper urinary tract. Open pyeloplasty has traditionally been viewed as

Table 3 Comparison of patient characteristics and surgical outcomes between primary and secondary LPP carried out by a single surgeon Primary LPP (n = 103) Mean age, years (range) Sex (male/female) Disease side (left/right) Mean body mass index, 2 kg/m (range) Mean operative time, min (range) Mean blood loss, mL (range) Mean hospital stay, days (range) Mean follow-up periods, months (range) Success rate, % (n/total) Complication rate, % (n/total)

370

Secondary LPP (n = 9)

P-value

32.3 (1–66) 54/49 61/42 20.3 (10.3–29.9)

27.5 (17–47) 6/3 9/0 21.3 (18.6–24.5)

0.33 0.41 0.01 0.32

183 (80–330)

241 (165–340)

0.002

33 (20–250)

66 (20–230)

0.03

5.1 (2–14)

6.1 (3–13)

0.27

25.9 (1–98)

40.0 (1–146)

0.14

97.9 (97/99) 8.8 (3/103)

100 (9/9) 22.2 (2/9)

0.41 0.01

the reference standard.1–3 Endoscopic incision through retrograde and antegrade approaches was developed to provide a minimally invasive alternative to open surgery.4,5,23 However, the overall success rate of these techniques can be approximately 10–25% lower than for open pyeloplasty, particularly in circumstances such as marked hydronephrosis, poor renal function and the presence of an anterior crossing vessel.6,7 In addition, endoscopic incisions are associated with a risk of perioperative hemorrhage, with 3–11% of patients requiring blood transfusion.4,24,25 LPP was first introduced in 1993 by Schuessler et al., and it has emerged as an alternative first-line option with success rates that parallel those of the open approach.8 We have also achieved excellent results with the transperitoneal approach over the past 12 years, and continue to use it as the standard approach at our institution. LPP allows the surgeon to carry out operative steps similar to those in open pyeloplasty, such as dissection, transection and suturing. However, LPP is considered a difficult procedure that requires considerable proficiency in intracorporeal suturing. Although most literature regarding LPP is in the context of primary repair, LPP has also been shown to have excellent success rates for persistent UPJO after a previously failed procedure.15,18–20,26,27 Likewise, the surgical outcome in the series reported here was also excellent. Intraoperatively, we have encountered significant periureteral fibrosis, which has contributed to the difficulty of the approach, and has increased the operative time and blood loss. Indeed, LPP for secondary UPJO took significantly more operative time, had significantly more blood loss and a higher complication rate than those for primary UPJO (Table 3). Crossing vessels were seen in four cases (30.8%), and three of these underwent an endourological procedure as an initial treatment. The time from initial treatment to redo LPP in the patients with an endourological procedure was shorter than that in the patients with an open or laparoscopic procedure (P = 0.03, data not shown). A crossing vessel has been suggested to be one of the major causes of failed endopyelotomy.7 Avoidance of treatment of the crossing vessels could be a possible cause of the early recurrence in patients with endourological procedures. Therefore, in patients with failed primary endourological procedures in the short-term, a great deal of thought should be given to the presence of the crossing vessels. Furthermore, we had the three patients who received initial treatment at our institution followed by redo LPP. One patient underwent endopyelotomy as the initial procedure, and missed crossing vessel was observed at redo LPP. Another two cases underwent open and laparoscopic pyeloplasty. The cause of the failure in these cases was considered to be insufficient spatulation length at the narrow segment in the initial treatment. LPP is technically challenging and has a long learning curve, and it must be noted that our excellent surgical outcome was the result of the procedure being carried out by expert surgeons. One of the most difficult processes in LPP was ureteropelvic anastomosis, with the procedure being particularly difficult in one secondary case. Adhesive tissue delaminates and bleeds easily. Therefore, extreme care was required to prevent tissue damage. Although the 100% success rate in the present study supports the approach, our enthusiasm for the technique must be tempered because of the small sample size. © 2015 The Japanese Urological Association

LPP was feasible treatment for secondary UPJO

Piaggio et al. made a comparative review between laparoscopic reoperative pyeloplasty and open reoperative pyeloplasty in children.28 Success rates and rehospitalization rates were similar, but the mean operative time was longer and mean hospitalization was shorter in laparoscopic cases. Basiri et al. reported on 18 patients treated with reoperative LPP after a failed open pyeloplasty.15 They mainly used vertical flap (in 10 cases) and dismembered pyeloplasty (in six cases) techniques because of severe and long ureteral stricture. The success rate was 83.3%, and no complication or blood transfusion occurred intraoperatively. Over the past decade, the use of robotic assistance in urological laparoscopy has expanded. Robot-assisted laparoscopic surgery has the advantages of 3-D visualization, 6° of motion and no tremor. For these reasons, a faster learning curve with the robot compared with laparoscopy was shown.29 Niver et al. reported robot-assisted LPP for primary versus secondary repair.30 They carried out robot-assisted primary repair in 97 patients and secondary pyeloplasty in 20 patients with no intraoperative conversion. No significant differences were found in the patient demographics, operative data, or postoperative or radiographic outcomes for the primary analysis. They concluded that robot-assisted LPP is a safe and durable option for secondary UPJO. Thus, robot-assisted LPP for secondary UPJO might be a more effective procedure than LPP with regard to easing the difficulty, and its effectiveness might be more apparent in secondary UPJO than in primary UPJO.

Conflict of interest None declared.

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Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: long-term results.

To evaluate the long-term results of laparoscopic pyeloplasty in patients with secondary ureteropelvic junction obstruction after failed primary inter...
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