Retroperitoneal laparoscopic non-dismembered pyeloplasty for uretero-pelvic junction obstruction due to crossing vessels: A matched-paired analysis and review of literature
Jens Rassweilera*(),Jan Kleinb,Ali Serdar Goezena
a Department of Urology and Pediatric Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heibronn, Germany b Department of Urology, Medical School Ulm, University of Ulm, Ulm, Germany
Objective: To compare laparoscopic Anderson-Hynes pyeloplasty (LAHP) and retroperitoneal laparoscopic YV-pyeloplasty (LRYVP) in ureteropelvic junction obstruction (UPJ) in presence of a crossing vessels (CV). Methods: Our database showed 380 UPJO-cases,who underwent laparoscopic retroperitoneal surgery during the last 2 decades including 206 non-dismembered LRYVP, 157 dismembered pyeloplasties LAHP, and 17 cases of laparoscopic ureterolysis. Among them 198 cases were suitable for a matched-pair (2:1) analysis comparing laparoscopic retroperitoneal non-dismembered LRYVP (Group 1, n = 131) and dismembered LAHP (Group 2, n = 67) in presence of a crossing vessel. Patients were matched according to age, gender, kidney functions, and obstruction grade. Complications were graded according to modified Clavien-classification. Results: Comparative data were similar between both groups (LRYVP vs. LAHP) including mean operating time (112 min vs. 114 min), complication rates (4.2% vs. 7.3%) mainly Grade 1-2 according to Clavien classification, and success rates (90% vs. 89%). These results reflected in the reviewed literature indicate that LRYVP provides the advantage of minimal dissection in case of CV with similar outcome. However, redundant pelvis and anteriorly crossing vessels still require a dismembered pyeloplasty LAHP. Conclusion: LRYVP has achieved similar results compared with the previous golden standard of open surgery, especially in case of crossing vessels apart from presence of a redundant pelvis or anteriorly crossing vessel. This can be further improved when using the small access retroperitoneoscopic technique respectively mini-laparoscopy.
Rassweiler Jens,Klein Jan,Serdar Goezen Ali. Retroperitoneal laparoscopic non-dismembered pyeloplasty for uretero-pelvic junction obstruction due to crossing vessels: A matched-paired analysis and review of literature[J]. Asian Journal of Urology,
2018, 5(3): 172-181.
Algorhythm of modern diagnosis of uretero-pelvic junction (UPJ)-obstruction primarily based on findings of colour-duplex ultrasound (CDUS), and magnetic resonance urography respectively isotope nephrogram (ING) with split function and a furosemide wash-out) to evaluate functional relevance of the stenosis. Retrograde pyelography (RPG) is used prior to the procedure. AHP, Anderson-Hynes pyeloplasty; LEP, laserendopyelotomy; YVP, YV-pyeloplasty; CT, computed tomography.
Trocar arrangement for right laparoscopic retroperitoneal pyeloplasty: Optic port (PⅠ) between M. abdominisexternus ① and M. lattisimusdorsi ② at the lumbar trigone ③. Five or ten micrometer port for right hand (PⅡ), 3/5 mm ④ rectus muscle port for left hand (PⅢ). Optional 3/5 mm port (PⅣ) medially.
Access for small-access retroperitoneoscopic technique (SMART)-pyeloplasty (A) Self-made balloon-trocar using finger of latex-free glove fixed to 5 mm-trocar; (B) Balloon dilatation using air-insufflation via 5 mm-trocar und endoscopic control; (C) Placement of two 3 mm-trocars under endoscopic control; (D) Use of ETHOS-platform during small access retroperitoneoscopic technique SMART-pyeloplasty providing armrests and a support for the chest of the surgeon.
Laparoscopic retroperitoneal pyeloplasty using YV-plasty (LRYVP) in case of anteriorly crossing vessel (A) Schematic drawing of left anteriorly crossing vessel; (B) Schematic drawing of principle of YV-plasty; (C) Schematic drawing of anatomical situation after YV-plasty; (D) Final endoscopic view after anastomosis.
Laparoscopic retroperitoneal pyeloplasty—technical details of non-dismembered pyeloplasty (SMART-technique). (A) Incision of renal pelvis and spatulation of ureter in a Y-form. The incised stenotic UPJ is included in the pelvis; (B) Initiation of pyeloplasty in a continuous fashion (Vicryl, 4-0, RB1-needle) at the medial side of the pelvis and ureter; (C) Creation of neo-UPJ anastomosing the pelvic flap to the spatulated ureter; (D) Exposition of the medial part of the anastomosis in V-form. SMART, small access retroperitoneoscopic technique; UPJ, uretero-pelvic junction.
Laparoscopic retroperitoneal pyeloplasty—Dismembered pyeloplasty (LAHP) in case of posteriorly crossing vessel. (A) Schematic drawing of posteriorly crossing vessel; (B) Resection of stenotic part, reduction of pyleon and spatulation of ureter; (C) Schematic drawing of anatomical situation after dismembered pyeloplasty. (D) Laparoscopic picture of the reconstructed ureteropelvic junction after dismembered pyeloplasty.
Parameters
Non-dismembered (LRYVP)
Dismembered pyeloplasty (LAHP)
p-Value
n
131
67
Mean age (year)
34.6 ± 2
32.6 ± 1.6
0.5
Gender
0.3
Female (%)
74 (58)
33 (49)
Male (%)
57 (42)
34 (51)
Preoperative pain
116 (89)
57 (85)
0.3
Preoperative obstruction grade n, (%)
0.3
Grade 1
3 (3)
2 (3)
Grade 2
75 (57)
29 (43)
Grade 3
53 (40)
36 (54)
Parameters
Non-dismembered (LRYVP)
Dismembered pyeloplasty (LAHP)
p-Value
n
131
67
Mean preoperative kidney functions
35.1 ± 1.1
35.9 ± 1.0
0.5
Mean postoperative kidney functions
36.3 ± 1.0
37.7 ± 1.0
0.2
Mean operation time (min)
112 ± 33.4
114 ± 45.1
0.3
Complications according to Clavien Classification n (%)
0.2
Grade 1
1 (0.8)
3 (4.4)
Grade 2
2 (1.4)
2 (2.9)
Grade 3a
2 (1.4)
0
Grade 3b
1 (0.8)
0
Grade 4
-
-
Grade 5
-
-
Success rate, n (%)
118 (90)
60 (89)
0.6
Cosmetic aspect of small access retroperitoneoscopic technique (SMART)-pyeloplasty vs. retroperitoneoscopy. (A) Minimal scars 3 months after SMART; (B) Significantly larger scars after conventional retroperitoneoscopy.
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