Management of secondary ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty

PURPOSE: Laparoscopic pyeloplasty has been established as a minimally invasive alternative to open pyeloplasty. However, little is known about the treatment of patients in whom this technique fails. We present our experience with treating ureteropelvic junction obstruction after failed primary laparoscopic pyeloplasty. MATERIALS AND METHODS: From August 1993 to September of 2003, 227 patients underwent laparoscopic pyeloplasty for primary ureteropelvic junction obstruction. Of these patients 10 (4.4%), including 6 females and 4 males 24 to 62 years old (mean age 42.1), underwent secondary treatment after laparoscopic pyeloplasty failed. The type of secondary intervention varied by anatomical factors, and patient and surgeon preference. Success was defined as symptomatic relief and improved radiographic imaging at latest followup. RESULTS: Secondary interventions were repeat laparoscopic pyeloplasty in 1 patient, retrograde endoscopic balloon dilation in 2 and endopyelotomy in 7 (laser, cold knife and cutting balloon endopyelotomy in 3, 2, and 2, respectively). No postoperative complications were seen. Patients were followed for a mean of 25.5 months (range 3 to 96) after the second procedure. Seven of 10 secondary interventions (70%) were successful with no obstruction on followup imaging. Three of 10 interventions (30%) failed, namely 1 laparoscopic pyeloplasty, 1 endoscopic balloon dilation and 1 laser endopyelotomy. Failure of the second procedure occurred at a mean of 9.3 months. CONCLUSIONS: When given the choice, most patients select endoscopic management after failed primary laparoscopic pyeloplasty due to its minimally invasive nature and low complication rate. Success rates are 70% with repeat intervention. Some patients require a third intervention.     

Laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction in children

Objectives:   To present our initial experience with laparoscopic pyeloplasty and to evaluate the safety and short-term outcome of this technique in children.
Methods:   Thirteen kidney units in twelve children underwent laparoscopic dismembered pyeloplasty for the management of ureteropelvic junction obstruction (UPJO) at our institution between 2005 and 2008. Patient age at surgery was 18–177 months (mean 89.8 months). There were six boys and six girls. Ten had unilateral UPJO with a normal contralateral kidney, one had bilateral UPJO and one had UPJO of a solitary kidney. We used 3- and 5-mm instruments for grasping, blunt dissection, incising and suturing to facilitate safe and precise surgery. The outcome was measured by the operative time and resolution of obstruction and symptoms.
Results:   Median operative time was 275 min (range 154–420). There was a slight relationship between age and operative time. No major perioperative complications occurred in any cases. Median renal pelvic anterior–posterior diameter at ultrasonography significantly decreased from 8.6 cm (range 3.8–22.0) preoperatively to 3.9 cm (1.0–8.9) postoperatively ( P  < 0.05). The median pre- and postoperative split renal function on diuretic renography in unilateral cases was 37.3% (range 29.7–46.4) and 39.5% (27.8–48.0), respectively. Overall, successful resolution of UPJO was observed in 12 of 13 kidneys (92.3%).
Conclusions:   Laparoscopic pyeloplasty represents a safe and effective option in the surgical treatment of children with UPJO.     

首次手术失败后再行腹腔镜肾盂成形术的临床研究

目的:探讨开放或腹腔镜肾盂成形术失败后再次行腹腔镜肾盂成形术的可行性和疗效。方法:从2004年9月~2012年5月,我们对32例肾盂输尿管连接部梗阻行肾盂成形术后再梗阻的患者采用经腹腔入路腹腔镜肾盂成形术治疗。同期开展首次腹腔镜肾盂成形术30例。术前统计两组患者的年龄、性别、体重、左右侧和积水程度,比较两组手术时间、术中术后并发症、住院时间和手术成功率,并把手术时间和术中出血与文献报道的结果相比。手术成功率以临床症状的缓解和影像学上积水和肾功能的改善来判断。两组所有数据均通过SPSS16.0专业软件进行统计,以P0.05为差别有统计学意义。结果:术前两组患者在年龄、性别、左右侧和积水程度上的差别无统计学意义(P0.05)。两组均无严重术中并发症,无中转开放手术者。再次手术组的平均手术时问和术中出血量多于初次手术组(P0.05);两组患者的术后住院时间和手术成功率差别无统计学意义(P0.05)。结论:首次的开放手术或腹腔镜手术会造成肾盂输尿管周围粘连,给再次腹腔镜肾盂成形术带来困难,但只要腹腔镜操作技术熟练,再次行腹腔镜肾盂成形术仍安全可行,还保持了腹腔镜手术微创的优点,且经腹腔途径更容易完成手术。     

Laparoscopy versus dorsal lumbotomy for ureteropelvic junction obstruction repair

PURPOSE: Laparoscopic pyeloplasty offers similar success rates compared to open surgery. However, the advanced laparoscopic skills required may limit its widespread application. In select patients the dorsal lumbotomy approach can provide similar postoperative advantages to minimally invasive surgery. We analyze the perioperative management of laparoscopy vs dorsal lumbotomy for the repair of ureteropelvic junction obstruction. MATERIALS AND METHODS: In a retrospective review 13 patients who underwent dorsal lumbotomy pyeloplasty were compared to 19 patients who underwent laparoscopic pyeloplasty between 1998 and 2003. Preoperative confirmation of obstruction was obtained through excretory urogram or renal Lasix scan. All 13 patients undergoing dorsal lumbotomy had a dismembered pyeloplasty. Of the 19 laparoscopic cases 16 had a dismembered pyeloplasty and 3 had a Fenger procedure. Average followup was 12 months for the open group and 13.3 months for the laparoscopic group. Postoperative results were evaluated with excretory urogram or renal Lasix scan as well as subjective outcomes by the patients. RESULTS: Operative time was slightly longer for the laparoscopy group at 231 minutes vs 200 minutes. Estimated blood loss and postoperative morphine requirements were also similar. Hospital stay was 3.3 days for the dorsal lumbotomy group compared to 2.4 for the laparoscopy group. The overall success rate for the laparoscopic group was 94.7% compared to 100% for the dorsal lumbotomy group. Each group had 1 complication, paresthesia of anterior/medial thigh that resolved by 6 months. CONCLUSIONS: Our preliminary results show that a dismembered dorsal lumbotomy pyeloplasty is comparable to laparoscopic dismembered pyeloplasty with regard to intraoperative and postoperative hospital course.     

Laparoscopic pyeloplasty for ureteropelvic junction obstruction: Outcome of initial 12 procedures

BACKGROUND: Open pyeloplasty has been the gold standard for surgical treatment of ureteropelvic junction (UPJ) obstruction, enjoying a long-term success rate exceeding 90%. Unfortunately, this procedure requires a muscle incision that entails some degree of morbidity. We have, therefore, investigated the feasibility of laparoscopic pyeloplasty for UPJ obstruction and report here the outcomes of our early cases. The median follow up is 25 months (range, 12-42 months). METHODS: Between March 1999 and September 2001 we performed laparoscopic pyeloplasty on 12 ureters in 11 patients presenting with symptomatic hydronephrosis, secondary to a short stenosis of the UPJ or to ventrally crossing vessels; bilateral pyeloplasty was performed as a single procedure in one patient. We performed dismembered Anderson-Hynes pyeloplasty, Fenger plasty and Y-V plasty in eight, two and two ureters, respectively. All procedures were carried out transperitoneally. RESULTS: The procedure was completed successfully in all cases. Crossing vessels were noted in six of 12 ureters (50.0%). Mean operative time and blood loss in 11 patients (including one bilateral case) were 272.8 min (range, 175-480 min) and 96.4 mL (range, 20-340 mL), respectively. Postoperative complications were noted in two patients (18.2%): one instance of prolonged urine leakage and one anastomotic re-stricture. Eleven of 12 ureters (91.6%) demonstrated a patent UPJ on excretory urography and/or improvement of renal function on diuretic renography at a minimum follow up of 12 months. CONCLUSION: Although the procedure requires advanced laparoscopic skills, it can be safely and successfully completed as frequently as the conventional open procedure. Laparoscopic pyeloplasty seems to be a valuable alternative to open pyeloplasty for UPJ obstruction.     

Retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction

PURPOSE: We developed a new approach of retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction as an alternative to conventional antegrade or retrograde endopyelotomy. MATERIALS AND METHODS: From February 1997 to August 1999 we treated 5 cases of ureteropelvic junction obstruction due to crossing vessels that were diagnosed by helical computerized tomography. Ureterovascular hydronephrosis characterized by a malrotated renal pelvis with anterior crossing vessels was observed in 4 cases and ureteropelvic junction obstruction with a posterior crossing artery was present in 1. After endoureterotomy stent insertion under cystoscopic guidance we performed retroperitoneoscopic endopyelotomy with the kidney in standard position. Crossing vessels were transposed to a higher position to remove obstruction and fixed with peripelvic tissue via retroperitoneoscopy. In all cases a longitudinal incision approximately 1.5 cm. long was made with a potassium titanyl phosphate laser. RESULTS: Convalescence was uneventful in all patients and the endoureterotomy stent was removed 4 to 8 weeks after surgery. Postoperatively helical computerized tomography showed the successful transposition of crossing vessels and significant hydronephrosis resolution in all cases. All patients were asymptomatic during followup of 17 to 28 months. CONCLUSIONS: Despite our small number of patients our results are sufficient to conclude that retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels is a simple and reliable method for treating ureterovascular hydronephrosis and associated conditions.     

腹腔镜下手术治疗肾盂输尿管连接部狭窄

目的 评价腹腔镜下手术治疗肾盂输尿管连接部狭窄梗阻(UPJO)的疗效.方法 UPJO患者102例.男56例,女46例.平均年龄31(6～62)岁.左侧53例,右侧49例.102例均经临床及影像学检查证实.肾盂分离平均28(20～46)mm,重度积水21例、中度63例、轻度18例.采用腹膜后径路行离断式肾盂输尿管成形术.术中打开肾周筋膜,以肾下极为标志游离出肾盂输尿管连接部,切除狭窄部分,肾盂输尿管端端连续吻合并留置双J管.结果 102例手术均成功.手术时间平均120(70～180)min,术中出血量平均80(50～100)ml.无严重并发症发生.术后住院平均8.5(6～14)d.102例随访平均9(3～15)个月,经B超复查肾积水消失30例,72例肾盂分离较术前平均减少12(8～26)mm.IVU检查85例吻合口无狭窄.结论 腹腔镜下离断式肾盂输尿管成形术治疗UPJO有效、可行,可以替代开放手术.     

腹腔镜下手术治疗肾盂输尿管连接部狭窄

目的 评价腹腔镜下手术治疗肾盂输尿管连接部狭窄梗阻(UPJO)的疗效.方法 UPJO患者102例.男56例,女46例.平均年龄31(6～62)岁.左侧53例,右侧49例.102例均经临床及影像学检查证实.肾盂分离平均28(20～46)mm,重度积水21例、中度63例、轻度18例.采用腹膜后径路行离断式肾盂输尿管成形术.术中打开肾周筋膜,以肾下极为标志游离出肾盂输尿管连接部,切除狭窄部分,肾盂输尿管端端连续吻合并留置双J管.结果 102例手术均成功.手术时间平均120(70～180)min,术中出血量平均80(50～100)ml.无严重并发症发生.术后住院平均8.5(6～14)d.102例随访平均9(3～15)个月,经B超复查肾积水消失30例,72例肾盂分离较术前平均减少12(8～26)mm.IVU检查85例吻合口无狭窄.结论 腹腔镜下离断式肾盂输尿管成形术治疗UPJO有效、可行,可以替代开放手术.     

腹腔镜下手术治疗肾盂输尿管连接部狭窄

目的 评价腹腔镜下手术治疗肾盂输尿管连接部狭窄梗阻(UPJO)的疗效.方法 UPJO患者102例.男56例,女46例.平均年龄31(6～62)岁.左侧53例,右侧49例.102例均经临床及影像学检查证实.肾盂分离平均28(20～46)mm,重度积水21例、中度63例、轻度18例.采用腹膜后径路行离断式肾盂输尿管成形术.术中打开肾周筋膜,以肾下极为标志游离出肾盂输尿管连接部,切除狭窄部分,肾盂输尿管端端连续吻合并留置双J管.结果 102例手术均成功.手术时间平均120(70～180)min,术中出血量平均80(50～100)ml.无严重并发症发生.术后住院平均8.5(6～14)d.102例随访平均9(3～15)个月,经B超复查肾积水消失30例,72例肾盂分离较术前平均减少12(8～26)mm.IVU检查85例吻合口无狭窄.结论 腹腔镜下离断式肾盂输尿管成形术治疗UPJO有效、可行,可以替代开放手术.     

Endoscopic and laparoscopic treatment of ureteropelvic junction obstruction

PURPOSE: Although open pyeloplasty remains the gold standard for treating ureteropelvic junction obstruction, endourology and laparoscopy have revolutionized the management of upper tract stenosis. We present our diagnostic and minimally invasive therapeutic algorithm for the treatment of ureteropelvic junction obstruction. MATERIALS AND METHODS: A total of 13 females and 9 males with a mean age of 34.2 years suffering from ureteropelvic junction obstruction were treated with percutaneous endopyelotomy or laparoscopic dismembered pyeloplasty and followed for 47 to 61 months (mean 53.8) and 47 to 62 months (mean 52.5), respectively. Diagnosis was based on findings of ultrasound, excretory urography, furosemide washout renogram and retrograde ureteropyelography. In cases of ureteral kinking color duplex sonography and spiral computerized tomography were performed. In 14 patients with intrinsic stenosis percutaneous endopyelotomy was performed, while the remaining 8 patients (5 with crossing vessels, 2 with an extremely distended pelvis and 1 with a 2.5 cm. stricture) were treated with a laparoscopic dismembered Anderson-Hynes pyeloplasty. RESULTS: In the endopyelotomy group (success rate 92.8%), mean operation time was 1.2 hours, estimated blood loss was 152 ml., unit doses of analgesics were 5.4 tablets, days of hospitalization were 4.2 and time to return to normal activities was 15.7 days. In the laparoscopic group (success rate of 100%) the aforementioned variables were 3.5 hours (p <0.05), 150 ml., 6.3 tablets, 5 and 17.8 days, respectively. Long-term followup excretory urography and/or diuretic renal scan demonstrated improvement in all patients. CONCLUSIONS: Percutaneous endopyelotomy should be the treatment of choice for intrinsic ureteropelvic junction obstruction. Laparoscopic dismembered pyeloplasty, although technically challenging, provides excellent results for extrinsic or complicated ureteropelvic junction stenosis.     

后腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻

目的:评价后腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻(ureteropelvic junction obstruction,UPJO)技术要点及临床疗效。方法:通过后腹腔途径在腹腔镜下对30例UPJO患者行离断式肾盂成形术,其中男18例,女12例,年龄在16～48岁;异常血管压迫4例,合并泌尿系感染8例。结果:30例手术均获成功,无一例中转开放手术。手术时间120～235min,平均105min;出血量85～135ml,平均115ml。30例术后随访6～24个月,经B超、IVU检查,肾盂输尿管吻合口未见明显狭窄,患肾积水明显减轻或消失,临床症状消失。结论:后腹腔镜肾盂成形术是一种创伤小、安全可靠、疗效确切的微创手术方法。     

Retrospective comparison of retroperitoneal laparoscopic versus open dismembered pyeloplasty for ureteropelvic junction obstruction

PURPOSE: We evaluated the clinical value of retroperitoneal laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction compared with open surgery. MATERIALS AND METHODS: The clinical data of 56 patients who underwent retroperitoneal laparoscopic dismembered pyeloplasty were retrospectively compared with those of 40 patients who underwent open dismembered pyeloplasty through a retroperitoneal flank approach. The Student t test, Pearson chi-square test and Mann-Whitney rank sum test were applied for statistical analysis as appropriate. RESULTS: Patient demographic data were similar between the 2 groups. In the laparoscopic group operative time (80 vs 120 minutes), estimated blood loss (10 vs 150 ml), recovery of intestinal function (1 vs 2 days), analgesic requirements (diclofenac sodium suppository) (75 vs 150 mg), incision length (3.5 vs 21 cm) and postoperative hospital stay (7 vs 9 days) were better than in the open group (p <0.001 for all). No intraoperative complications occurred in either group. The incidence of postoperative complications (2 of 56, 3.6% vs 3 of 40, 7.5%, p = 0.729) and success rates (55 of 56, 98.2% vs 39 of 40, 97.5%, p = 0.058) were equivalent in the 2 groups. CONCLUSIONS: Retroperitoneal laparoscopic dismembered pyeloplasty is a minimally invasive, safe and effective therapy for ureteropelvic junction obstruction with low morbidity, shorter convalescence and excellent outcomes, and can be accomplished reasonably quickly in experienced hands.     

Laparoscopic pyeloplasty for ureteropelvic junction obstruction

PURPOSE: We performed laparoscopic pyeloplasty in 11 patients with ureteropelvic junction (UPJ) obstruction and evaluated the clinical outcomes of this surgery. MATERIALS AND METHODS: Between August 2001 and February 2004, 11 patients with UPJ obstruction underwent laparoscopic pyeloplasty in our institute. In all patients, symptoms were presented and UPJ obstruction was confirmed by radiographic examinations. Ten patients had primary obstruction, while one patient had secondary obstruction. Retroperitoneal approach was applied in all but one patient who needed intraperitoneal approach due to secondary obstruction. We performed Anderson-Hynes dismembered pyeloplasty, Hellstr?m technique and Fenger plasty in 8, 2 and 1 patient, respectively. Nephropexy was performed in 2 patients with nephroptosis, and isthmusectomy was performed in 1 patient with horseshoe kidney, simultaneously. RESULTS: The mean operative time was 312 minutes (210-371) and the mean blood loss (including urine) was 75 ml. No blood transfusion was required, and all procedures were performed safely. Crossing vessels were found in 5 patients (45%). Pyelonephritis was the only postoperative complication, managed by the administration of antibiotics. Symptoms were disappeared without recurrences in all patients at mean follow up time of 18 months (6-36). (CONCLUSION: Although the number of cases was small with relatively short follow up period, the clinical outcomes of laparoscopic pyeloplasty in our institute were almost satisfied, as previously reported by other investigators. Laparoscopic pyeloplasty might be one of the standard treatments for patients with UPJ obstruction, although we should carefully consider about indication, approach and operation method.     

腹腔镜手术治疗肾盂输尿管移行处狭窄

目的:评价腹腔镜手术治疗肾盂输尿管移行处狭窄(UPJ)的临床效果。方法:经腹腔路径对19例确诊的UPJ行腹腔镜离断式肾盂输尿管成形术,男12例,女7例,肾脏积水重度6例,中度8例,轻度5例,IVU13例显影良好,6例显影延迟。结果:19例手术全部成功,手术时间110~240min,平均150min,术中出血50~100m1,术后住院6~10d,平均7.8d,无严重并发症发生,随访3~15个月,肾积水程度均减轻,IVU无吻合口狭窄。结论:腹腔镜下离断式肾盂输尿管成形术治疗UPJ有效、可行,可以替代开放手术。     

后腹腔镜肾盂成形术治疗儿童肾盂输尿管连接部狭窄15例报告

目的探讨后腹腔镜下离断性肾盂成形术即Anderson-Hynes手术治疗儿童肾盂输尿管连接部梗阻（UPJ0）的疗效。方法采用后腹腔镜下Anderson-Hynes手术治疗肾盂输尿管连接部梗阻所致中、重度肾积水的患者15例。病程2周～5年,均为腰部钝痛不适就诊,所有患者均经影像学明确UPJ0诊断。结果后腹腔镜离断式肾盂成形术耗时120～230（155．0±37．4）min,术中出血20-55（35．0±9．2）mL。无中转开放手术。术后2～4d拔出腹膜后引流管,切口均一期愈合,术后8～10周拔出D-J管,无漏尿及吻合口狭窄,随访3～24（18．0±4．1）个月,B超及静脉肾盂造影（IVU）提示积水改善、肾功能恢复。结论后腹腔镜离断式肾盂成形术在手术创伤、住院时间、术后恢复等方面优于开放手术,有望替代开放术式。     

后腹腔镜非离断成形术治疗肾盂输尿管连接处梗阻

目的:评价3种后腹腔镜非离断成形术治疗肾盂输尿管连接处梗阻(UPJO)的临床疗效及其可行性。方法:对36例UPJO均有不同程度肾盂积水患者,分别使用FoleyY-V成形术、Fenger成形术及Hellstrm术行非离断成形术。结果:无一例改开放手术。在平均28个月的随访中,17例接受FoleyY-V成形术的患者中有2例复发,行开放离断成形术后解除梗阻;11例接受Fenger成形术的患者中1例复发,使用球囊扩张后治愈;8例接受Hellstrm术的患者均达到手术成功标准。结论:非离断成形术中保留异常狭窄段可能是导致术后有较高复发率的重要因素,因此在条件允许情况下应尽量选择离断成形术。对于Hellstrm术,在严格控制适应证的前提下,不失为一种治疗单纯因异位血管压迫而导致UPJO的较好手术方式。     

Laparoendoscopic single-site (LESS) pyeloplasty for horseshoe ureteropelvic junction obstruction

Background and Objective:

Pyeloplasty in horseshoe kidneys can be challenging due to aberrant vasculature, renal malrotation, and ectopic location. Fewer than 20 cases of minimally invasive (MIS) pyeloplasty in horseshoe kidneys have been reported in the literature to date. We herein report the first 2 cases of laparoendoscopic single-site (LESS) pyeloplasty for UPJ obstruction in horseshoe kidneys.

Methods:

Two patients with symptomatic ureteropelvic junction obstruction in horseshoe kidneys were treated with an Anderson-Hynes LESS pyeloplasty. This was performed using three 5-mm trocars through a single umbilical incision, plus an accessory 3-mm port at the anterior axillary line to facilitate suturing and subsequent drain placement.

Results:

Both patients had BMI <23. The operative times were 204 minutes and 171 minutes. Blood loss was negligible, and no intraoperative complications occurred. To date, 9-month renography for patient 1 demonstrates stable renal function and unobstructed drainage. After stent removal, patient 2 was asymptomatic.

Conclusion:

In experienced hands, LESS reconstructive techniques are applicable to complex renal anomalies. LESS pyeloplasty for UPJ obstruction associated with horseshoe kidneys is feasible, safe, and effective in select patients.