2014 Essay Contest—Clinical
JOURNAL OF ENDOUROLOGY Volume 28, Number 12, December 2014 ª Mary Ann Liebert, Inc. Pp. ---–--DOI: 10.1089/end.2014.0230
Microlaparoscopy Versus Conventional Laparoscopy in Transperitoneal Pyeloplasty Aaron D. Benson, MD, Trisha M. Juliano, MD, Davis P. Viprakasit, MD, FACS, and S. Duke Herrell, MD, FACS
Abstract
Background and Purpose: Laparoscopic pyeloplasty has emerged as the gold standard for repair of ureteropelvic junction obstruction. Microlaparoscopic (MLP, < 3 mm) instrumentation has improved markedly and can now be used for suturing and complex dissection needed during laparoscopic pyeloplasty. We present our experience with microlaparoscopy compared with conventional laparoscopy for transperitoneal pyeloplasty. Methods: We performed a retrospective analysis of hybrid MLP, using a 5-mm camera in a hidden umbilical incision, and 1.9 or 3 mm working instruments and compared with patients undergoing conventional laparoscopic pyeloplasty (CLP). The data for MLP and CLP were compared using the Student t test, Pearson chisquare test, and Fisher exact test, where appropriate. Results: Between January 2009 and May 2013, there were 19 MLP and 27 CLP procedures performed. The MLP group mean age was younger than the CLP group (34 vs 50 years; P = 0.0003). Body mass index, previous treatment rates, operative time, length of stay, ureteral stent duration, and complication rates were not statistically different between the MLP and CLP groups. Strict success rates (indicated by follow-up renal scan T½ < 20 min) were similar between MLP and CLP groups (89.5% vs 88.9%; P = 0.95). No MLP procedures were converted to CLP or open approaches. Conclusions: From technical, perioperative, and outcome perspectives, transperitoneal pyeloplasty with microlaparoscopy is both safe and feasible in our hands compared with conventional laparoscopy, and results in subjectively superior cosmesis. This is the largest MLP series to date and contains, to our knowledge, the only cases described using prototype 1.9 mm instruments. approaches, such as laparoendoscopic single-site (LESS) surgery, have been proposed and touted to potentially decrease invasiveness and improve cosmesis, but reported results vary.3–5 Considering the technical difficulty of pure laparoscopic LESS surgery for even the most skilled laparoscopic surgeons, the use of robotics in combination with the LESS approach has been proposed.6–8 While this approach may ease technical difficulty, using the robot increases cost, decreases case margin, and may necessitate a larger incision and increased use of accessory equipment such as the GelPort system (Applied Medical, Rancho Santa Margarita, CA). In 2009, we sought an alternative approach and undertook the development of a microlaparoscopic approach using £ 3 mm working instruments for the performance of adult dismembered laparoscopic pyeloplasty. The main concerns regarding microlaparoscopy and its instruments were decreased intraoperative durability of the microlaparoscopic instruments, increased skill needed to operate, and overall decreased ability to perform complex tasks, such as intracorporeal suturing.9,10 Before 2009, microlaparoscopy had
Introduction
L
aparoscopic pyeloplasty has emerged as the gold standard approach option for the repair of both primary and secondary ureteropelvic junction obstruction (UPJO). The laparoscopic approach not only maintains the efficacy of the open procedure but also offers the benefits of a minimally invasive approach including decreased convalescence, pain, hospitalization, and improved cosmesis.1,2 Because pyeloplasty is a nonextirpative procedure (i.e., no need for large specimen extraction incision), it can be not only leveraged for laparoscopy but also to improve cosmesis by use of reduced trocar sizes. Cosmesis is an important consideration because patients needing UPJO repair are often children, adolescents, or young adults, in whom minimal visible scarring may be especially appealing. Over the past decade, use of the da Vinci robotic platform (Intuitive Surgical Inc., Sunnyvale, CA) has increased exponentially and has resulted in widespread translation of laparoscopic pyeloplasty. Recently, new minimally invasive
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
1
2
BENSON ET AL.
been used for pyeloplasty only in a small series of primary UPJO procedures in a pediatric population11 and as adjunctive trocars in procedures in adults necessitating minimal-tono specimen removal or suturing.12 To address the feasibility and outcomes of our hybrid microlaparoscopic pyeloplasty (MLP) in adults, a single surgeon’s and institutional experience with both MLP and conventional laparoscopic pyeloplasty (CLP) was retrospectively analyzed and compared. Methods
A retrospective review of adult patients who underwent laparoscopic transperitoneal dismembered pyeloplasty performed by a single surgeon (SDH) led team from January 2009 through May 2013 was performed. All patients underwent standard preoperative evaluation with a history, physical examination, and functional/anatomical renal imaging. CLP was performed either via standard pure laparoscopic instruments or with robot assistance using camera and instrument ports ranging in size from 5 mm to 12 mm, while MLP used 1.9 mm to 3 mm (Karl Storz Inc., Tuttlingen, Germany) working instruments with a 5-mm umbilical camera port (hybrid approach) (Figs. 1, 2). All procedures included in this series and period were approached transperitoneally, and we universally performed an AndersenHynes dismembered pyeloplasty technique with crossing vessel transposition and pelvic reduction at the discretion of the attending surgeon. Our technique for patient positioning and laparoscopic pyeloplasty has been previously published and was followed in all cases other than the exclusion of initial retrograde pyelography in some patients.13 Our technique for MLP performing initial entry and insufflation consists of visual access via an optical 5-mm trocar (Ethicon Endosurgery, Cornelia, GA) access in combination with a 0-degree, 5-mm camera through an incision within the typical concavity of the
FIG. 1. Microlaparoscopy uses ports and instruments with diameters smaller than the most compact counterparts in conventional laparoscopy, as demonstrated by the larger 5-mm reusable laparoscopic trocar and instrument (A) compared with the smaller 1.9-mm microlaparoscopic needle holder (B), 1.9-mm microlaparoscopic scissors (C), and 1.9 mm microlaparoscopic hook electrocautery instrument (D).
FIG. 2. The hybrid approach to microlaparoscopic pyeloplasty uses an optical 5-mm trocar (Ethicon Endosurgery) (A) through an incision within the typical concavity of the umbilicus often hidden in an umbilical skin fold and microlaparoscopic instruments through 3.5-mm microlaparoscopic trocars (B). umbilicus often hidden in an umbilical skin fold. The trocar tip is tunneled slightly caudally and laterally to result in a more optimal angle of visualization. In addition, the dilating tip design, 5-mm size, and insertion angle minimize the risk of hernia, so fascial closure is not necessary. Once insufflated, the microlaparoscopic ports (3.5 mm) are placed under direct vision. Previous versions of the trocars were short and needed securing sutures to prevent accidental extraction, while, more recently, longer trocars are available. The upper ureter and ureteropelvic junction area are dissected. The ureter is divided below the UPJO and spatulated. In some cases, 5-mm scissors were inserted through the 5mm umbilical trocar and a 3-mm lens used through a microlaparoscopic trocar to speed division and resection of the redundant pelvis. Two 4-0 polyglactin (8 in) sutures are brought in tail first through the 5-mm trocar or the site of one of the microlaparoscopic trocars. Intracorporeal suturing and knot tying is performed using the microlaparoscopic needle holders. The stent is inserted after anastomosis and before closure of the renal pelvis after which standard drain (3 mm) placement and skin closures are performed. Stent placement confirmation and postoperative care are consistent with previously published technique and postoperative care pathway.13 Data from these clinical interactions were collected and analyzed, which included patient age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, laterality, pre- and postoperative creatinine levels, previous UPJO treatment, pre- and postoperative diuretic renography results, operative time, estimated blood loss (EBL), presence of crossing vessel, need for transfusion, length of stay (LOS), ureteral stent duration, complications, length of follow-up, and need for re-treatment. Success was defined by postoperative diuretic renography T½ less than 20 minutes and/or resolution of preoperative symptoms. These data for MLP and CLP patients were compared using the Student t test, Pearson chi-square test, and Fisher exact test, where appropriate. Results
From January 2009 through May 2013, 46 laparoscopic transperitoneal dismembered pyeloplasties were performed by
MLP VS CLP
3
a single surgeon (SDH). There were 27 CLP (7 performed with robot assistance) and 19 MLP patients (Table 1). The mean age was lower in MLP patients (34 vs 50 years; P = 0.0003), but the sex distribution was similar (P = 0.13). The mean BMI was not significantly different in the MLP group compared with the CLP group (24 vs 27; P = 0.05). The distribution between groups in ASA categories I–II and III–IV were not significantly different (P = 0.06). Among the CLP patients, 6 (22.2%) had previous UPJO treatment compared with 1 (5.3%) MLP patients (P = 0.38). Mean preoperative creatinine level was similar between groups (1.0 vs 1.0 mg/dL; P = 0.48). There were more identified crossing renal vessels in the MLP group (12 vs 9; P = 0.046). There was no difference between groups in operative time (197 vs 208 min; P = 0.48), mean EBL (57 vs 77 mL; P = 0.23), or mean LOS (1.1 vs 1.3 days; P = 0.07). There were no transfusions needed in the series (Table 2). There was no significant difference in the overall postoperative creatinine level (0.02 vs 0.0 mg/dL; P = 0.70) or change in creatinine level from preoperative values in either group (P = 1.0 vs 1.0 mg/dL; 0.74). There was no difference between MLP and CLP groups for duration of indwelling ureteral stent (46 vs 46 days; P = 0.91), length of follow-up (244 vs 380 days; P = 0.18), or complications (P = 0.28). There were six complications in the MLP group. One patient was readmitted for pain and nausea 7 weeks after surgery, but demonstrated no evidence of obstruction on imaging; in one patient, gross hematuria developed and clot urinary retention necessitating percutaneous nephrostomy drainage, but following this, postoperative renal scan T½ was 6.7 minutes. The other patients’ postoperative courses were complicated by urinary tract infection (UTI) or pain managed expectantly. Two MLP patients with treatment failure underwent redo robot-assisted laparoscopic (RAL) pyeloplasty because of persistent pain and/or evidence of continued obstruction. Intermittent obstruction that could not be defined by renal scan (postoperative T½ 11 minutes) developed in one of these patients, but was consistent on imaging with an intermittent obstructive kink during renal ptosis. This patient’s pain resolved after repeated pyeloplasty and renal pexing. The CLP group had four complications, consisting of Candida urosepsis, UTI, ureteral stent-related pain, or per-
Table 1. Patient Demographics
n Age (mean) Sex Male Female BMI (mean) ASA I–II III–IV Previous treatment
MLP (%)
CLP (%)
P value
19 34
27 50
0.0003*
9 (47.4) 10 (52.6) 24
7 (25.9) 20 (74.1) 27
0.13 0.13 0.05
17 (89.5) 2 (10.5) 1 (5.3)
18 (66.7) 9 (33.3) 5 (18.5)
0.06 0.06 0.38
*Statistical significance indicated by P value
JOURNAL OF ENDOUROLOGY Volume 28, Number 12, December 2014 ª Mary Ann Liebert, Inc. Pp. ---–--DOI: 10.1089/end.2014.0230
Microlaparoscopy Versus Conventional Laparoscopy in Transperitoneal Pyeloplasty Aaron D. Benson, MD, Trisha M. Juliano, MD, Davis P. Viprakasit, MD, FACS, and S. Duke Herrell, MD, FACS
Abstract
Background and Purpose: Laparoscopic pyeloplasty has emerged as the gold standard for repair of ureteropelvic junction obstruction. Microlaparoscopic (MLP, < 3 mm) instrumentation has improved markedly and can now be used for suturing and complex dissection needed during laparoscopic pyeloplasty. We present our experience with microlaparoscopy compared with conventional laparoscopy for transperitoneal pyeloplasty. Methods: We performed a retrospective analysis of hybrid MLP, using a 5-mm camera in a hidden umbilical incision, and 1.9 or 3 mm working instruments and compared with patients undergoing conventional laparoscopic pyeloplasty (CLP). The data for MLP and CLP were compared using the Student t test, Pearson chisquare test, and Fisher exact test, where appropriate. Results: Between January 2009 and May 2013, there were 19 MLP and 27 CLP procedures performed. The MLP group mean age was younger than the CLP group (34 vs 50 years; P = 0.0003). Body mass index, previous treatment rates, operative time, length of stay, ureteral stent duration, and complication rates were not statistically different between the MLP and CLP groups. Strict success rates (indicated by follow-up renal scan T½ < 20 min) were similar between MLP and CLP groups (89.5% vs 88.9%; P = 0.95). No MLP procedures were converted to CLP or open approaches. Conclusions: From technical, perioperative, and outcome perspectives, transperitoneal pyeloplasty with microlaparoscopy is both safe and feasible in our hands compared with conventional laparoscopy, and results in subjectively superior cosmesis. This is the largest MLP series to date and contains, to our knowledge, the only cases described using prototype 1.9 mm instruments. approaches, such as laparoendoscopic single-site (LESS) surgery, have been proposed and touted to potentially decrease invasiveness and improve cosmesis, but reported results vary.3–5 Considering the technical difficulty of pure laparoscopic LESS surgery for even the most skilled laparoscopic surgeons, the use of robotics in combination with the LESS approach has been proposed.6–8 While this approach may ease technical difficulty, using the robot increases cost, decreases case margin, and may necessitate a larger incision and increased use of accessory equipment such as the GelPort system (Applied Medical, Rancho Santa Margarita, CA). In 2009, we sought an alternative approach and undertook the development of a microlaparoscopic approach using £ 3 mm working instruments for the performance of adult dismembered laparoscopic pyeloplasty. The main concerns regarding microlaparoscopy and its instruments were decreased intraoperative durability of the microlaparoscopic instruments, increased skill needed to operate, and overall decreased ability to perform complex tasks, such as intracorporeal suturing.9,10 Before 2009, microlaparoscopy had
Introduction
L
aparoscopic pyeloplasty has emerged as the gold standard approach option for the repair of both primary and secondary ureteropelvic junction obstruction (UPJO). The laparoscopic approach not only maintains the efficacy of the open procedure but also offers the benefits of a minimally invasive approach including decreased convalescence, pain, hospitalization, and improved cosmesis.1,2 Because pyeloplasty is a nonextirpative procedure (i.e., no need for large specimen extraction incision), it can be not only leveraged for laparoscopy but also to improve cosmesis by use of reduced trocar sizes. Cosmesis is an important consideration because patients needing UPJO repair are often children, adolescents, or young adults, in whom minimal visible scarring may be especially appealing. Over the past decade, use of the da Vinci robotic platform (Intuitive Surgical Inc., Sunnyvale, CA) has increased exponentially and has resulted in widespread translation of laparoscopic pyeloplasty. Recently, new minimally invasive
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
1
2
BENSON ET AL.
been used for pyeloplasty only in a small series of primary UPJO procedures in a pediatric population11 and as adjunctive trocars in procedures in adults necessitating minimal-tono specimen removal or suturing.12 To address the feasibility and outcomes of our hybrid microlaparoscopic pyeloplasty (MLP) in adults, a single surgeon’s and institutional experience with both MLP and conventional laparoscopic pyeloplasty (CLP) was retrospectively analyzed and compared. Methods
A retrospective review of adult patients who underwent laparoscopic transperitoneal dismembered pyeloplasty performed by a single surgeon (SDH) led team from January 2009 through May 2013 was performed. All patients underwent standard preoperative evaluation with a history, physical examination, and functional/anatomical renal imaging. CLP was performed either via standard pure laparoscopic instruments or with robot assistance using camera and instrument ports ranging in size from 5 mm to 12 mm, while MLP used 1.9 mm to 3 mm (Karl Storz Inc., Tuttlingen, Germany) working instruments with a 5-mm umbilical camera port (hybrid approach) (Figs. 1, 2). All procedures included in this series and period were approached transperitoneally, and we universally performed an AndersenHynes dismembered pyeloplasty technique with crossing vessel transposition and pelvic reduction at the discretion of the attending surgeon. Our technique for patient positioning and laparoscopic pyeloplasty has been previously published and was followed in all cases other than the exclusion of initial retrograde pyelography in some patients.13 Our technique for MLP performing initial entry and insufflation consists of visual access via an optical 5-mm trocar (Ethicon Endosurgery, Cornelia, GA) access in combination with a 0-degree, 5-mm camera through an incision within the typical concavity of the
FIG. 1. Microlaparoscopy uses ports and instruments with diameters smaller than the most compact counterparts in conventional laparoscopy, as demonstrated by the larger 5-mm reusable laparoscopic trocar and instrument (A) compared with the smaller 1.9-mm microlaparoscopic needle holder (B), 1.9-mm microlaparoscopic scissors (C), and 1.9 mm microlaparoscopic hook electrocautery instrument (D).
FIG. 2. The hybrid approach to microlaparoscopic pyeloplasty uses an optical 5-mm trocar (Ethicon Endosurgery) (A) through an incision within the typical concavity of the umbilicus often hidden in an umbilical skin fold and microlaparoscopic instruments through 3.5-mm microlaparoscopic trocars (B). umbilicus often hidden in an umbilical skin fold. The trocar tip is tunneled slightly caudally and laterally to result in a more optimal angle of visualization. In addition, the dilating tip design, 5-mm size, and insertion angle minimize the risk of hernia, so fascial closure is not necessary. Once insufflated, the microlaparoscopic ports (3.5 mm) are placed under direct vision. Previous versions of the trocars were short and needed securing sutures to prevent accidental extraction, while, more recently, longer trocars are available. The upper ureter and ureteropelvic junction area are dissected. The ureter is divided below the UPJO and spatulated. In some cases, 5-mm scissors were inserted through the 5mm umbilical trocar and a 3-mm lens used through a microlaparoscopic trocar to speed division and resection of the redundant pelvis. Two 4-0 polyglactin (8 in) sutures are brought in tail first through the 5-mm trocar or the site of one of the microlaparoscopic trocars. Intracorporeal suturing and knot tying is performed using the microlaparoscopic needle holders. The stent is inserted after anastomosis and before closure of the renal pelvis after which standard drain (3 mm) placement and skin closures are performed. Stent placement confirmation and postoperative care are consistent with previously published technique and postoperative care pathway.13 Data from these clinical interactions were collected and analyzed, which included patient age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, laterality, pre- and postoperative creatinine levels, previous UPJO treatment, pre- and postoperative diuretic renography results, operative time, estimated blood loss (EBL), presence of crossing vessel, need for transfusion, length of stay (LOS), ureteral stent duration, complications, length of follow-up, and need for re-treatment. Success was defined by postoperative diuretic renography T½ less than 20 minutes and/or resolution of preoperative symptoms. These data for MLP and CLP patients were compared using the Student t test, Pearson chi-square test, and Fisher exact test, where appropriate. Results
From January 2009 through May 2013, 46 laparoscopic transperitoneal dismembered pyeloplasties were performed by
MLP VS CLP
3
a single surgeon (SDH). There were 27 CLP (7 performed with robot assistance) and 19 MLP patients (Table 1). The mean age was lower in MLP patients (34 vs 50 years; P = 0.0003), but the sex distribution was similar (P = 0.13). The mean BMI was not significantly different in the MLP group compared with the CLP group (24 vs 27; P = 0.05). The distribution between groups in ASA categories I–II and III–IV were not significantly different (P = 0.06). Among the CLP patients, 6 (22.2%) had previous UPJO treatment compared with 1 (5.3%) MLP patients (P = 0.38). Mean preoperative creatinine level was similar between groups (1.0 vs 1.0 mg/dL; P = 0.48). There were more identified crossing renal vessels in the MLP group (12 vs 9; P = 0.046). There was no difference between groups in operative time (197 vs 208 min; P = 0.48), mean EBL (57 vs 77 mL; P = 0.23), or mean LOS (1.1 vs 1.3 days; P = 0.07). There were no transfusions needed in the series (Table 2). There was no significant difference in the overall postoperative creatinine level (0.02 vs 0.0 mg/dL; P = 0.70) or change in creatinine level from preoperative values in either group (P = 1.0 vs 1.0 mg/dL; 0.74). There was no difference between MLP and CLP groups for duration of indwelling ureteral stent (46 vs 46 days; P = 0.91), length of follow-up (244 vs 380 days; P = 0.18), or complications (P = 0.28). There were six complications in the MLP group. One patient was readmitted for pain and nausea 7 weeks after surgery, but demonstrated no evidence of obstruction on imaging; in one patient, gross hematuria developed and clot urinary retention necessitating percutaneous nephrostomy drainage, but following this, postoperative renal scan T½ was 6.7 minutes. The other patients’ postoperative courses were complicated by urinary tract infection (UTI) or pain managed expectantly. Two MLP patients with treatment failure underwent redo robot-assisted laparoscopic (RAL) pyeloplasty because of persistent pain and/or evidence of continued obstruction. Intermittent obstruction that could not be defined by renal scan (postoperative T½ 11 minutes) developed in one of these patients, but was consistent on imaging with an intermittent obstructive kink during renal ptosis. This patient’s pain resolved after repeated pyeloplasty and renal pexing. The CLP group had four complications, consisting of Candida urosepsis, UTI, ureteral stent-related pain, or per-
Table 1. Patient Demographics
n Age (mean) Sex Male Female BMI (mean) ASA I–II III–IV Previous treatment
MLP (%)
CLP (%)
P value
19 34
27 50
0.0003*
9 (47.4) 10 (52.6) 24
7 (25.9) 20 (74.1) 27
0.13 0.13 0.05
17 (89.5) 2 (10.5) 1 (5.3)
18 (66.7) 9 (33.3) 5 (18.5)
0.06 0.06 0.38
*Statistical significance indicated by P value
