Foley’s catheter was removed after 24 h and the tube drain was removed when it ceased output. Internal stent was removed by means of cystoscopy after 6 weeks.
Patients were followed up with IVU, magnetic resonance urography, and diethylene triamine penta-acetic acid scan, for both functional and morphological outcome at 3, 6, and 12 months. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow-up.
Data were collected and processed using SPSS, version 18 (SPSS Inc., Chicago, Illinois, USA). P-values less than 0.05 were considered statistically significant.
This study included 29 patients with a mean age of 4.23±2.1 years (range 3–16 years). There were 12 male and 17 female patients with 32 obstructed renal units at UPJ (three bilateral). Thirteen patients had right-sided UPJO, 13 had left-sided UPJO, and three had bilateral UPJO. The most common presentation was loin pain (25 cases), whereas two patients presented with hematuria and two patients were accidently discovered. Twenty-six patients had unilateral UPJO (four out of them had a congenital ectopic kidneys).
All cases were completed laparoscopically without any conversion. Aberrant vessels were detected in six patients. Concomitant multiple renal stones were found in one case. The mean operative time was 143.9±22.6 (range 110–210) (Table 1).
All patients were given diclofenac sodium to control postoperative pain. The mean postoperative hospital stay was 4.1±1.5 days (range 3–8 days). Tube drains were removed on the third postoperative day when drainage had stopped, with a mean of 3.4±1.2 days (range 2–8 days). One patient developed postoperative fever and was managed conservatively with proper antibiotics. The mean duration of stenting was 5.8±2.11 weeks (range 6–10 weeks). The mean follow-up of the patients was 36.34±5.18 months (range 22–60 months). There was one case of recurrence UPJO giving a success rate of 96.9%.
Two (6.9%) patients had persistent urine leakage after TLP and were managed conservatively and the leakage stopped after 2 weeks (Table 2). One of them improved without further intervention, whereas the other patient developed recurrent UPJO, which was managed with double-J fixation first and then with retrograde endopyelotomy after 1 year.
Postoperative evaluation was carried out with abdominal ultrasound; IVU and renal scan were performed 3–8 months later. In all patients there was significant improvement in UPJO with improved renal functions and reduction in the size of renal pelvis (Figs 3 and 4Figs 3 and 4). Comparative analysis of preoperative and postoperative IVU revealed statistically significant differences between preoperative and postoperative results as regards the degree of hydronephrosis (P=0.016) (Table 3).
Laparoscopic pyeloplasty is a first-line option for the management of UPJO. It has a greater success rate than that of endopyelotomy and is associated with a shorter and less intense convalescence compared with open pyeloplasty. The technique is well established and reproducible, although it is more difficult in certain situations, such as after a previous pyeloplasty and intrarenal pelvis 11.
The transperitoneal approach is more familiar to most surgeons and offers the following advantages: much wider workspace that would allow easier addition of techniques, such as transposition of polar vessels or remodeling of the pelvis and resolution of secondary lithiasis, and the anatomical landmarks allow better guidance and more easily reproduce the steps of open surgery 12.
In our study, as well as in other studies 3,5,133,5,133,5,13, the incidence of intraoperative blood loss was minimal and the requirement for blood transfusion was rare. The estimated blood loss in our study was less than 50 ml in 86.2% of patients and between 50 and 100 ml in 13.8%. None required blood transfusion. Inagaki et al. 14 found that the mean blood loss was 158 ml. Such results are comparable to blood loss reported in open pyeloplasty.
The mean operative time in the present study was 143.9 min (range 110–220 min), which is nearly similar to that reported by other researchers 5,15,165,15,165,15,16. In the work of Mandahani et al.15, the mean operative time was 246 min (range 100–480 min). Recently, Juliano and colleagues reported a mean operative time of 127 min (range 45–370 min). The significant difference in the operative time found in several studies may be attributed to the presence of different surgeons with different experiences. The technique of suturing, the methods used for knot tying, the inclusion of recurrent UPJO, and the occurrence of intraoperative complications are important factors related to operative time 7.
The type of TLP is another factor in determining the mean operative time. Szydełko and colleagues found that patients who underwent nondismembered Y-V plasty had significantly shorter operative time while maintaining similar postoperative outcomes. The shorter operative time in the Y-V plasty group was explained by the fact that fewer anastomotic sutures were needed in this procedure, which made it technically easier and more feasible 17.
Many urologists prefer to perform retrograde urography before proceeding with TLP, to more precisely define the length and location of the strictured segment and to rule out distal obstruction and then insert double-J stent retrogradely before completion of the anastomosis. However, such technique adds to the increased operative time 1,18,191,18,191,18,19. Others performed double-J placement in an antegrade manner just preoperatively. In this study, double-J stent was inserted in all cases antegradely during the operation. Two steps may have a role in diminishing the mean operative time in this study: the first step was the fixation of redundant renal pelvis to anterior abdominal wall using vicryl 2/0 as a sling, which acts as retraction, and sparing one trocar; and the second step was the insertion of double-J stent over the guidewire passed through puncture needle after spatulation of the ureter 20–2220–2220–22.
A double-J stenting is a standard of care to drain pyeloplasty in many centers (25). It may have an advantage of lessened nursing care and reduced morbidity after pyeloplasty. Egan and colleagues have shown that double-J stenting may result in more rapid resolution of hydronephrosis after pyeloplasty. The double-J ureteral stent is often placed after ureteral spatulation and before beginning the anterior wall of the anastomosis to minimize the risk for undue traction or compromise to the reanastomosis 23. However, stent malpositioning has been reported with blind antegrade stenting. Malpositioning of the lower end of the double-J stent is usually associated with difficulties in negotiating the ureterovesical junction 20.
Most surgeons perform the anastomosis in a running manner. Lapra-Ty clips may be used to minimize knot tying, and specialized instruments such as the endostitch device may facilitate suturing. Important principles include the creation of a tension-free watertight anastomosis with preservation of the periureteral blood supply 24. In this study, we performed the anastomosis in a continuous running vicryl suture. The authors started TLP after gaining a good experience in different laparoscopic procedures and mastering intracorporeal suturing and knot tying.
The presence of stones is recognized as a complication of the UPJO, and the diagnosis creates dilemmas as regards treatment. Inagaki et al.14 reported the presence of kidney stones in 16% of patients. Rivas et al.12 reported on concomitant kidney stones in 12 of 62 patients (19%) who had undergone transperitoneal TLP. They removed stones in eight cases using a flexible cystoscope and a nitinol N-circle basket, whereas in the remaining four cases the stones were extracted using laparoscopic grasping instruments. In cases of UPJO associated with renal stones, a flexible cystoscope or ureteroscope can be inserted through a laparoscopic port into the pyelotomy before closing the defect for removing the stone from the renal pelvis or calyces using forceps or Dormia basket. The light source and camera can be transferred to the cystoscope or the ureteroscope 11. In this study, extraction of multiple concomitant calyceal stones from ectopic kidney was carried out by introduction of the ureteroscope from the operating trocar sheath.
In this study, one case developed urine leakage, which stopped spontaneously within 2 weeks. Another case developed recurrent UPJO, which was managed with double-J stent first and with retrograde endopyelotomy after 1 year. Shoma et al.3 reported two cases of postoperative complications: one had mild hematuria, which was managed conservatively, and the second developed urine leakage, which stopped on the ninth postoperative day. Lasmar et al.5 reported a postoperative complication rate of 10.9% in 10 patients in the form of urine leakage (six cases), urinary fistula (one case), and port site infection (three case), and all were managed conservatively. Juliano et al. 7 reported 9.6% postoperative complication rate, and urine leakage occurred in eight cases (6.1%); all cases were managed conservatively.
One of the most distressing complications of TLP is conversion to open surgery. This conversion has been reported to be in the range of 0–1.8% 5,75,7. In this study, there was no single case of conversion to open surgery and all operations were completed laparoscopically without any complication. This is in agreement with that mentioned by Shoma et al.3, who studied 40 cases of TLP without conversion to open surgery. The success rate of TLP in the current study was 96.9% (31/32), which is compatible with that reported in the literature. The success rate of TLP has been reported to be consistently high, at 87–98% 3,5–73,5–73,5–73,5–7. In contrast, Metzelder et al.20 reported poor success for laparoscopic nondismembered Y-V pyeloplasty. Moreover, Casale and colleagues reported a success rate of 94% for dismembered pyeloplasty and 43% for nondismembered pyeloplasty in children with UPJO. The difference in outcomes between the two laparoscopic techniques was attributed to the dysplastic tissue found in pelviureteric junction obstructions, which is only rearranged in nondismembered procedures but resected in Anderson-Hynes dismembered pyeloplasty 21.
Despite observed success in relieving obstruction, functional improvement after UPJO repair is less certain. One study showed no improvement after pyeloplasty in patients, with preoperative renal function of less than 20% 18 8. In another study, only two of 10 patients with preoperative renal function less than 30% improved after the repair 9. In the work of Khan et al.10, the majority of patients had persistent hydronephrosis after surgery and the improvement in renal function and T½ was noted in less than 50% of cases. In the present study, there was a statistically significant difference between preoperative and postoperative IVU results as regards the degree of hydronephrosis (P=0.016). Moreover, there was a statistically significant improvement in the postoperative GFR than in the preoperative values after 6 months of follow-up (P=0.006). This can be explained by the fact that 93.8% of renal units we studied had preoperative GFR greater than 20 ml/min/1.73 m2 and 50% of renal units had GFR greater than 40 ml/min/1.73 m2.
Our study may be limited by the lack of randomization, the small number of cases, and the heterogeneity of patients studied as regards ages and type of TLP (Tables 4 and 5Tables 4 and 5, Fig. 5).
Laparoscopic pyeloplasty has a minimal level of morbidity, short hospital stay, better cosmesis, and excellent radiological and functional outcomes.
My gratitude and sincere thanks to Prof. Eraky, Professor of Urology, Mansura Urology and Nephrology Institute for his continuous support and learning brilliant ideas. My deep thanks to Prof. Hussein Galal, Staff members and colleges in the Department of Urology and Pediatric Surgery, Al-Azher Univesity for their support and advice.
Conflicts of interest
There are no conflicts of interest.
1. Lee H, Han SW. Ureteropelvic junction obstruction: what we know and what we don’t know. KJU 2009; 50:423–431.
2. Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM. Laparoscopic dismembered pyeloplasty. J Urol 1993; 150:1795–1799.
3. Shoma AM, El Nahas AR, Bazeed MA. Laparoscopic pyeloplasty: a prospective randomized comparison between the transperitoneal approach and retroperitoneoscopy. J Urol 2007; 178:2020–2024.
4. Calvert RC, Morsy MM, Zelhof B, Rhodes M, Burgess NA. Comparison of laparoscopic and open pyeloplasty in 100 patients with pelvi-ureteric junction obstruction. Surg Endosc 2008; 22:411–414.
5. Lasmar MT, Castro HA Jr, Vengjer A, Guerra FA, Souza EA, Rocha LM. Transperitoneal laparoscopic pyeloplasty: Brazilian initial experience with 55 cases. Int Braz J Urol 2010; 36:678–684.
6. Adeyoju AB, Hrouda D, Gill IS. Laparoscopic pyeloplasty: the first decade. BJU Int 2004; 94:264–267.
7. Juliano RV, Mendonca RR, Meyer F, Rubinstein M, Lasmar MT, Korkes F, et al.. Long-term outcome of laparoscopic pyeloplasty: multicentric comparative study of techniques and accesses. J Laparoendosc Adv Surg Tech A 2011; 21:399–403.
8. Gupta M, Tuncay OL, Smith AD. Open surgical exploration after failed endopyelotomy: a 12-year perspective. J Urol 1997; 157:1613–1618.
9. Dimarco DS, Gettman MT, McGee SM. Longterm success of antegrade endopyelotomy compared with pyeloplasty at a single institution. J Endourol 2006; 20:707–712.
10. Tripathi M, Kumar R, Chandrashekar N, Sharma S, Bal C, Bandopadhyaya G, Malhotra A. Diuretic radionuclide renography in assessing Anderson-Hynes pyeloplasty in unilateral pelviureteric junction obstruction. Hell J Nucl Med 2005; 8:154–157.
11. Wolf JS. Laparoscopic transperitoneal pyeloplasty. J Endourology 2011; 25:173–178.
12. Rivas JG, Alonso Y Gregorio S, Sanchez LC, Guerin Cde C, Gomez AT, Togores LH, Barthel JJ. Approach to kidney stones associated with ureteropelvic junction obstruction during laparoscopic pyeloplasty. Cent European J Urol 2014; 66:440–444.
13. Zhang X, Li HZ, Ma X, Zheng T, Lang B, Zhang J, et al.. Retrospective comparison of retroperitoneal laparoscopic versus open dismembered pyeloplasty for ureteropelvic junction obstruction. J Urol 2006; 176:1077–1080.
14. Inagaki T, Rha KH, Ong AM, Kavoussi LR, Jarrett TW. Laparoscopic pyeloplasty: current status. BJU Int 2005; 95 (Suppl 2):102–105.
15. Mandhani A, Kumar D, Kumar A, Kapoor R, Dubey D, Srivastava A, Bhandari M. Safety profile and complications of transperitoneal laparoscopic pyeloplasty: a critical analysis. J Endourol 2005; 19:797–802.
16. Bachmann A, Ruszat R, Forster T, Eberli D, Zimmermann M, Muller A, et al.. Retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction (UPJO): solving the technical difficulties. Eur Urol 2006; 49:264–272.
17. Szydełko T, Kasprzak J, Apoznański W, et al.. Comparison of dismembered and nondismembered Y-V laparoscopic pyeloplasty in patients with primary hydronephrosis. J Laparoendosc Adv Surg Tech A 2010; 20:7–12.
18. Moon DA, El-Shazly MA, Cm Chang, et al.. Laparoscopic pyeloplasty evaluation of a new gold standard. Urology 2006; 67:932–936.
19. Bansal P, Gupta A, Mongha R. Laparoscopic versus open pyeloplasty: comparison of two surgical approaches – a single center experience of three years. J Min Access Surg 2008; 4:76–79.
20. Metzelder ML, Schier F, Petersen C, Truss M, Ure BM. Laparoscopic transabdominal pyeloplasty in children is feasible irrespective of age. J Urol 2006; 175:688–691.
21. Casale P, Grady RW, Joyner BD, Zeltser IS, Figueroa TE, Mitchell ME. Comparison of dismembered and nondismembered laparoscopic pyeloplasty in the pediatric patient. J Endourol 2004; 18:875–878.
22. Pahwa M, Pahwa AR, Girotra M, Abrahm RR, Kathuria S, Sharma A. Defining the pros and cons of open, conventional laparoscopy, and robot-assisted pyeloplasty in a developing nation. Adv Urol 2014; 2014:850156.
23. Egan SC, Stock JA, Hanna MK. Renal ultrasound changes after internal double-J stented pyeloplasty for ureteropelvic junction obstruction. Tech Urol 2001; 7:276–280.
© 2015 Annals of Pediatric Surgery
24. Klingler HC, Remzi M, Janetschek G, et al.. Comparison of open versus laparoscopic pyeloplasty techniques in treatment of ureteropelvic junction obstruction. Eur Urol 2003; 44:340–345.