Int Urol Nephrol DOI 10.1007/s11255-013-0591-z
UROLOGY - ORIGINAL PAPER
Laparoscopic ureterocalicostomy for complicated upper urinary tract obstruction: mid-term follow-up Marco Antonio Arap • Hiury Andrade • Fabio Cesar Miranda Torricelli • Francisco Tibor Denes • Anuar Ibrahim Mitre • Ricardo Jorda˜o Duarte • Miguel Srougi
Received: 19 August 2013 / Accepted: 16 October 2013 Ó Springer Science+Business Media Dordrecht 2013
Abstract Purpose To report on the largest series of laparoscopic ureterocalicostomies done for complicated upper urinary obstruction. Methods We retrospectively reviewed the data from 6 transperitoneal laparoscopic ureterocalicostomies performed in our institution from January 2008 to January 2012. Symptomatic complicated upper urinary obstruction was the main reason for all the procedures. The recorded data included age, gender, clinical presentation, duration of symptoms, laterality, mean operative time, hospital stay, complications and clinical and functional outcomes. Results The median patient age was 20.1 (2–44) years, and all patients were females. Patients underwent laparoscopic ureterocalicostomy due to previous failed procedures (3 patients), anatomic abnormalities (2 patients) and a severe upper ureteral stenosis (1 patient). The median operative time was 215 (180–270) min. There were no major complications. There were no conversions to open surgery. In a median follow-up of 30 (8–56) months, all patients presented with clinical and radiological improvement with no signs of obstruction. In all cases, the
M. A. Arap H. Andrade F. C. M. Torricelli F. T. Denes A. I. Mitre R. J. Duarte M. Srougi Division of Urology, University of Sao Paulo Medical School, Sa˜o Paulo, Brazil M. A. Arap (&) Rua Adma Jafet, 50, 3rd Floor, Sa˜o Paulo, SP CEP 01308-050, Brazil e-mail: [email protected]
postoperative renal scintigraphy revealed a T1/2 lower than 10 min. Conclusion Laparoscopic ureterocalicostomy is feasible and associated with high success rate in well-selected cases with complicated upper urinary obstructions. Keywords Drainage Hydronephrosis Laparoscopy Treatment outcome Ureteral obstruction Introduction Laparoscopic ureterocalicostomy is a technique mostly used in cases of failed pyeloplasties [1, 2], in which a reanastomosis is difficult due to intense fibrotic scar tissue. Only few case descriptions have been published proving the feasibility of the technique [2–4], since the indication for the procedure is rare and it requires an advanced laparoscopic technique with the partial amputation of the inferior renal pole. In most cases of ureteropelvic junction obstruction, a dismembered laparoscopic pyeloplasty is the technique of choice [5]. But in cases of intrarenal pelvis, high ureteral insertion, giant hydronephrosis and horseshoe kidney, a laparoscopic ureterocalicostomy may be used with good outcomes [6, 7]. In cases of secondary ureteropelvic obstruction, a new attempt of laparoscopic pyeloplasty or an endopyelotomy are reasonable options as both procedures can provide good outcomes [8–10]. However, in some specific cases, these alternatives are not the best option and a more complex procedure is required. In this study, we present our experience with laparoscopic ureterocalicostomy for patients with complicated upper urinary obstruction, which to our knowledge is the largest series published to date.
123
Int Urol Nephrol
Patients and methods We retrospectively evaluated the charts of all patients who underwent laparoscopic ureterocalicostomies for complicated upper urinary obstruction at the authors’ center from January 2008 to January 2012. A total of 6 charts were retrieved, and all patients were invited to a visit in the clinic. The patients were evaluated for urinary obstruction using renal scintigraphy and either contrast-based computed tomography (CT) scan (4 patients) or intravenous urography (2 patients). Three patients were previously submitted to failed procedures (open pyeloplasty, repeat retroperitoneal laparoscopic pyeloplasty and transperitoneal pyeloplasty, all due to ureteropelvic junction obstruction), one patient presented with a severe upper ureteral stenosis due to a previous open ureterolithotomy
Fig. 1 Intra-operative image showing high ureteral insertion associated with a malrotated kidney (renal pelvis was posteriorly located). UPJ ureteral pelvic junction
and 2 patients had no previous procedures but presented with anatomic abnormalities that could contra-indicate a safe dismembered pyeloplasty (both with high ureteral insertion associated with a malrotated kidney—Fig. 1). All patients had a thin renal parenchyma in the preoperative image evaluation, particularly in the lower pole (Fig. 2), and they were counseled on ureterocalicostomy as an alternative to avoid nephrectomy based on their age and renal split function. If the intra-operative conditions were not good enough to a safe pyeloplasty (or re-pyeloplasty), a laparoscopic ureterocalicostomy would be done. Age, gender, clinical presentation, duration of symptoms, laterality, mean operative time, hospital stay, complications and clinical and functional results were analyzed. Postoperatively, urinary obstruction was evaluated clinically and with renal scintigraphy 6 weeks after double-J stent removal. According to our institution’s protocol, if no obstruction was detected in the first postoperative renal scintigraphy, patients would not be submitted to a contrast-based image in order to prevent radiation exposure. On the other hand, if patients had maintained symptoms of obstruction or inconclusive results in the renal scintigraphy, they were to be re-evaluated after 2 months with CT scan or intravenous urography. Informed consent was obtained from all patients before the surgery. All patients before surgery were advised about surgical risks as bleeding, conversion, urinary diversion (ureterocalicostomy) and also nephrectomy. Procedure was always preceded by an 8-h fast and intravenous prophylactic cefalotin at anesthetic induction. After general anesthesia, a Foley catheter and an orogastric tube were positioned. Patients were then placed in a 45° lateral flank position. The three-port technique was preferably used, with the camera port (10 mm in all cases) placed at the umbilicus and two working ports (5 mm) placed according
Fig. 2 a Computed tomography (CT) scan showing some renal parenchyma in the left middle pole. b CT scan showing a thin parenchyma in the left renal lower pole
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Int Urol Nephrol
to the intra-operative anatomic findings. When needed, a fourth 5-mm port was inserted to help with liver retraction or dissection and suturing. In all patients who had previous abdominal procedures, pneumoperitoneum was achieved with an open technique and a Hasson trocar was used instead of the 10-mm umbilical trocar. All others were approached using the Veress needle technique. A 30° camera was used in all cases. In all procedures, the colon was initially reflected off the kidney, and the upper ureter was identified and dissected cranially up to the renal pelvis or up to the fibrosis, which was the main indication for ureterocalicostomy. The final decision in favor of an ureterocalicostomy was taken during the procedure in all patients according to surgeon discretion. The difficulties to dissect and isolate the proximal ureter in a safer manner to perform a pyeloplasty (or re-pyeloplasty) due to fibrosis or anatomic conditions were the main reasons for ureterocalicostomies. No vascular clamping was needed in any case, since the renal parenchyma in lower pole was thin and bleeding could be controlled using cautery. Two different surgical techniques were used by three different surgeons (MAA, FTB and AIM). The classic dismembered ureterocalicostomy was used in 4 patients. The ureter was transected, and the proximal end was clamped using a Hem-o-lockÒ device. The ureter was then spatulated at its lateral border to a sufficient length, and the inferior renal pole was amputated (Fig. 3a). The posterior anastomosis was performed using a 4-0 polyglycolic acid running suture, and a double-J catheter was positioned in an antegrade manner using a mounted guidewire via one of the trocars. The anastomosis was then completed with a 4-0 polyglycolic acid running suture (Fig. 3b). Care was taken to approximate both ureteral and caliceal mucosa in order to prevent anastomotic stricture. The peritoneal cavity was drained with a closed suction drain located lateral to the
anastomosis. A termino-lateral anastomosis was used in 2 patients, with no ureteral transection. Briefly, a longitudinal incision was made at the lateral aspect of the ureter before amputation of the renal pole. All other steps were identical to the dismembered technique. The Foley catheter and abdominal drain were left in place for 48 h, and the double-J catheter was maintained for 6 weeks. A good outcome was defined as resolution or significant improvement in patient symptomatology (in a subjective manner) associated with an improvement or resolution in the scintigraphy curve.
Results The median patient age was 20.1 (2–44) years, and all patients were females. The main complaints were lumbar pain (83 %, 5 patients) and urinary infection (67 %, 4 patients). Regarding the laterality, right-sided procedures were done in 50 % of cases (3 patients). Mean duration of the procedures was 215 (180–270) min, and mean estimated blood loss was 100 (50–250) mL. The median length of hospital stay was 4.5 (3–7) days. There were no conversions to open surgery. No intraoperative complication was observed. According to Clavien’s classification, there was 1 grade I complication (adynamic ileus) in a child, treated clinically. There were no grade II–V complications. After a median (range) follow-up of 30 (8–56) months, all patients had a complete clinical (symptomatology) and radiological (renal scintigraphy curve) improvement in the obstruction. In all cases, the postoperative renal scintigraphy revealed a T1/2 lower than 10 min. The renal function improved in 3 patients and remained stable in the others (n = 3). No patient presented with upper urinary tract infections in the follow-up period.
Fig. 3 a Renal lower pole amputation. b Final aspect of the laparoscopic ureterocalicostomy
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Int Urol Nephrol Table 1 Clinical and outcome data Patient
Age
Symptoms
Indication
Technique
Preop DTPA (%)
Postop DTPA (%)
1
2
UTI
Failed pyeloplasty
T-L
42
51
2
27
Pain ? UTI
Failed pyeloplasty
T-T
34
45
3
24
Pain ? UTI
High UPJ and malrotated kidney
T-T
26
23.5
4
16
5
8
6
44
Pain
High UPJ and malrotated kidney
T-T
25.5
56
Pain ? UTI
Failed pyeloplasty
T-L
59
55
Pain
Ureteral stenosis
T-T
30
27
UTI urinary tract infection, T-T termino-terminal, T-L termino-lateral
A summary of the patient’s data and clinical outcome is shown in Table 1.
Discussion Ureterocalicostomy was initially described in 1948 by Neuwirt [11] and later reproduced by other authors [12– 14]. The technique involves removal of the inferior renal pole, ureteral sectioning with preservation of the peri-ureteral fat, ureteral spatulation and a wide tension-free mucosal anastomosis. In 2003, Cherullo et al. [15] published a survival porcine model to evaluate the feasibility of the laparoscopic procedure and the authors concluded that it is a feasible technique and it effectively duplicates the established principles of the open surgery. One year later, Gill et al. [3] showed the results of two laparoscopic ureterocalicostomies done in women due to ureteral pelvic junction (UPJ) obstruction. One patient was later submitted to nephrectomy, as her symptoms were maintained, despite patency of the anastomosis and better renal drainage. The technique has also been described for the treatment of giant hydronephrosis [16] and complex UPJ obstruction [17]. The robotic technique was first described in 2007 in a patient with a refractory ureteral stenosis due to multiple interventions for stones [18]. In 2009, Schimpf and Wagner [19] described the case of a patient with UPJ obstruction who was successfully treated with a robotic-assisted laparoscopic ureterocalicostomy. The advantages of laparoscopy are well established for complex urologic procedures, such as adrenalectomies [20], pyeloplasties [5] and prostatectomies [21]. Despite the extensive use of laparoscopy for urologic surgeries, almost all reports of laparoscopic ureterocalicostomies are single-case or two-case series in which the authors describe the feasibility of the procedure. To our knowledge, there are 5 cases successfully treated published to date [3, 15– 17]. Our series is the largest of the literature, surpassing all other published cases. We also show a great efficacy with the procedure, as all patients had patency of the anastomosis and resolution of the symptoms. In cases of re-
123
operation (4 patients), ureterocalicostomy had another advantage. As the procedure included the exposure of the upper ureter and the lower renal pole, it did not require any further dissection on the previously manipulated ureteropelvic junction. Indications for laparoscopic ureterocalicostomy are rare. Usually, the decision is made intra-operatively, when local factors such as intense fibrosis, giant hydronephrosis with small renal pelvis and long ureteral stenosis prevent an adequate tension-free anastomosis. It is important to remember that in many cases of recurrent stenosis, re-pyeloplasty or endopyelotomy are alternatives that can be used. However, in most of our cases, these options could not be used, as 4 patients were previously submitted to upper renal procedures (3 pyeloplasties and 1 ureterolithotomy) and had a long ureteral stenosis. The two remaining cases were a high implanted ureter in a malrotated kidney and a giant hydronephrosis due to UPJ obstruction with crossing vessels. Furthermore, our group does not have a good experience with endopyelotomy [22]. All patients were counseled on laparoscopic ureterocalicostomy before the surgery as an alternative to preserve the renal unit. One of the concerns in performing an ureterocalicostomy is the thickness of renal parenchyma to perform lower pole amputation without hilar occlusion. In all cases, the attending surgeon double checked the CT image in order to ensure that renal parenchyma was thin enough to allow such procedure. Overall, all patients presented complete clinical improvement after a median (range) follow-up of 30 (8–56) months. In addition, radiological success (obstruction resolution) was achieved in all renal units according to renal scintigraphy evaluation, although renal function did not improve in three cases. Unfortunately, with the exception of robotic ureterocalicostomies, there are no other series to which we could compare our results. As with pure laparoscopy, the robotic Da Vinci platformÒ has proved to be safe and effective for such complicated cases [18, 19] and the outcome is similar to what we found. However, robotics is not available in every center, and therefore, pure
Int Urol Nephrol
laparoscopy will also be routine in some large-scale centers, such as ours. We believe that patients with prior surgery on ureteropelvic junction and/or renal anatomic abnormalities that prevent a safe access to the proximal ureter are potential candidates for laparoscopic ureterocalicostomy. This procedure when performed by surgeons with expertise in laparoscopy approach presents good outcomes. There are some limitations to the study. We do not have a control group. However, due to the rarity of the procedure and the lack of good alternatives for these patients, a control group would be very difficult to find. Because this is a retrospective analysis and no other type of treatment was compared, we cannot conclude that ureterocalicostomy was the best option for these cases. However, we did show that the procedure was effective and secure. The relative short follow-up of 30 months could also be an issue for the outcome analysis. However, this is less relevant as most complications and recurrences almost always occur early in the postoperative period.
Conclusion Laparoscopic ureterocalicostomy is a safe and effective option for well-selected patients with complicated upper urinary obstruction who are not candidates for other procedures such as pyeloplasties. Conflict of interest
No conflict of interests.
References 1. Rohrmann D, Snyder HM 3rd, Duckett JW Jr, Canning DA, Zderic SA (1997) The operative management of recurrent ureteropelvic junction obstruction. J Urol 158:1257–1259 2. Selli C, Rizzo M, Moroni F, Dedola G, Amorosi A (1992) Ureterocalicostomy in the treatment of pyeloplasty failures. Urol Int 48:274–277 3. Gill IS, Cherullo EE, Steinberg A, Desai MM, Abreu SC, Ng C, Kaouk JH (2004) Laparoscopic ureterocalicostomy: initial experience. J Urol 171:1227–1230 4. Matlaga BR, Shah OD, Singh D, Streem SB, Assimos DG (2005) Ureterocalicostomy: a contemporary experience. Urology 65: 42–44
5. Arap MA, Torricelli FC, Mitre AI, Chambo JL, Duarte RJ, Srougi M (2013) Lessons from 90 consecutive laparoscopic dismembered pyeloplasties in a residency program. Scand J Urol Nephrol 47:323–327 6. Osman T, Eltahawy I, Fawaz K, Shoeib M, Elshawaf H, El Halaby R (2011) Ureterocalicostomy for treatment of complex cases of ureteropelvic junction obstruction in adults. Urology 78:202–207 7. Mesrobian HG, Kelalis PP (1989) Ureterocalicostomy: indications and results in 21 patients. J Urol 142:1285–1287 8. Park J, Kim WS, Hong B, Park T, Park HK (2008) Long-term outcome of secondary endopyelotomy after failed primary intervention for ureteropelvic junction obstruction. Int J Urol 15:490–494 9. Patel T, Kellner CP, Katsumi H, Gupta M (2011) Efficacy of endopyelotomy in patients with secondary ureteropelvic junction obstruction. J Endourol 25:587–591 10. Sundaram CP, Grubb RL 3rd, Rehman J, Yan Y, Chen C, Landman J, McDougall EM, Clayman RV (2003) Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction. J Urol 169:2037–2040 11. Neuwirt K (1948) Implantation of the ureter into the lower calyx of the renal pelvis. Urol Cutaneous Rev 52:351 12. Duckett JW, Pfister RR (1982) Ureterocalicostomy for renal salvage. J Urol 128:98–101 13. Kay R (1988) Ureterocalicostomy. Urol Clin N Am 15:129–133 14. Hawthorne NJ, Zincke H, Kelalis PP (1976) Ureterocalicostomy: an alternative to nephrectomy. J Urol 115:583–586 15. Cherullo EE, Gill IS, Ponsky LE, Banks KL, Desai MM, Kaouk JH, Meraney AM, Skacel M, Sung GT (2003) Laparoscopic ureterocalicostomy: a feasibility study. J Urol 169:2360–2364 16. Agarwal MM, Sharma D, Singh SK, Kumar S, Bhattacharya A, Acharya N, Mandal AK (2007) Laparoscopic ureterocalicostomy for salvage of giant hydronephrotic kidney: initial experience. Urology 70:590 17. Kumar S, Panigrahy B (2009) Laparoscopic management of complex ureteropelvic junction obstruction. J Laparoendosc Adv Surg Tech A 19:521–528 18. Korets R, Hyams ES, Shah OD, Stifelman MD (2007) Roboticassisted laparoscopic ureterocalicostomy. Urology 70:366–369 19. Schimpf MO, Wagner JR (2009) Case report: robotic-assisted laparoscopic ureterocalicostomy with long-term follow-up. J Endourol 23:293–295 20. Bruhn AM, Hyams ES, Stifelman MD (2010) Laparoscopic and robotic assisted adrenal surgery. Minerva Urol Nefrol 62:305–318 21. Sandhu GS, Nepple KG, Tanagho YS, Andriole GL (2013) Laparoscopic prostatectomy for prostate cancer: continued role in urology. Surg Oncol Clin N Am 22:125–141 22. Brito AH, Mitre AI, Arap S (2002) Endopyelotomy with the Acucise catheter. Int Braz J Urol 28:302–309 (discussion 309–310)
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UROLOGY - ORIGINAL PAPER
Laparoscopic ureterocalicostomy for complicated upper urinary tract obstruction: mid-term follow-up Marco Antonio Arap • Hiury Andrade • Fabio Cesar Miranda Torricelli • Francisco Tibor Denes • Anuar Ibrahim Mitre • Ricardo Jorda˜o Duarte • Miguel Srougi
Received: 19 August 2013 / Accepted: 16 October 2013 Ó Springer Science+Business Media Dordrecht 2013
Abstract Purpose To report on the largest series of laparoscopic ureterocalicostomies done for complicated upper urinary obstruction. Methods We retrospectively reviewed the data from 6 transperitoneal laparoscopic ureterocalicostomies performed in our institution from January 2008 to January 2012. Symptomatic complicated upper urinary obstruction was the main reason for all the procedures. The recorded data included age, gender, clinical presentation, duration of symptoms, laterality, mean operative time, hospital stay, complications and clinical and functional outcomes. Results The median patient age was 20.1 (2–44) years, and all patients were females. Patients underwent laparoscopic ureterocalicostomy due to previous failed procedures (3 patients), anatomic abnormalities (2 patients) and a severe upper ureteral stenosis (1 patient). The median operative time was 215 (180–270) min. There were no major complications. There were no conversions to open surgery. In a median follow-up of 30 (8–56) months, all patients presented with clinical and radiological improvement with no signs of obstruction. In all cases, the
M. A. Arap H. Andrade F. C. M. Torricelli F. T. Denes A. I. Mitre R. J. Duarte M. Srougi Division of Urology, University of Sao Paulo Medical School, Sa˜o Paulo, Brazil M. A. Arap (&) Rua Adma Jafet, 50, 3rd Floor, Sa˜o Paulo, SP CEP 01308-050, Brazil e-mail: [email protected]
postoperative renal scintigraphy revealed a T1/2 lower than 10 min. Conclusion Laparoscopic ureterocalicostomy is feasible and associated with high success rate in well-selected cases with complicated upper urinary obstructions. Keywords Drainage Hydronephrosis Laparoscopy Treatment outcome Ureteral obstruction Introduction Laparoscopic ureterocalicostomy is a technique mostly used in cases of failed pyeloplasties [1, 2], in which a reanastomosis is difficult due to intense fibrotic scar tissue. Only few case descriptions have been published proving the feasibility of the technique [2–4], since the indication for the procedure is rare and it requires an advanced laparoscopic technique with the partial amputation of the inferior renal pole. In most cases of ureteropelvic junction obstruction, a dismembered laparoscopic pyeloplasty is the technique of choice [5]. But in cases of intrarenal pelvis, high ureteral insertion, giant hydronephrosis and horseshoe kidney, a laparoscopic ureterocalicostomy may be used with good outcomes [6, 7]. In cases of secondary ureteropelvic obstruction, a new attempt of laparoscopic pyeloplasty or an endopyelotomy are reasonable options as both procedures can provide good outcomes [8–10]. However, in some specific cases, these alternatives are not the best option and a more complex procedure is required. In this study, we present our experience with laparoscopic ureterocalicostomy for patients with complicated upper urinary obstruction, which to our knowledge is the largest series published to date.
123
Int Urol Nephrol
Patients and methods We retrospectively evaluated the charts of all patients who underwent laparoscopic ureterocalicostomies for complicated upper urinary obstruction at the authors’ center from January 2008 to January 2012. A total of 6 charts were retrieved, and all patients were invited to a visit in the clinic. The patients were evaluated for urinary obstruction using renal scintigraphy and either contrast-based computed tomography (CT) scan (4 patients) or intravenous urography (2 patients). Three patients were previously submitted to failed procedures (open pyeloplasty, repeat retroperitoneal laparoscopic pyeloplasty and transperitoneal pyeloplasty, all due to ureteropelvic junction obstruction), one patient presented with a severe upper ureteral stenosis due to a previous open ureterolithotomy
Fig. 1 Intra-operative image showing high ureteral insertion associated with a malrotated kidney (renal pelvis was posteriorly located). UPJ ureteral pelvic junction
and 2 patients had no previous procedures but presented with anatomic abnormalities that could contra-indicate a safe dismembered pyeloplasty (both with high ureteral insertion associated with a malrotated kidney—Fig. 1). All patients had a thin renal parenchyma in the preoperative image evaluation, particularly in the lower pole (Fig. 2), and they were counseled on ureterocalicostomy as an alternative to avoid nephrectomy based on their age and renal split function. If the intra-operative conditions were not good enough to a safe pyeloplasty (or re-pyeloplasty), a laparoscopic ureterocalicostomy would be done. Age, gender, clinical presentation, duration of symptoms, laterality, mean operative time, hospital stay, complications and clinical and functional results were analyzed. Postoperatively, urinary obstruction was evaluated clinically and with renal scintigraphy 6 weeks after double-J stent removal. According to our institution’s protocol, if no obstruction was detected in the first postoperative renal scintigraphy, patients would not be submitted to a contrast-based image in order to prevent radiation exposure. On the other hand, if patients had maintained symptoms of obstruction or inconclusive results in the renal scintigraphy, they were to be re-evaluated after 2 months with CT scan or intravenous urography. Informed consent was obtained from all patients before the surgery. All patients before surgery were advised about surgical risks as bleeding, conversion, urinary diversion (ureterocalicostomy) and also nephrectomy. Procedure was always preceded by an 8-h fast and intravenous prophylactic cefalotin at anesthetic induction. After general anesthesia, a Foley catheter and an orogastric tube were positioned. Patients were then placed in a 45° lateral flank position. The three-port technique was preferably used, with the camera port (10 mm in all cases) placed at the umbilicus and two working ports (5 mm) placed according
Fig. 2 a Computed tomography (CT) scan showing some renal parenchyma in the left middle pole. b CT scan showing a thin parenchyma in the left renal lower pole
123
Int Urol Nephrol
to the intra-operative anatomic findings. When needed, a fourth 5-mm port was inserted to help with liver retraction or dissection and suturing. In all patients who had previous abdominal procedures, pneumoperitoneum was achieved with an open technique and a Hasson trocar was used instead of the 10-mm umbilical trocar. All others were approached using the Veress needle technique. A 30° camera was used in all cases. In all procedures, the colon was initially reflected off the kidney, and the upper ureter was identified and dissected cranially up to the renal pelvis or up to the fibrosis, which was the main indication for ureterocalicostomy. The final decision in favor of an ureterocalicostomy was taken during the procedure in all patients according to surgeon discretion. The difficulties to dissect and isolate the proximal ureter in a safer manner to perform a pyeloplasty (or re-pyeloplasty) due to fibrosis or anatomic conditions were the main reasons for ureterocalicostomies. No vascular clamping was needed in any case, since the renal parenchyma in lower pole was thin and bleeding could be controlled using cautery. Two different surgical techniques were used by three different surgeons (MAA, FTB and AIM). The classic dismembered ureterocalicostomy was used in 4 patients. The ureter was transected, and the proximal end was clamped using a Hem-o-lockÒ device. The ureter was then spatulated at its lateral border to a sufficient length, and the inferior renal pole was amputated (Fig. 3a). The posterior anastomosis was performed using a 4-0 polyglycolic acid running suture, and a double-J catheter was positioned in an antegrade manner using a mounted guidewire via one of the trocars. The anastomosis was then completed with a 4-0 polyglycolic acid running suture (Fig. 3b). Care was taken to approximate both ureteral and caliceal mucosa in order to prevent anastomotic stricture. The peritoneal cavity was drained with a closed suction drain located lateral to the
anastomosis. A termino-lateral anastomosis was used in 2 patients, with no ureteral transection. Briefly, a longitudinal incision was made at the lateral aspect of the ureter before amputation of the renal pole. All other steps were identical to the dismembered technique. The Foley catheter and abdominal drain were left in place for 48 h, and the double-J catheter was maintained for 6 weeks. A good outcome was defined as resolution or significant improvement in patient symptomatology (in a subjective manner) associated with an improvement or resolution in the scintigraphy curve.
Results The median patient age was 20.1 (2–44) years, and all patients were females. The main complaints were lumbar pain (83 %, 5 patients) and urinary infection (67 %, 4 patients). Regarding the laterality, right-sided procedures were done in 50 % of cases (3 patients). Mean duration of the procedures was 215 (180–270) min, and mean estimated blood loss was 100 (50–250) mL. The median length of hospital stay was 4.5 (3–7) days. There were no conversions to open surgery. No intraoperative complication was observed. According to Clavien’s classification, there was 1 grade I complication (adynamic ileus) in a child, treated clinically. There were no grade II–V complications. After a median (range) follow-up of 30 (8–56) months, all patients had a complete clinical (symptomatology) and radiological (renal scintigraphy curve) improvement in the obstruction. In all cases, the postoperative renal scintigraphy revealed a T1/2 lower than 10 min. The renal function improved in 3 patients and remained stable in the others (n = 3). No patient presented with upper urinary tract infections in the follow-up period.
Fig. 3 a Renal lower pole amputation. b Final aspect of the laparoscopic ureterocalicostomy
123
Int Urol Nephrol Table 1 Clinical and outcome data Patient
Age
Symptoms
Indication
Technique
Preop DTPA (%)
Postop DTPA (%)
1
2
UTI
Failed pyeloplasty
T-L
42
51
2
27
Pain ? UTI
Failed pyeloplasty
T-T
34
45
3
24
Pain ? UTI
High UPJ and malrotated kidney
T-T
26
23.5
4
16
5
8
6
44
Pain
High UPJ and malrotated kidney
T-T
25.5
56
Pain ? UTI
Failed pyeloplasty
T-L
59
55
Pain
Ureteral stenosis
T-T
30
27
UTI urinary tract infection, T-T termino-terminal, T-L termino-lateral
A summary of the patient’s data and clinical outcome is shown in Table 1.
Discussion Ureterocalicostomy was initially described in 1948 by Neuwirt [11] and later reproduced by other authors [12– 14]. The technique involves removal of the inferior renal pole, ureteral sectioning with preservation of the peri-ureteral fat, ureteral spatulation and a wide tension-free mucosal anastomosis. In 2003, Cherullo et al. [15] published a survival porcine model to evaluate the feasibility of the laparoscopic procedure and the authors concluded that it is a feasible technique and it effectively duplicates the established principles of the open surgery. One year later, Gill et al. [3] showed the results of two laparoscopic ureterocalicostomies done in women due to ureteral pelvic junction (UPJ) obstruction. One patient was later submitted to nephrectomy, as her symptoms were maintained, despite patency of the anastomosis and better renal drainage. The technique has also been described for the treatment of giant hydronephrosis [16] and complex UPJ obstruction [17]. The robotic technique was first described in 2007 in a patient with a refractory ureteral stenosis due to multiple interventions for stones [18]. In 2009, Schimpf and Wagner [19] described the case of a patient with UPJ obstruction who was successfully treated with a robotic-assisted laparoscopic ureterocalicostomy. The advantages of laparoscopy are well established for complex urologic procedures, such as adrenalectomies [20], pyeloplasties [5] and prostatectomies [21]. Despite the extensive use of laparoscopy for urologic surgeries, almost all reports of laparoscopic ureterocalicostomies are single-case or two-case series in which the authors describe the feasibility of the procedure. To our knowledge, there are 5 cases successfully treated published to date [3, 15– 17]. Our series is the largest of the literature, surpassing all other published cases. We also show a great efficacy with the procedure, as all patients had patency of the anastomosis and resolution of the symptoms. In cases of re-
123
operation (4 patients), ureterocalicostomy had another advantage. As the procedure included the exposure of the upper ureter and the lower renal pole, it did not require any further dissection on the previously manipulated ureteropelvic junction. Indications for laparoscopic ureterocalicostomy are rare. Usually, the decision is made intra-operatively, when local factors such as intense fibrosis, giant hydronephrosis with small renal pelvis and long ureteral stenosis prevent an adequate tension-free anastomosis. It is important to remember that in many cases of recurrent stenosis, re-pyeloplasty or endopyelotomy are alternatives that can be used. However, in most of our cases, these options could not be used, as 4 patients were previously submitted to upper renal procedures (3 pyeloplasties and 1 ureterolithotomy) and had a long ureteral stenosis. The two remaining cases were a high implanted ureter in a malrotated kidney and a giant hydronephrosis due to UPJ obstruction with crossing vessels. Furthermore, our group does not have a good experience with endopyelotomy [22]. All patients were counseled on laparoscopic ureterocalicostomy before the surgery as an alternative to preserve the renal unit. One of the concerns in performing an ureterocalicostomy is the thickness of renal parenchyma to perform lower pole amputation without hilar occlusion. In all cases, the attending surgeon double checked the CT image in order to ensure that renal parenchyma was thin enough to allow such procedure. Overall, all patients presented complete clinical improvement after a median (range) follow-up of 30 (8–56) months. In addition, radiological success (obstruction resolution) was achieved in all renal units according to renal scintigraphy evaluation, although renal function did not improve in three cases. Unfortunately, with the exception of robotic ureterocalicostomies, there are no other series to which we could compare our results. As with pure laparoscopy, the robotic Da Vinci platformÒ has proved to be safe and effective for such complicated cases [18, 19] and the outcome is similar to what we found. However, robotics is not available in every center, and therefore, pure
Int Urol Nephrol
laparoscopy will also be routine in some large-scale centers, such as ours. We believe that patients with prior surgery on ureteropelvic junction and/or renal anatomic abnormalities that prevent a safe access to the proximal ureter are potential candidates for laparoscopic ureterocalicostomy. This procedure when performed by surgeons with expertise in laparoscopy approach presents good outcomes. There are some limitations to the study. We do not have a control group. However, due to the rarity of the procedure and the lack of good alternatives for these patients, a control group would be very difficult to find. Because this is a retrospective analysis and no other type of treatment was compared, we cannot conclude that ureterocalicostomy was the best option for these cases. However, we did show that the procedure was effective and secure. The relative short follow-up of 30 months could also be an issue for the outcome analysis. However, this is less relevant as most complications and recurrences almost always occur early in the postoperative period.
Conclusion Laparoscopic ureterocalicostomy is a safe and effective option for well-selected patients with complicated upper urinary obstruction who are not candidates for other procedures such as pyeloplasties. Conflict of interest
No conflict of interests.
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