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ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 361-366

Laparoscopic versus open pyeloplasty in the management of ureteropelvic junction obstruction


Department of Urology, Faculty of Medicine, Menoufia University, Menufia, Egypt

Date of Submission23-Oct-2016
Date of Acceptance13-Jan-2017
Date of Web Publication25-Sep-2017

Correspondence Address:
Atef Badawy
Urology Department, Faculty of Medicine, Menoufia University, Menufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215467

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  Abstract 

Objectives
This study aimed to compare the results and outcome of laparoscopic versus open pyeloplasty in the management of ureteropelvic junction obstruction.
Background
Since the first successful open pyeloplasty in 1891 by Kuster, many approaches for ureteropelvic junction obstruction correction has been developed. Successful laparoscopic pyeloplasty was initially introduced by Schuessler in 1993. Laparoscopic pyeloplasty has decreased morbidity of flank incision and shorter hospital stay with excellent surgical outcomes.
Materials and methods
This study was conducted as a prospective nonrandomized study at the urology department, faculty of medicine, Menoufia University, Egypt. A total of 30 patients were included and divided into two groups. The first group included 21 patients who underwent open pyeloplasty between May 2010 and June 2013. The second group included nine patients who underwent laparoscopic pyeloplasty between June 2010 and May 2013. Preoperative, intraoperative, and postoperative variables and outcome were evaluated.
Results
Demographic data for patients in the two groups were similar. There were 21 patients (eight male and 13 female patients) in the open group, with a mean age of 23 ± 5.5 (17–38), versus nine patients (four male and five female patients) in the laproscopic group, with a mean age of 23 ± 3.8 (18–27). Compared with the open group, the laparoscopic group had prolonged operative time (251 ± 55.7 vs. 129 ± 20.7). The mean follow-up period was 18.5 versus 18.8 for the open group and the laparoscopic group, respectively. During the 3-month follow-up period, postoperative glomerular filtration rate% and postoperative T1/2 per minutes were comparable in both groups, without statistical difference; they were 33 ± 11.8 and 12 ± 8.7 versus 35 ±11.7 versus 16 ± 14.5 for the open group and the laparoscopic group, respectively.
Conclusion
Perioperative complications, hospital stay, and success rate are comparable between open and laparoscopic pyeloplasty, with prolonged operative time for the laparoscopic group and larger morphine equivalent dose for the open group.

Keywords: laparoscopic, open pyeloplasty, ureteropelvic junction obstruction


How to cite this article:
Badreldin M, Abdel Elbaky TM, Abdallah MM, Badawy A. Laparoscopic versus open pyeloplasty in the management of ureteropelvic junction obstruction. Menoufia Med J 2017;30:361-6

How to cite this URL:
Badreldin M, Abdel Elbaky TM, Abdallah MM, Badawy A. Laparoscopic versus open pyeloplasty in the management of ureteropelvic junction obstruction. Menoufia Med J [serial online] 2017 [cited 2019 Aug 24];30:361-6. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/361/215467


  Introduction Top


Ureteropelvic junction obstruction (UPJO) is the most common congenital disease in the ureter. Although it may be discovered incidentally, the most common clinical symptoms are flank pain, renal colic, hematuria, and infection, and can lead to progressive hydronephrosis and renal dysfunction [1],[2].

Since Kuster reported the first successful open pyeloplasty in 1891, the surgical correction of UPJO has been approached in many ways. Anderson-Hynes dismembered pyeloplasty, first described in 1949, remains most popular today [3].

The reference standard for treatment of UPJO has been open pyeloplasty, with a success rate of more than 90% [4].

To decrease the morbidity of a flank incision, minimally invasive techniques to treat UPJO have been developed, with endoscopic endopyelotomy being first such technique to be widely accepted [5]. However, the success rate is less than that of open pyeloplasty, and there are some risk factors such as massive hydronephrosis and poor renal function, which decrease the success rate [6].

Laparoscopic pyeloplasty, initially introduced by Schuessler in 1993, gives the advantages of surgical reconstruction while eliminating the morbidity of a flank incision. Numerous studies report shorter hospital stay with excellent surgical outcomes [7].

The widespread acceptance of laparoscopic surgery has been largely propelled by the public awareness that minimally invasive surgery is associated with less pain, quicker return to normal activity, and better cosmetic results [8].

During the initial learning curve for urologists into laparoscopy, a significant hurdle that needs to be overcome is the adjustment from an environment that is both tactile and visual to a surgical field that is very limited in a tactile sense and a magnified visual field, but in two dimensions only [9]. Intracorporeal suturing remains the limiting factor for the widespread application of laparoscopy to treat urologic conditions that require complex reconstruction (pyeloplasty, partial nephrectomy, and prostatectomy). Limited range of movement, two dimensional viewing, and fulcrum effect, all limit efficient intracorporeal suturing for an inexperienced laparoscopist [10].


  Patients and Methods Top


In this prospective nonrandomized study we have two groups. The first group included 21 patients who underwent open pyeloplasty between May 2010 and June 2013. The second group included nine patients who underwent laparoscopic pyeloplasty for the treatment of UPJO between March 2011 and May 2013.

In the open group, patients were positioned in dead lateral position except one patient with pelvic kidney, who had infraumbilical midline incision. Supracostal incision was carried out for 20 patients. No retrograde was carried out for any patient, because there were clear anatomical studies for these patients; therefore retrograde pyelography was not indicated in these patients. In all patients a JJ stent was placed intraoperatively in an antegrade manner.

The procedure started by dissection of the renal pelvis and ureter with ureteropelvic junction (UPJ) exposure. Anderson-hyens repair was performed in 14 patients, Fenger plasty was performed in five patients, and Y-V plasty was performed in two patients. A retroperitoneal tubal drain was left near but not on the repair at the conclusion of the procedure.

In the laparoscopic group, retrograde pyelography, before the pyeloplasty procedure, was performed in 5/9 cases, followed by ureteric catheter insertion to the ipsilateral ureter to 10–12 cm in the middle ureter. This technique keeps the renal pelvis dilated and facilitates the JJ insertion in a retrograde manner during the procedure, just before completion of the anastomosis. There were four cases in which a JJ stent was inserted in an antegrade manner through the uppermost port.

A veress needle was used in all patients. The transperitoneal approach was carried out in six cases, and retroperitoneal access was performed in three cases (retroperitoneal access was a surgeon preference; all of them were performed by the same surgeon). Laparoscopic instrumentations used were laparoscopic needle driver, hook, suction irrigator device, blunt tip grasper, and laparoscopic scissors.

In the transperitoneal approach (six cases), a three-port system was implemented in 5/6 cases and all of them were performed on the left side. There was no indication for a fourth port insertion. Four ports were indicated in 1/6 cases (right side); the fourth port was inserted in the midline above the umbilicus for liver retraction. In the retroperitoneal approach (three cases) also a three-port system was implemented in all cases.

In the transperitoneal approach, initially, the ureter was identified in the retroperitoneum. The proximal ureter, UPJ, and renal pelvis were completely freed, and the proximal ureter was then spatulated laterally for 1–2 cm. Anastomosis was carried out by accurate placement of running 4–0 polyglactin sutures at the apex of the spatulated ureter. The ureter was sutured to the most dependent part of the pyelotomy and the two dismembered ends were reapproximated with intracorporeal continuous knots.

Retroperitoneal laparoscopic pyeloplasty: Gerota's fascia is incised parallel to the psoas muscle, and the perinephric fat is dissected to reveal the lower pole of the kidney, which is then mobilized and identification of the ureter and UPJ is carried out. All retroperitoneal cases were performed on using Anderson-Hynes repair type.

Postoperative care: All patients started oral feeding on the first postoperative day. Analgesics were administered as required. The urethral catheter was removed within 24–36 h. The drain was removed when drainage was negligible (<50 ml/day), usually within 3–5 days. The stent was removed within 3–6 weeks in most cases.


  Results Top


Demographic data for the two groups are shown in [Table 1]. Both groups were comparable with regard to age, sex, and affected side, with no statistical significance. Fourteen patients presented with flank pain, two were incidentally discovered in the open group versus seven and two patients in the laparoscopic group.
Table 1: Preoperative variables of open and laparoscopic groups

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Degree of hydronephrosis was mild/moderate in 10patients; however, 11 patients presented with severe hydronephrosis, with four in the open group and five in the laparoscopic group. In the open group, preoperative ipsilateral split function mean was 27 ± 12.5 (16–54), which is lower than that in the laparoscopic group 32 ± 19.57 (15–65), without statistical difference. Preoperative ipsilateral T1/2 time by minutes mean was 35 ± 10.11 (22–57) in the open group versus 27 ± 5.79 (18–34) in the laparoscopic group [Table 1].

Associated renal stones and crossing vessels in the open group were 9.5 and 28.5%, versus 0 and 44.4% in the laparoscopic group, respectively.

The mean operative time, mean estimated blood loss, and hospital stay by hours in the open group was 129±20.76 (90–160), 156 ± 56.07 (100–250), and 64±27.7, versus 251 ± 55.77 (180–330), 430 ± 778.84 (100–2500), and 70 ± 43.38 (48–184), respectively. No blood transfusion was indicated in the open group; however, it was indicated in one case of the laparoscopic group [Table 2].
Table 2: Intraoperative and postoperative variables of open and laparoscopic groups

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Dismembered repair was performed in 14 patients (66.6%) in the open group versus 88.8% in the laparoscopic group. Intraoperative complications occurred in two patients (9.5%) in the open group. The first one was tear of the ureteral spatulation; creation of another one mandated more mobilization of the kidney so as to avoid tension repair. The second complication was injury to the lower pole vessel, which was ligated and transected; the patient did not receive blood transfusion.

Intraoperative complications occurred in three patients (33.3%) in the laparoscopic group. In the first case, injury to ipsilateral gonadal artery during ureteral dissection led to massive bleeding, immediate exploration, and transfusion of 4 U of blood (only case converted to open in this study). We regarded that conversion to open pyeloplasty in this case is one of laparoscopic complications; therefore, this patient who was in the laparoscopic group was converted to the open group because of bleeding. In the second case, the transmesenteric approach was tried first, but failed because dilated pelvis was more proximal to transmesenteric access; therefore, formal retroperitoneal approach was tried. The third case was in the retroperitoneal group, in which fragmentation of homemade balloon to three parts was carried out, which were successfully removed. Postoperative complications in the open group occurred in four patients (19%), which were as follows: persistent leak for 17 days, which was managed conservatively; persistent leak for 9 days, which mandated drain withdrawal after KUB; persistent pyuria (pus over 100) (cultures were negative); and wound infection in one patient, which was managed conservatively. Postoperative complications in the laparoscopic group occurred in two patients. Patient developed pyonephrosis in single left kidney immediately postoperative, wide pore nephrostomy was inserted, and Sever incrustation over the JJ stent prevents its removal by ureteroscopy, so, indicated for successful percutaneous approach.

All postoperative complications were evaluated according to the Clavien–Klein classification [Table 3].
Table 3: Postoperative complications according to the Clavien–Klein grading system

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Morphine equivalent dose mean was 36 ± 17.52 (15–80), which was statistically significant compared with the laparoscopic group [20 ± 4.63 (15–30)]. Clavien–Klein surgical score was 2 for all patients in the open group, whereas it was 2.1 ± 0.33 in the second group. The mean follow-up period by months was 18.5± 8.8 (3–36) in the open group, which was comparable to the second group [18.8 ± 7 (3–30)].

As regards the outcome, we evaluated functional outcome in terms of postoperative ipsilateral split glomerular filtration rate% and T1/2 drainage per minutes; moreover, radiological and clinical outcomes were evaluated after 3 months and 1year postoperatively. There were comparable results between the two groups as regards outcome and success rate. Outcome variables are presented in [Table4].
Table 4: Outcome variables for open and laparoscopic groups

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All statistical analyses were carried out using Jmp software, version 9.2 (Cary, NC, USA). Using univariant analysis, three factors were statistically significant, which were operative time, morphine equivalent dose, and stent removal time. However, using multivariate analysis, only operative time was highly significant (P = 0.005) [Figure 1] and [Figure 2].
Figure 1: Outcome variables for open and laparoscopic groups.

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Figure 2: Intraoperative and postoperative variables of open and laparoscopic groups.

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  Discussion Top


Open pyeloplasty has been the gold standard therapy for the repair of UPJ obstruction for many years, with success rates as high as 90% [11].

Since introduction in 1993 by Schuessler, laparoscopic pyeloplasty has become an accepted treatment option for UPJO repair, with equivalent success rates to open surgery. [12].

We compared our results with other published studies for open pyeloplasty. The mean operative time was 129 min and the mean estimated blood loss was 156 ml in our study. In the study by Clavert et al. [13], they concluded that the mean operative time was 91 min for the open group, which is lower than that in our series time, and 159 min for the laparoscopic group. The mean hospital stay was 5.4 days for the laparoscopic group and 5.6 days for the open group, which is longer than that in our series; this may be because of our policy, in open pyeloplasty, of discharging the patient after a full diet regimen has been regained in the outpatient clinic at the time of drain removal. Success rate was 90.9%, which is comparable to that observed in our series (88.2%).

In the laparoscopic group, according to the findings by Janetschek et al. [14] they found that crossing vessel was a frequent cause of UPJO. They detected crossing vessels in 79% of patients. In our series, crossing vessels were detected in 52% of patients in the laparoscopic group and 28.5% in the open group.

According to most literature, success was defined as symptom resolution and improved radiological or renographic parameters during the follow-up period.

According to most series, failure usually occurs early and usually becomes symptomatic. Long-term follow-up for successful cases in our study demonstrated late recurrence of one case (4.7%) in the open group after 18 months follow-up; she managed by redo open pyeloplasty with successful outcome. However, the mean time to failure in our study was 5.7 months, which is comparable to Davenport series in which it was 4.6 months [15].

Several studies quantify the learning curve for laparoscopic pyeloplasty in 30–50 cases, referring of course to surgeons who have never performed any type of laparoscopic surgery [16],[17]. In our study, all open cases were performed on by expert surgeons; however, the laparoscopic group was preformed on by surgeons still in laparoscopic learning curve (six cases), except one surgeon who had performed more than 200 retroperitoneal laparoscopic pyeloplasty; he did three cases in our study, and all of them were retroperitoneal approach.

Postoperative complication after open pyeloplasty in our series occurred in four patients (19%); however, it occurred in two patients (22.2%) in the laparoscopic group. These results were comparable to those of Srivastava et al. [17] series, which stated that postoperative complications were comparable in both open and laparoscopic groups without statistically significant difference.

During the 3-month follow-up period, only 17/21 patients in the open group and 6/9 in the laparoscopic group underwent follow-up visits; however, at the 1-year visit, an additional two patients had been lost to follow-up in each group.


  Conclusion Top


Perioperative complications, hospital stay, and success rate are comparable between open and laparoscopic pyeloplasty, with prolonged operative time for the laparoscopic group and larger morphine equivalent dose for the open group.

Acknowledgements

Conflicts of interest

None declared.

 
  References Top

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Lee DI, et al. Retroperitoneal laparoscopic cryoablation of small renal tumors: intermediate results. Urology 2003; 61:83–88.  Back to cited text no. 9
    
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Hernandez JD, et al. Qualitative and quantitative analysis of the learning curve of a simulated surgical task on the da Vinci system. Surg Endosc 2004; 18:372–378.  Back to cited text no. 10
    
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O'Reilly PH, et al. The long-term results of Anderson-Hynes pyeloplasty. BJU Int 2001; 87:287–289.  Back to cited text no. 11
    
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Soulie M, et al. Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: comparison of two surgical approaches. Urology 2001; 57:443–447.  Back to cited text no. 12
    
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Calvert RC, et al. Comparison of laparoscopic and open pyeloplasty in 100 patients with pelvi-ureteric junction obstruction. Surg Endosc 2008; 22:411–414.  Back to cited text no. 13
    
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Janetschek G, Peschel R, Bartsch G. Laparoscopic Fenger plasty. J Endourol 2000; 14:889–893.  Back to cited text no. 14
    
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Davenport K, et al. Our experience with retroperitoneal and transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction obstruction. Eur Urol 2005; 48:973–977.  Back to cited text no. 15
    
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Singh O, Gupta SS, Arvind NK. Laparoscopic pyeloplasty: an analysis of first 100 cases and important lessons learned. Int Urol Nephrol 2011; 43:85–90.  Back to cited text no. 16
    
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Srivastava A, et al. Laparoscopic pyeloplasty: a versatile alternative to open pyeloplasty. Urol Int 2009; 83:420–424.  Back to cited text no. 17
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table4]



 

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