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.     

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。     

Minimally invasive surgical management of ureteropelvic junction obstruction: laparoscopic and robot-assisted laparoscopic pyeloplasty

Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by an intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Until recently, open pyeloplasty and endoscopic techniques have been the main surgical options, with the intent of complete excision or incision of the obstruction. The introduction of laparoscopy and robot-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. These techniques offer substantial benefits to patients by reducing morbidity, hastening postoperative recovery, and improving cosmetic outcome. During the last decade, laparoscopic pyeloplasty has garnered much interest. However, because of the technically challenging nature of this procedure, it is performed only at select medical centers by surgeons with advanced laparoscopic training. The recent introduction of robotics to the field of minimally invasive surgery may facilitate this procedure and allow for more widespread implementation by surgeons of varying skill levels. This review is limited primarily to the treatment of congenital or acquired UPJ obstruction via laparoscopic and robot-assisted laparoscopic pyeloplasty. Herein, we report the early results, ongoing evolution, and potential future role for these novel surgical procedures.     

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。     

腹膜后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻62例临床分析

目的:评价腹膜后腹腔镜手术治疗肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)的手术技巧和临床效果。方法:回顾性分析施行经腹膜后腹腔镜肾盂成形术的62例肾盂输尿管连接部梗阻患者的临床资料。根据62例患者发病机理的不同,20例行腹膜后腹腔镜肾盂输尿管连接部周围压迫组织松解术,28例行Y-V成形术,14例行离断成形术。术后随访3~36个月。结果:所有患者手术均顺利完成,静脉肾盂造影(intravenous urography,IVU)提示造影剂通过良好,肾积水均明显改善。结论:腹膜后腹腔镜治疗肾盂输尿管连接部梗阻创伤小,患者术后痛苦小、康复快、住院时间短、疗效显著,可作为治疗肾盂输尿管连接部梗阻的首选方法。     

后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻的临床价值

目的探讨后腹腔镜肾盂成形术治疗肾盂输尿管连接部（UPJ）梗阻的适应证选择、手术技巧及临床应用价值。方法回顾性分析经后腹腔镜肾盂成形术治疗的13例UPJ梗阻患者的临床资料。患者中男7例，女6例，年龄11—47岁。钬激光腔内切开失败1例，高位输尿管开口1例，狭窄段〉2cm或UPJ完全闭锁3例，单纯重度肾积水4例，异位血管压迫2例，合并肾盂结石2例。结果13例手术均获成功。手术时间120～200min，平均175min；出血量60～110ml，平均75ml。术后平均住院时间7．5d（5～8d）。围手术期无并发症。随访3—19个月，UPJ吻合口无狭窄，肾积水、肾功能均得到改善。结论后腹腔镜肾盂成形术是治疗UPJ梗阻的有效、可行的微创手术。可以替代开放手术，成为腔内切开治疗失败、高位输尿管开口、异位血管压迫或伴有重度肾积水、结石的UPJ梗阻患者的首选术式。     

Minimally invasive retroperitoneoscopic ureterolithotomy

PURPOSE: We assessed the efficacy of modified technique of retroperitoneal ureterolithotomy for managing ureteral stones. MATERIALS AND METHODS: Between December 1999 and March 2002, 31 patients underwent retroperitoneal ureterolithotomy. In most cases only 3 ports (a 10 mm., 2 5 mm. and in a few 2, 3 mm.) were used without any ureteral stent or catheter. The stone was removed from the primary port site, while visualizing retrieval through the 3/5 mm. port using fine laparoscope. Ureterotomy closure was performed by intracorporeal interrupted sutures of 4-zero polyglactin. RESULTS: The 20 males and 11 females had a mean age of 38.5 years. Mean operative time was 67 minutes and mean hospital stay was 2.4 days. The mean analgesic requirement was 42.2 mg. meperidine. Mean followup was 8 months. There were no significant postoperative complications except persistent urine leakage in 2 patients 48 hours after surgery. An internal stent was placed and leakage subsided without any consequences. CONCLUSIONS: The modified, minimally invasive technique of retroperitoneal ureterolithotomy is highly effective and efficient without an associated increase in the complication rate.     

后腹腔镜离断式肾盂成形术在肾盂输尿管连接部梗阻治疗中的应用

目的探讨后腹腔镜离断式肾盂成形术治疗肾盂输尿管连接部梗阻的临床价值。方法回顾性分析后腹腔镜离断式肾盂成形术治疗10例肾盂输尿管连接部梗阻患者的临床资料。其中男7例,女3例,年龄9～39岁。左侧6例,右侧4例。10例患者均有不同程度腰部胀痛史,病程3～30个月。结果 10例手术均获成功,无中转开放手术病例,术中证实异位血管压迫3例,原发性肾盂输尿管连接部狭窄7例。手术时间120～240min,平均180min,术中失血量50～100ml,平均75ml,术后住院7～9d。围手术期所有病例无漏尿等并发症发生。随访3～18个月,超声提示患者肾积水程度减轻,IVU提示肾盂输尿管连接部吻合口无狭窄,术前显影延迟病例显影时间提前,所有患者腰痛症状缓解。结论后腹腔镜离断式肾盂成形术治疗肾盂输尿管连接部梗阻技术可行,安全有效,其远期疗效有待进一步观察。     

腹膜后腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻的临床价值

目的:探讨腹膜后腹腔镜肾盂成形术治疗输尿管连接部(ureteropelvic junction,UPJ)梗阻的适应证、手术技巧及临床应用价值。方法:回顾分析腹膜后腹腔镜肾盂成形术治疗17例UPJ梗阻患者的临床资料。其中男11例,女6例,22～38岁,高位输尿管开口2例,UPJ完全闭锁4例,单纯重度肾积水7例,异位血管压迫4例,合并肾盂结石3例。结果:17例手术均获成功,手术时间80～240min,平均120min,出血50～130ml,平均85ml,术后平均住院8.5d(7～10d)。围手术期无并发症发生。随访3～12个月,UPJ吻合无狭窄,肾积水、肾功能均获改善。结论:基层医院行腹膜后腹腔镜肾盂成形术是治疗UPJ梗阻有效、安全的术式,可代替开放手术,作为UPJ梗阻患者的首选术式。     

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.     

Minimally invasive adrenalectomy: a cohort study of surgical approach and outcomes

Background

In the context of minimally invasive adrenal surgery, there remains debate about whether the transperitoneal adrenalectomy (TPA) and posterior retroperitoneoscopic adrenalectomy (PRA) approach have equivalent indications. This study aims to examine complication and conversion rates associated with three surgical approaches for adrenal tumours over the last 17 years in a specialized endocrine surgical unit.

Methods

All adrenalectomy cases performed in the period 2005–2021 were identified within a prospectively maintained surgical database. A retrospective cohort study was undertaken with patients divided into two cohorts (2005–2013 and 2014–2021). Surgical approach (open adrenalectomy (OA), TPA, PRA), tumour size, histopathology, complication and conversion rates were compared.

Results

During the study period, 596 patients underwent adrenalectomy with 31 and 40 cases each year per cohort. The dominant surgical approach per cohort significantly changed from TPA (79% versus 17%) to PRA (8% versus 69%, P < 0.001), whilst the frequency of OA remained stable (13% versus 15%). TPA removed larger tumours (3.0 ± 2.9 cm) than PRA (2.8 ± 2.2 cm, P = 0.02), with the median size increasing from 3.0 ± 2.5 to 4.5 ± 3.5 cm per cohort (P < 0.001). The maximum tumour sizes treated by TPA and PRA were 15 and 12 cm, respectively. Adrenocortical adenoma was the commonest pathology treated by either laparoscopic technique. Complication rates were greatest for OA (30.1%) with no significant difference between minimally invasive approaches (TPA 7.3%, PRA 8.3%, P = 0.7). Both laparoscopic techniques had equivalent conversion rates (3.6%). PRA was preferably converted to TPA (2.8%) over OA (0.8%).

Conclusion

This study demonstrates the transition from TPA to PRA, offering similarly low complication and conversion rates.     

经皮顺行腔内切开术治疗肾盂输尿管连接部梗阻

目的:探讨应用经皮顺行腔内切开术(PAE)治疗肾盂输尿管连接部梗阻(UPJO)的适应症、疗效及技巧。方法:UPJO患者75例,其中肾盂输尿管连接部(UPJ)闭锁26例(34.7%)。男38例,女37例,平均年龄35(21～68)岁。左侧31例,右侧44例。原发性UPJO 39例(合并结石37例),开放UPJO成形术后8例,腹腔镜UPJO成形术后4例,开放手术取石术后14例,PCNL术后10例。均经B超、KUB、IVU、CT、逆行肾盂造影检查确诊。结果:Ⅰ期成功内切开69例(92.0%),4例(5.3%)间隔1周后Ⅱ期手术成功,2例放弃Ⅱ期治疗。单一应用PAE 59例(80.8%),PAE联合输尿管镜逆行内切开14例(19.2%)。术后3～6个月拔除输尿管支架管,随访6个月时,62例(84.9%)无复发,复发患者11例(15.1%)中包括UPJ闭锁患者10例。随访12个月时,55例(75.3%)无复发,24个月时52例(71.2%)无复发。21例复发患者中,9例行第二次PAE手术治愈,2例行第三次PAE手术后治愈,1例行开放肾盂成形术,9例每3～6个月更换双J管或动态观察。结论:PAE可以作为原发性UPJO的一线治疗。继发性UPJO或其他成形术后再狭窄的UPJO复发率高,但是PAE适用范围广,可重复性好,仍然是微创腔内治疗的有效手段。     

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.     

后腹腔镜辅助小切口治疗肾盂输尿管连接部梗阻

目的评价后腹腔镜辅助小切口离断肾盂成形术治疗肾盂输尿管连接部梗阻（UPJO）的临床价值。方法回顾性分析2004年1月至2006年11月在我院行后腹腔镜辅助离断肾盂成形术患者22例，男性14例，女性8例。年龄18-37岁，平均26岁。其中重度肾积水3例，中度10例，轻度9例。结果本组21例患者均成功施行手术，无1例转为开放性手术。手术时间为（92．9±16．3）min，术中出血量为（18．9±6．3）ml，术后住院时间为（8．0±1．3）d。术后尿漏1例。经随访，术后3个月肾积水明显缓解率为95．5％。结论后腹腔镜辅助小切口离断肾盂成形术治疗肾盂输尿管连接部梗阻是一种安全、有效、微创的治疗方法。     

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.     

Minimally invasive laparoscopic neobladder

PURPOSE: To our knowledge orthotopic reconstruction after laparoscopic radical cystectomy has not been described in the human. After anatomical and surgical studies on cadavers we developed an original technique and performed the first laparoscopic radical cystectomy with pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction in a patient. MATERIALS AND METHODS: Our technique has 3 steps, namely laparoscopic pelvic clearance, external reconstruction and laparoscopic reconstruction. After cystoprostatectomy and lymphadenectomy were completed via laparoscopy we removed the surgical specimens through a 5 cm. supraumbilical incision. Through the same incision an ileal loop was extracted from the abdominal cavity, isolated, detubularized and partially reconfigured. Intestinal continuity was restored extracorporeally. All intestinal loops were inserted back into the abdomen and pneumoperitoneum was started again. The ureteroileal (nipple valve) and urethroileal anastomoses were formed via laparoscopy and the neobladder was then completed with an intracorporeal running suture. RESULTS: Operative time was 450 minutes and blood loss was 350 ml. Postoperatively pain was minimal. The patient was ambulatory, regained bowel activity on postoperative day 2 and began food intake 2 days later. He was discharged home on postoperative day 7 with an indwelling catheter, which was removed after 7 days. Histopathological examination showed organ confined bladder cancer without margin invasion. CONCLUSIONS: To our knowledge we report the first case of laparoscopic radical cystectomy with ileal orthotopic reconstruction. This original technique combines the advantages of minimally invasive laparoscopy with the speed and safety of open surgery.