Laparoscopic dismembered tubularized flap pyeloplasty: a novel technique.

PURPOSE: Laparoscopic dismembered pyeloplasty is now an effective option for ureteropelvic junction obstruction. We describe a novel laparoscopic technique of dismembered tubularized flap pyeloplasty for a difficult recurrent long ureteropelvic junction stricture. MATERIALS AND METHODS: A 73-year-old woman with ureteropelvic junction obstruction of a solitary left kidney had undergone failed multiple procedures, including open pyeloplasty, balloon incision endopyelotomy, retrograde balloon dilation and percutaneous endopyelotomy. Using a 4-port transperitoneal laparoscopic technique, the upper ureter was dissected, the scarred ureteropelvic junction stricture was excised and the dismembered ureteropelvic junction was closed with a stitch. A wide base renal pelvic flap was created and tubularized to bridge the 3 cm. upper ureteral defect. Laparoscopic intracorporeal freehand suturing was done to reconstruct the renal pelvis and upper ureter over a Double-J stent (Medical Engineering Corp., New York, New York). RESULTS: Total operative time was 4.5 hours and hospital stay was 4 days. The stent was removed 3 weeks later. At the 2-month followup the patient was asymptomatic. Excretory urography and diuretic renal scan confirmed a widely patent upper ureter with unobstructed drainage. CONCLUSIONS: Dismembered renal pelvis tubularized flap pyeloplasty can be successfully performed laparoscopically to bridge a long upper ureteral defect. This approach is feasible even in a ureteropelvic junction in which previous surgery has failed.     

Laparoscopic ureterocalicostomy: initial experience

PURPOSE: Ureterocalicostomy is a reconstructive option in the rare patient with surgically failed or difficult ureteropelvic junction (UPJ) obstruction with fibrosis and significant hydronephrosis. We introduce the technique of laparoscopic ureterocalicostomy. MATERIALS AND METHODS: Laparoscopic ureterocalicostomy was performed in 2 patients, of whom 1 had UPJ obstruction and multiple secondary calculi in a dilated, dependent lower pole calix, and 1 had surgically failed UPJ obstruction with a scarred pelvis and significant hydronephrosis. Using a transperitoneal technique the UPJ was dismembered and suture ligated, the cut end of the ureter was spatulated, the attenuated lower pole renal parenchyma was amputated and mucosa-to-mucosa ureterocaliceal anastomosis was performed with running 4-zero absorbable suture over a stent. In the first case 32 renal calculi were also removed using a combination of laparoscopic nephroscopy and intraoperative ultrasonography. RESULTS: In cases 1 and 2 operative time was 5.2 and 2.5 hours, estimated blood loss was 200 and 75 cc, and hospital stay was 2 days, respectively. There were no intraoperative complications. The stent was removed at 8 and 5 weeks, respectively. Postoperative retrograde pyelogram and diuretic renal scan confirmed anastomotic patency and improved drainage in each patient. At 9 months patient 1 remains without flank symptoms and a second renal scan at 6 months showed further improvement in drainage. Patient 2, who continued to be symptomatic with flank discomfort despite objective improvement in drainage parameters, elected secondary nephrectomy at 6 months. CONCLUSIONS: Laparoscopic ureterocalicostomy is feasible and it effectively duplicates established open surgical principles. To our knowledge the initial experience in the literature is presented.     

Ureterocalicostomy: indications and results in 21 patients

Ureterocalicostomy was performed in 21 patients for ureteropelvic junction obstruction. Ten patients had failed pyeloplasty, 10 had anomalies of renal fusion, ascent or rotation in conjunction with ureteropelvic junction obstruction and 1 had failed prior ureterocalicostomy. Patient age at operation ranged from 6 months to 17 years and averaged 9 years. Of the 21 patients in this series 19 had excellent results after ureterocalicostomy with decrease or total elimination of hydronephrosis. There were 2 postoperative complications in 2 patients: prolonged anastomotic urinary leakage in 1 and a Candida perinephric abscess in 1. Ureterocalicostomy should be considered in selected patients with previous unsuccessful pyeloplasty, ureteropelvic junction obstruction associated with anomalies of renal fusion, rotation or ascent, an intrarenal pelvis or a short ureter. Although endopyelotomy or ureteropelvic junction dilation should be considered in patients who fail pyeloplasty, ureterocalicostomy continues to be a reliable salvage procedure in these patients; it bypasses extensive peripelvic scarring, provides for dependent drainage and compensates for lack of adequate ureteral length.     

MISSED ANTERIOR CROSSING VESSELS DURING OPEN RETROPERITONEAL PYELOPLASTY: LAPAROSCOPIC TRANSPERITONEAL DISCOVERY AND REPAIR

PURPOSE: Extrinsic ureteropelvic junction obstruction due to anterior crossing segmental renal vessels is present in more than 50% of patients in adulthood. In this situation the ureter must usually be dismembered and transposed anterior to the crossing vascular structures, where it is anastomosed to the renal pelvis. Via the open retroperitoneal approach there may be a limited view of the anterior surface of the ureteropelvic junction and, hence, anterior crossing vessels may possibly be missed. We describe 2 patients with ureteropelvic junction obstruction in whom anterior vessels were missed during open retroperitoneal repair. Laparoscopic transperitoneal secondary pyeloplasty with posterior displacement of the crossing renal vessel was performed in each case. MATERIALS AND METHODS: Two patients presented with symptomatic congenital ureteropelvic junction obstruction after failed endopyelotomy in 1 and failed open retroperitoneal procedures in both. Preoperatively spiral computerized tomography angiography with a ureteropelvic junction protocol revealed crossing vessels in the 2 cases. This finding was confirmed at transperitoneal laparoscopic pyeloplasty. The ureter and renal pelvis were transposed anterior to the crossing vessels and 2 rows of running sutures were placed to complete the anastomosis. RESULTS: The 2 laparoscopic procedures were completed successfully. The anterior crossing vessels were preserved in each case. Currently the patients are asymptomatic and furosemide washout renal scan was normal. CONCLUSIONS: Spiral CT angiography reliably delineates the renal vascular anatomy in patients with ureteropelvic junction obstruction. This study may be valuable before planned open retroperitoneal ureteropelvic junction obstruction repair. Laparoscopic pyeloplasty may successfully manage anterior crossing vessels associated with secondary ureteropelvic junction obstruction.     

Laparoscopic management of ureteropelvic junction obstruction in patients with upper urinary tract anomalies

PURPOSE: We report our experience with the laparoscopic management of ureteropelvic junction obstruction in patients with upper urinary tract abnormalities. MATERIALS AND METHODS: Between July 1994 and May 2002, 7 men and 4 women with upper urinary tract anatomical abnormalities were referred to our institution for management of symptomatic ureteropelvic junction obstruction. Anomalies included horseshoe kidneys in 5 cases, pelvic kidneys in 3, a pancake kidney in 1, a malrotated kidney in 1 and a duplicated collecting system in 1. Three patients had associated renal stones that were extracted during reconstruction. Mean patient age was 37.4 years (range 25 to 60). One patient had undergone a previously unsuccessful endopyelotomy and 2 had a history of abdominal surgery. RESULTS: Mean operative time was 195 minutes (range 85 to 403) and mean estimated blood loss was 122 cc (range 20 to 300). No patient in this series required transfusion. Average length of hospital stay was 3.2 days (range 2 to 5). Renal function failed to improve after surgery in 1 patient with poor renal function and severe hydronephrosis. The remaining 10 patients (91%) had durable clinical and/or radiographic success during a followup of 32.6 and 21.3 months, respectively. There were no major complications. CONCLUSIONS: Laparoscopic pyeloplasty is an effective treatment alternative for ureteropelvic junction obstruction associated with renal or urinary tract anomalies.     

Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction

PURPOSE: Laparoscopic pyeloplasty has become a viable option for the treatment of select patients with primary ureteropelvic junction obstruction with success rates similar to those of open surgery. However, little has been written on the application of this technique for secondary ureteropelvic junction obstruction. We report the largest series of secondary ureteropelvic junction obstruction managed by laparoscopic pyeloplasty. MATERIALS AND METHODS: Between March 1994 and March 2001, 36 patients underwent laparoscopic transperitoneal pyeloplasty for secondary ureteropelvic junction obstruction. The patients had undergone an average of 1.3 ureteropelvic junction procedures (range 1 to 4) prior to presentation, including cutting balloon retrograde endopyelotomy in 28, antegrade endoscopic endopyelotomy in 7, retrograde endoscopic endopyelotomy in 4, retrograde balloon dilation in 4 and open pyeloplasty in 3. A preoperative diagnosis of recurrent obstruction was confirmed by renal scan in 31 cases, retrograde pyelography in 2 and computerized tomography in 3. Of the 31 patients who underwent spiral computerized tomography angiogram 87% had crossing vessels. Laparoscopic repair comprised dismembered pyeloplasty in 31 cases, Fengerplasty in 3 and flap repair in 2. Postoperative renal scan or excretory urography objective followup was available for all patients at a mean of 10 months (range 3 to 40). Postoperative subjective patient well-being was assessed using an analog pain scale at a mean followup of 21.8 months (range 3 to 85). RESULTS: Average operative time was 6.2 hours (range 2.7 to 10). Average hospital stay was 2.9 days (range 1 to 7). One intraoperative complication occurred, that is bleeding necessitating conversion to an open procedure. Postoperative complications occurred in 8 cases, including anastomotic leakage in 4, and urinary tract infection, pneumonia, atelectasis, fever, bilateral upper extremity weakness and stone formation 2 months postoperatively in 1 each. On excretory urography, furosemide renal scan or the Whitaker test 32 of 36 patients (89%) had a widely patent ureteropelvic junction. Two patients (5.5%) had equivocal radiographic studies but were asymptomatic. In 2 patients the ureteropelvic junction was obstructed by renal scan. One patient had an indwelling stent for renal function deterioration and 1 was asymptomatic. Hence, 34 of the 36 patients (94%) had a reasonable objective response. Overall a 50% or greater decrease in pain was seen in 32 of 36 patients (89%). In the 4 patients with a less than 50% decrease in pain objective renal scans showed an open ureteropelvic junction. As such, the overall success rate of a greater than 50% decrease in pain, a patent ureteropelvic junction and stable or improved function of the affected renal unit was 83% (30 of 36 patients). CONCLUSIONS: For secondary ureteropelvic junction obstruction, laparoscopic pyeloplasty can be performed safely with a success rate comparable to that of standard open pyeloplasty. The patient benefits of laparoscopic ureteropelvic junction repair of secondary ureteropelvic junction obstruction are similar to the benefits of laparoscopic repair of primary ureteropelvic junction obstruction.     

Transperitoneal laparoscopic pyeloplasty for pelvic kidneys with ureteropelvic junction obstruction in children: technique and preliminary outcomes.

BACKGROUND: Laparoscopic pyeloplasty is rapidly becoming an acceptable procedure for ureteropelvic junction obstruction in the pediatric population. We present our experience with transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction in pelvic kidneys in pediatric patients. METHODS: A transperitoneal laparoscopic approach was used for performing a pyeloplasty in 4 patients, 7 months to 8 years of age (mean age, 3.14), with ureteropelvic junction obstruction in a pelvic kidney. RESULTS: Average operative time was 2.1 hours (range, 1.5 to 2.8). Mean hospital stay was 2.15 days (range, 1 to 7). No intraoperative complications were noted. CONCLUSIONS: Transperitoneal laparoscopic pyeloplasty for pelvic kidneys is feasible in the pediatric population, and preliminary results appear to offer the same outcome as that seen in orthotopic kidneys.     

Retroperitoneoscopic pyeloplasty: Using reconstructive methods based on intraoperative findings

AIM: Reconstructive laparoscopic procedures have been recognized as a less invasive treatment than conventional open procedures. However, although the laparoscopic pyeloplasty has also been accepted as useful, few findings have been reported relevant to the retroperitoneal approach. To elucidate its effectiveness and safety, laparoscopic surgery via the retroperitoneal approach was examined in our institution. Furthermore, the importance of laparoscopic observation for ureteropelvic junction and urine passage ureteropelvic junction without indwelling ureteral stent. METHODS: Between July 1998 and December 2004, 13 men and 15 women underwent laparoscopic retroperitoneal surgery for ureteropelvic junction obstruction. The mean patient age was 33.6 years (range: 13-70 years). Methods of repair were determined by intraoperative findings for the relationship between the ureteropelvic junction and surrounding vessels. An indwelling ureteral stent was removed before initiating laparoscopic operation to observe the relationship between ureteropelvic junction and aberrant vessels more precisely. RESULTS: An aberrant renal vessel was found in 13 patients (46%). Dismembered pyeloplasty was carried out in 21 patients, Y-V plasty in five patients and Hellstrom technique in two patients. Ureteral transposition was not required in dismembered pyeloplasty cases. All patients achieved retroperitoneoscopic pyeloplasty without open conversion. The mean operative time was 272 min (range: 155-490 min). The mean estimated blood loss was 44 mL (range: 10-200 mL). No major complications were observed during the intraoperative period, but urinary tract infection occurred in two patients in the postoperative period. In all patients except one, obstruction was improved or resolved. CONCLUSIONS: Laparoscopic retroperitoneal surgery is not only able to repair ureteropelvic junction obstruction, but can also be done safety and less invasively. We believe that laparoscopic observation without indwelling stent will contribute to a more appropriate choice of pyeloplasty.     

Prenatal puncture of a unilateral hydronephrosis leading to fetal urinoma and postnatal nephrectomy

We report the first case of retroperitoneoscopic ureterocalicostomy in a 17-year-old male patient with severe left hydronephrosis caused by a long congenital upper ureteral stenosis. With a retroperitoneoscopic approach, the stenotic segment was resected, the thin renal parenchyma overlying the lower calyx was fenestrated by a modest excision, and the proximal ureter was anastomosed to the lower pole in an end-to-end manner. At 2 years postoperatively, the patient was asymptomatic, with a significant reduction in hydronephrosis and a patent upper ureter. Retroperitoneoscopic ureterocalicostomy is technically feasible and can provide long-term successful reconstruction of a complicated ureteropelvic junction obstruction.     

腹腔镜结合开放手术在肾盂成形术中的应用

目的 探讨腹腔镜结合开放手术在肾盂成形术中的应用价值。方法 肾盂输尿管连接部梗阻患者45例，经腹腹腔镜下游离肾盂及部分输尿管上段，将正对肾盂输尿管连接部体表投影水平的套管戳口向头侧延长1～2cm，自该切口将肾盂输尿管连接部提出腹壁外进行成形操作。结果 45例手术均获成功。手术时间40～85min，平均58min；术中出血量15～30ml，平均22ml。术中术后无并发症。34例随访3～36个月，平均11个月，IVU检查吻合口无梗阻，B超提示患肾积水减轻。结论 与开放手术和全腹腔镜手术相比，肾盂成形术中联合应用腹腔镜与开放手术技术可减少腹腔镜手术的操作难度，缩短手术时间，并不明显增加腹壁创伤，值得临床推广应用。     

Laparoscopic pyeloplasty with concomitant pyelolithotomy

PURPOSE: We present our experience with laparoscopic pyeloplasty plus pyelolithotomy in patients in whom stones were not the cause of ureteropelvic junction obstruction. MATERIALS AND METHODS: A transperitoneal approach was used for laparoscopic pyeloplasty and pyelolithotomy in 19 patients (20 renal units). Before ureteropelvic junction repair stones were extracted through a small pyelotomy that was eventually incorporated into the final pyeloplasty incision. Stones in the renal pelvis were removed with rigid graspers under direct laparoscopic vision. A flexible cystoscope introduced through a port was used to extract stones in the calices. The renal pelvis was reconstructed based on the anatomy of the ureteropelvic junction. RESULTS: A median of 1 stone (range 1 to 28) was recovered. In 11, 8 and 1 patients the Anderson-Hynes dismembered pyeloplasty, Y-V plasty and the Heinecke Mickulicz procedure were performed, respectively. At 3 months 2 patients had residual calculi for a procedural stone-free rate of 90%. There was no evidence of obstruction in 18 of the 20 cases (90%), as confirmed by negative diuretic scan or radiological improvement of hydronephrosis. At a mean followup of 12 months (range 3 to 57) 2 additional patients had recurrent stones for an overall long-term stone-free rate of 80% (16 of 20). CONCLUSIONS: Laparoscopic pyelolithotomy is feasible when combined with pyeloplasty. Our results are comparable to those of stone removal during open pyeloplasty or percutaneous endopyelotomy. The advantages of open surgery appear to be maintained in this minimally invasive approach.     

腹腔镜手术治疗肾盂输尿管连接部狭窄19例

目的 评价腹腔镜手术治疗肾盂输尿管连接部狭窄（ureteropelvic junctiono bstruction，UPJO）的疗效。方法 采用经腹路径对19例UPJO行离断式。肾盂输尿管成形术。打开侧腹膜，以。肾下极为标志游离出。肾盂输尿管连接部，切除狭窄部分，端端吻合肾盂输尿管并留置双J管。结果 19例手术全部成功，手术时间110～240min，平均150min。术中出血量50～100ml，平均80ml，无严重并发症发生。术后住院6～10d，平均7．8d。19例随访3～15个月，平均6个月，14例静脉尿路造影（intrarenous urography，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.     

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.     

Laparoscopic nephrectomy for infected, obstructed and non-functioning kidneys

Since laparoscopic nephrectomy was introduced by Clayman et al, it has been doubted whether it should be employed in patients with extensive perirenal fibrosis.In this series, 20 consecutive patients underwent laparoscopic nephrectomy for obstructed, infected, non-functioning kidneys. Preoperative assessment included urine cultures, abdominal sonography, intravenous pyelography, computerized tomography and a renal scan. Laparoscopic nephrectomies were performed using either the transperitoneal or the retroperitoneal approach.Patients' mean age was 52 years (range 20-77, SD = 15.2). Three patients underwent previous open surgery on the same kidney and 15 had percutaneous nephrostomies. The etiology of obstruction was stone disease in 15 cases, uretero-pelvic junction obstruction (3), iatrogenic ureteral injury (1), and infected multicystic kidney (1). Mean operative time was 224 minutes (range 140-325, SD = 57). Conversion to open surgery was necessary in one patient due to splenic injury. Mean hospital stay was 3 days (range 2-6, SD = 1).Laparoscopic nephrectomy was feasible in cases of severe perirenal fibrosis, with an acceptable rate of complications, and may be considered in patients with obstructed, infected, and non-functioning kidneys.     

Laparoscopic dismembered pyeloplasty in children younger than 2 years

PURPOSE: Since the first laparoscopic pyeloplasty was described in a child in 1995, there have been several reports of pyeloplasty in older children. However, to date there have been few reports of laparoscopic pyeloplasty in infants and toddlers. The aim of this study was to evaluate the results of laparoscopic pyeloplasty in children younger than 2 years. MATERIALS AND METHODS: All laparoscopic Anderson-Hynes pyeloplasties performed in children younger than 2 years were retrospectively reviewed. The diagnosis of ureteropelvic junction obstruction was confirmed on renal sonography and diuretic renogram. Laparoscopic pyeloplasties were performed via a transperitoneal route as originally described, with key modifications. All children were investigated with postoperative diuretic renogram and renal ultrasonography. RESULTS: A total of 38 children with ureteropelvic junction obstruction underwent laparoscopic Anderson-Hynes pyeloplasty between January 2001 and December 2005. Of these patients 11 (7 males and 4 females) were younger than 2 years at surgery (median 1.4, range 2 to 22 months) and 1 had bilateral ureteropelvic junction obstruction, for a total of 12 primary repairs. However, 2 patients (17%) required redo laparoscopic pyeloplasty, for a total of 14 laparoscopic dismembered pyeloplasties in this age group. Operative time ranged from 70 to 140 minutes (mean 100) and median hospital stay was 2 days. Followup studies showed normal drainage in all patients except 1, who after redo pyeloplasty exhibited significantly improved but still prolonged drainage. CONCLUSIONS: This study suggests that laparoscopic pyeloplasty can now be performed in young children with good results.     

Pieloplastia laparoscópica: técnica y resultados en 80 procedimientos consecutivos

ObjectiveTo present our long-term results with the Anderson-Hynes laparoscopic pyeloplasty, performed by a single surgeon.Material and methodsBetween August 1999 and December 2009, 79 patients (80 procedures) were operated for primary ureteropelvic junction obstruction. We use the Anderson-Hynes technique by a transperitoneal approach. Patients were evaluated with Ultrasound, Excretory urography and dynamic renal scintigraphy (Mag-3). The perioperative characteristics, complications and results were reviewed.ResultsWe performed 80 laparoscopic pyeloplasties in 79 patients. Mean operative time was 93.2 minutes (60-180). Crossing vessels were found in 38 of 82 (46.3%) renal units. Kidney abnormalities occurred in 4 patients (1 double ureteropelvic system, one associated retrocaval ureter, 1 horseshoe kidney and one pelvic kidney). Complications occurred in 5 procedures (6.5%): an immediately postoperative bleeding (Clavien 3b), 1 cecal volvulus (Clavien 3b), 1 urosepsis (Clavien 4th) and 1 urinary fistula (Clavien 3a). In this series there was neither mortality nor conversion to open surgery There was recurrence in 3 out of 80 patients (3.7%). They were resolved as follows: 1 percutaneous antegrade endopyelotomy, 1 secondary laparoscopic pyeloplasty and 1 robotic pyeloplasty. There was a 96.3%. of primary overall success rate.ConclusionsOur results show that laparoscopic pyeloplasty compares favorably with the result achieved by open surgery. We believe that laparoscopic pyeloplasty is a good surgical alternative for the management of primary ureteropelvic junction obstruction.     

Laparoscopic nephrectomy. Animal experiment and clinical application]

Laparoscopic nephrectomy was carried out on 6 sows in order to develop the procedures of clinical laparoscopic nephrectomy and the equipment necessary for this operation. Based on the animal experiments, it was shown that (1) retroperitoneal approach was difficult due to narrow space. (2) there must be at least 5 cm distance between each trocar and 4 or 5 trocar 1 cm in diameter were basically required. (3) The procedure consisted of incision and dissection of the peritoneum around the kidney, cutting and ligation of the ureter, dissection along the medial side of the ureter to approach the renal pedicle and clipping and cutting of the renal vessels. (4) The equipment required for this surgery must be functionally equivalent to those used in the open surgery. (5) In addition, the specifically designed equipment, such as a morcellator and an instrument to ligate renal vessels are necessary. The first clinical case of laparoscopic nephrectomy was a 34 years old man with a right non-functioning hydronephrosis due to ureteropelvic junction stricture. The surgery was successfully performed with a 110 ml blood loss. It took 7 and half hours because of abundant peri-renal fatty tissue and large extra-renal pelvis. The convalescence was uneventful. Laparoscopic nephrectomy can be applied on selected cases and the development of equipment will make the surgery more popular.     

Minimally invasive treatment of ureteropelvic junction obstruction: long-term experience with an algorithm for laser endopyelotomy and laparoscopic retroperitoneal pyeloplasty

PURPOSE: First line treatment of ureteropelvic junction obstruction is still open dismembered pyeloplasty. The development of videoendoscopic techniques like endopyelotomy and laparoscopy offers less invasive alternatives. The long-term outcome of an algorithm selectively using these techniques is presented. MATERIALS AND METHODS: From February 1995 to March 2006, 256 patients with ureteropelvic junction obstruction were treated with 113 laser endopyelotomies and 143 laparoscopic retroperitoneal pyeloplasties. According to changing selection criteria, an early group (92 in 1995 to 1999) treated with laser endopyelotomy for extrinsic as well as intrinsic stenoses, and a late group (164 in 2000 to 2006) treated with laser endopyelotomy for intrinsic stenosis, were evaluated. In the late group extrinsic ureteropelvic junction obstruction was treated with nondismembered pyeloplasty in cases of anteriorly and by dismembered pyeloplasty in cases of posteriorly crossing vessels or a redundant renal pelvis. RESULTS: Operating time of laser endopyelotomy averaged 34 (range 10 to 90) minutes with a complication rate of 5.3% and a success rate of 72.6% (intrinsic 85.7% vs extrinsic 51.4%). Operating time of laparoscopic retroperitoneal pyeloplasty averaged 124 (range 37 to 368) minutes with a 6.3% complication rate and an overall success rate of 94.4% (intrinsic 100% vs extrinsic 93.8%). In the late group the LAP success rate was 98.3% with no significant differences related to the cause of ureteropelvic junction obstruction (intrinsic 100% vs extrinsic 98.1%) or the type of pyeloplasty (YV plasty 97.0% vs Anderson-Hynes 97.7%). CONCLUSIONS: Laparoscopic retroperitoneal pyeloplasty yields an efficacy similar to that of open surgery. The inferior success of laser endopyelotomy even in optimally selected cases and the increasing expertise with endoscopic suturing may favor laparoscopic pyeloplasty with or without robotic assistance in the future.