Retroperitoneal laparoscopic pyeloplasty: Heilbronn experience

Abstract

Introduction: We aim to report our experience with the treatment of adult ureteropelvic junction obstruction (UPJO) using an algorithm with retroperitoneal laparoscopic pyeloplasty (RLPP) and to assess the treatment efficacy and results of this technique. Materials and Methods: A retrospective review of LPP operations in 138 adult patients (60 women, 78 men) at a single institute between 1995 and 2006 were performed. The diagnosis of UPJO was confirmed by renal ultrasound, intra venous urography (IVU), retrograde uretopyelography (RP) and diuretic renography. In cases of ureteral kinking, color duplex sonography with or without spiral computer tomography were added to verify the presence of crossing vessels. Flank pain was the predominant presenting complaint in 92% of the cases. 11.5% of the patients were presented with recurrent pyelonephritis in and 1.4% with hematuria. Patients with posterioriorly crossing vessels or a redundant renal pelvis were treated with dismembered LPP while cases with anteriorly crossing vessels underwent nondismembered LPP. In the earlier cases of our series easier procedures such as ureterolysis or Fenger plasty were chosen predominantly. A double J stent placement was performed preoperatively. All the procedures were performed via the retroperitoneal approach. A three port insertion is used with an additional port placed as needed. Success was defined as resolution of symptoms (improvement of flank pain), associated with stable or improved renal function, reduction of hydronephrosis on ultrasound or IVU. Results: Dismembered pyeloplasty was performed in 42 cases. Nondismembered pyeloplasty were performed by either YV plasty in 66 cases or Fenger plasty in 15 cases. The stenosis of UPJ was operated by only uretrolyses in 15 cases. The underlying patology for UPJO was exstrinsic, intrinsic and combined causes in 125, 7 and 6 cases respectively. The operating time was averaged 126 (range 37 to 368) minutes. All operations except one were completed laparoscopically without any intraoperative complications. Only one patient needed open conversion because a significant tension on anastomosis. Post operative complications were retroperitoneal hematoma in 5 cases, urinary leakage in 2 cases and ureteral stent obstruction in 1 case. The postoperative complication rate was calculated as 6.5 %. The mean hospital stay was 5 (range 3 to 10) days. The double J stents were removed postoperatively in four to six weeks following a RP to check there is no evidence of urinary leakage and control the UPJ. An IVU was performed 6 weeks after the stent removal. A diuretic renogram was performed at 3 months and annually therafter if needed. Long term follow up ranges from 6-141 (mean 65) months. Overall success rate was 94.2 %. The eight patients who developed recurrent symptoms and obstruction were accepted as failures and further treatment needed as laser endopyeolotomy in 4 cases, open pyeloplasty in 3 cases, nephrectomy in 1 case. Conclusion: Retroperitoneal LPP is safe and effective way to treat UPJO while providing a minimally invasive procedure resulting in less morbidity. We feel that, LPP is a valuable alternative of open pyeloplasty in adult patient group.

Özet

Üreteropelvik bileşke darlığı (ÜPBD) tedavisinde uyguladığımız retroperitoneal laparoskopik piyeloplasti (RLPP) ameliyatının sonuçlarını ve etkinliğini değerlendirmeyi amaçladık. Kliniğimizde Şubat 1995 ile Ekim 2006 yılları arasında ÜPBD saptanan 138 yetişkin hastaya RLPP uygulandı. İleri derecede hidronefroz veya arka çaprazlayan damar saptanan hastalarda dismembered piyeloplasti, ön çaprazlayan damar varlığında ise ağırlıklı olarak YV-plasti tercih edildi. Tanıda ultrasonografi (USG), intravenöz ürografi (IVÜ), retrograd üreteropiyelografi (RGP) ve diüretik renografi kullanıldı. Ameliyatın başarı kriterleri; belirtilerin ortadan kalkması ile birlikte İVÜ bulgularında ve USG’de böbrek işlevinin düzelmesi ve hidronefrozun azalması olarak kabul edildi. 42 hastaya dismembered piyeloplasti, 66 hastada YV-plasti ve 15 hastada Fenger-plasti yöntemi uygulandı. Ortalama ameliyat süresi 126 dakika olarak kaydedildi. Bir hastada açık cerrahiye dönme gereği oldu. Kan kaybı ortalama 40 cc olarak saptanıldı. Ortalama hastanede kalış süresi 5 gün idi. Ameliyat sırasında hiçbir hastada istenmeyen yan etki oluşmadı. Ameliyat sonrası istenmeyen yan etki olarak; 5 hastada hematom, 2 hastada anostomozdan idrar kaçağı, 1 hastada stent obstrüksüyonu ve 1 hastada port yeri enfeksiyonu saptanıldı (istenmeyen yan etki oranı: %6.5). Ortalama izlem süresi 65 ay ve genel başarı oranı %94.2 olarak hesaplanıldı. RLPP ÜPBD’nın tedavisinde kullanılan etkin ve güvenilir ve morbiditesi düşük bir minimal invaziv tedavi yöntemi olarak erişkin hasta grubunda açık piyeloplastinin önemli bir seçeneği olduğu kanısındayız

Keywords: Retroperitoneal alan,Laparoskopi,Ürolojik cerrahi prosedürler,Üretra tıkanması,Ultrasonografi,İleriye dönük çalışma