JOURNAL OF ENDOUROLOGY Volume 23, Number 5, May 2009 ª Mary Ann Liebert, Inc. Pp. 847–852 DOI: 10.1089=end.2008.0617
Retrograde Placement of Ureteral Stent and Ureteropelvic Anastomosis with Two Running Sutures in Transperitoneal Laparoscopic Pyeloplasty: Tips of Success in Our Learning Curve Rocco Papalia, M.D.,1,2 Giuseppe Simone, M.D.,1 Costantino Leonardo, M.D.,1 Salvatore Guaglianone, M.D.,1 Ester Forestiere, M.D.,1 Maurizio Buscarini, Ph.D.,2 and Michele Gallucci, Ph.D.1
Abstract
Purpose: We report our experience of transperitoneal laparoscopic dismembered pyeloplasties describing our step-by-step surgical technique, and we retrospectively analyze the impact on operative times of technical modifications that were introduced during the learning curve. Patients and Methods: From November 2002 to May 2008, 84 consecutive patients with ureteropelvic junction (UPJ) obstruction were selected for laparoscopic pyeloplasty (LP). The main steps of the surgical procedure are described. In the initial 14 patients who underwent LP, we performed intraoperative antegrade stenting, and we configured the ureteropelvic anastomosis with interrupted sutures; in the 25 following patients, anastomosis was performed with running sutures. In the latest 45 patients, the ureteral stent was positioned retrograde, and ureteropelvic anastomosis was performed with two running sutures. We evaluated the impact of technical modifications on the operative times, dividing patients into three groups (group A, first 14 patients; group B, following 25 patients; and group C, last 45 patients). Median operative times of each group were compared with the Student t test. Results: No major complications occurred, while postoperative urinary leakage was seen in three patients at bladder catheter removal (two in group A and one in group B). Mean operative blood loss was 70 mL, and mean hospital stay was 1.6 days. Median operative time was 115 min (range 110–125 min) for group A, 100 min (range 95–115 min) for group B, and 85 min (range 65–95 min) for group C; differences between operative times of groups A and B and between groups B and C were statistically significant (both P < 0.001). At a median followup of 38 months, recurrent symptoms developed in three patients. Overall, the success rate of the procedure was 96.5%. Conclusion: In a retrospective analysis of our series, the retrograde placement of the ureteral stent and the ureteropelvic anastomosis with two running sutures seemed to be tips of success in reducing operative times.
Introduction
A
lthough open dismembered pyeloplasty is the standard management of ureteropelvic junction (UPJ) obstruction, in the last decade, laparoscopic pyeloplasty (LP) has become increasingly popular. The laparoscopic procedure can be performed through a retroperitoneal or a transperitoneal approach, and equivalent success rates have been quoted in the literature.1–3 Laparoscopic Anderson-Hynes pyeloplasty, when reproducing the open procedure step by step, provides an excellent outcome.4 There is also evidence in the literature
that a laparoscopic nondismembered technique, such as a Fenger pyeloplasty, leads to a lower success rate than a dismembered pyeloplasty.5 A major drawback of LP is the skill necessary to perform intracorporeal suturing, which means a long learning curve before achieving the same effectiveness of open surgery with comparable operating time.6–8 In an attempt to improve the operative technique and to simplify the suturing, robot-assisted pyeloplasty was first described by Sung and colleagues9 in 1999. Gettmann and coworkers10 reported their preliminary results, which showed
1
Regina Elena National Cancer Institute, Rome, Italy. Campus Bio-Medico University of Rome, Rome, Italy.
2
847
848 shorter operative times with the da Vinci robotic system than with standard laparoscopic technique. The current use of robot-assisted LP is still limited by costs, instrumentation, and requirement of experienced table-side laparoscopic assistance. To date, no evidence supports the superiority of robot-assisted pyeloplasty vs LP. Jarrett and associates6 observed that average operative times decreased with surgeon experience, which certainly can reflect the increased skill. We found that technical modifications that were introduced progressively during our learning curve played a role in simplifying the procedure and reducing operative times. The aim of this study was to test the impact of technical modifications that we adopted (retrograde ureteral stenting and ureteropelvic anastomosis with two running sutures) on the operative times of LP. Materials and Methods From November 2000 to May 2008, 84 consecutive patients with UPJ obstruction underwent transperitoneal laparoscopic dismembered pyeloplasty: 78 underwent pyeloplasty as a primary surgical procedure, 6 underwent LP as a secondary treatment after failure of endoscopic antegrade endopyelotomy. Forty patients were men, and 44 were women. The median patient age was 42.4 years (range 32–51 yrs), and median body mass index was 24.5 (range 23–27. Most patients had a history of flank pain and=or urinary tract infections. All patients had preoperative evidence of hydronephrosis and delayed function demonstrated on excretory urography.
PAPALIA ET AL. Twenty-six pyeloplasties were on the left side and 58 were on the right side. All procedures were performed by the same surgeon (MG) through transperitoneal access. In the first 14 patients of our series (group A), the ureteral stent was positioned antegrade, and ureteropelvic anastomosis was performed with interrupted sutures. In the following 25 patients (group B), the ureteral stent was also placed antegrade while the ureteropelvic anastomosis was performed with two running sutures. In the last 45 patients (group C), the ureteral stent was positioned retrograde, and the ureteropelvic anastomosis was performed with two running sutures. Coexisting renal pelvis stones were preoperatively diagnosed by CT in three patients (3.5%)—one in group B and two in group C. All renal pelvis stones were removed with forceps under direct vision. We retrospectively analyzed operative data of the entire cohort. Median operative times of each group were compared with Student t test. Time for the cystoscopic-based procedures was included in the overall operative time. Surgical technique Under general anesthesia, preoperatively, a 5F Pollack Open-End Flexi-Tip! ureteral catheter (G14521) is placed retrograde on the hydrophilic guidewire (DPSCI-060028RPC-LP). The ureteral catheter and guidewire are secured to the urethral catheter to avoid sliding. After moving the patient to an extended flank position, we perform transperitoneal access with four trocars. First, a 12-mm trocar for the camera is placed along the pararectal line at
FIG. 1. (A) Transaction of the ureteropelvic junction using endoscissors; (B) spatulation of the ureter on a guidewire; (C) ureter spatulated; (D) first stitch on the inferior boundary of the pelvis.
TIPS IN LAPAROSCOPIC PYELOPLASTY the level of the umbilicus using the open Hasson technique, a 10-mm trocar is placed at the iliac fossa, midway between the umbilicus and the anterior superior iliac spine, and two 5-mm trocars are inserted along the midclavicular line in the upper abdominal quadrant and along the anterior axillary line just below the last rib. The first step is the incision of the line of Toldt, and subsequently the access to the retroperitoneal space. After identifying and freeing the ureter and the UPJ, the ureter is transected using endoscissors (Fig. 1A), and the obstructed part is left attached to the ureter. Ureter transposition is performed each time crossing vessels are found. When necessary, pyelotomy is performed to remove exceeding pelvis. Coexisting renal pelvis stones are removed with forceps. As soon as the UPJ is opened, the ureteral catheter is moved back through the urethra by an assistant and the guidewire is tented up by the surgeon with a forceps to facilitate the spatulation of the ureter (Fig. 1B). Once spatulated. the ureter (Fig. 1C), the inferior boundaries of the pelvis (Fig. 1D) and of the ureter (Fig. 2A) are anastomosed with a 3-0 FS-2 19-mm 3=8c poliglecaprone running suture. The posterior aspect of the anastomosis is now configured with both ureteral stent and guidewire moved back into the ureter, thus avoiding any interference when suturing the posterior boundaries of the pelvis and ureter. Once the posterior aspect of the anastomosis is configured (Fig. 2B), the guidewire and ureteral catheter are moved forward into the pelvis (Fig. 2C) and secured to bladder catheter to avoid their sliding out. The anterior aspect of the anastomosis is now performed with running suture, and the obstructed part of the ureter is removed.
849 No additional interrupted stitches are used. A drain is left in place, and the posterior peritoneum is closed overside with a running suture (Fig. 2D). At the end of the procedure, the patient is moved to the supine position, the ureteral catheter is removed, and a Double-J stent is placed retrograde on the same guidewire. Postoperative care The bladder catheter is usually removed the day after the procedure. If there is no evidence of urinary leakage, the drain is removed 6 to 8 hours after catheter removal. The Double-J stent is removed after 4 weeks. Diuretic renography is performed at 3 and 12 months and yearly thereafter. The procedures are classified as failures if postoperative renography demonstrates obstruction accompanied by symptoms or a reduction in function. Results Crossing vessels were intraoperatively detected in 26 of 84 (42%) patients. No procedures needed conversion to open surgery, and no major complications occurred in any patient. Minor complications observed included postoperative urinary leakage in three patients at bladder catheter removal (two in group A and one in group B). In these patients, the bladder catheter was newly placed and removed after 3 days without evidence of leakage. Mean operative blood loss was 70 mL (range 20–150 mL), and mean hospital stay was 1.6 days (range 1–4 d). Median operative times of groups A, B, and C were 115 min (range 110–125 min), 100 min (range 95–115 min), and 85 min (range
FIG. 2. (A) First stitch on the inferior boundary of the ureter; (B) posterior aspect of ureteropelvic anastomosis; (C) guidewire moved into the pelvis; (D) posterior peritoneum closed with running suture.
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PAPALIA ET AL.
FIG. 3.
Operative times of the three groups divided by the two tips described in the text.
65–95 min), respectively (Fig. 3 and Table 1). Although we found operative times progressively shortened by increasing surgeon skill, the retrograde placement of the ureteral stent and the ureteropelvic anastomosis with two running sutures had a significant impact on the reduction of operative times: Differences between operative times of groups A and B and between groups B and C were statistically significant (P values < 0.001). At a median follow-up of 38 months (range 6–90 mos), the success rate was 96.5%. Three (3.5%) patients had recurrent symptoms with evidence of obstruction demonstrated on renography. The mean time to failure was 3.68 months (range 2–6 mos). All three patients were successfully treated with retrograde endopyelotomy. Discussion Dismembered Anderson-Hynes pyeloplasty is now the gold standard for the management of primary UPJ obstruction.6–8,11 Since Schuessler and colleagues12 described the technique of LP in the 1990s, it has been gaining in popularity to duplicate the steps of open pyeloplasty in a minimally invasive way.
LP is comparable to open pyeloplasty in terms of success and complication rates.5 Although initial series suggested technical difficulties with prolonged operative times and lower success rate with LP than with open surgery, recent series report promising results that show the laparoscopic approach has a combined advantage over open surgery and endourologic techniques.4 In laparoscopic surgery, because of the two-dimensional view and restricted movements, it takes longer to dismember the UPJ, spatulate the ureter, and than place sutures for the reconstruction. In our experience, the major technical challenges were the spatulation of the ureter (avoiding its rotation), the antegrade ureteral stenting, which we abandoned, and suturing the ureteral and pelvic boundaries. We believe that the preoperative placing of the ureteral catheter and guidewire can be helpful in two steps: The countertraction of the guidewire makes spatulating the ureter easier and both anterior and posterior aspects of the anastomosis can be carried out without interferences with the Double-J stent. In fact, the posterior aspect is configured with both ureteral catheter and guidewire moved back into the ureter, and the anterior aspect is sutured with a Pollack open-
Table 1. Patient Groups, Techniques, and Median Operative Times of Each Group*
Group
Consecutive patients
A
1 to 14
B
15 to 39
C
40th to 85th
Technique Ureteral stent positioned antegrade; ureteropelvic anastomosis performed with interrupted sutures Ureteral stent positioned antegrade; ureteropelvic anastomosis performed with two running sutures Ureteral stent positioned retrograde; ureteropelvic anastomosis performed with two running sutures
*Student t test (significant threshold 0.001).
Median operative time
Student t test
115 min
100 min
Group A vs Group B P < 0.001
85 min
Group B vs Group C P < 0.001
TIPS IN LAPAROSCOPIC PYELOPLASTY end ureteral catheter in situ, which can be moved forward by an assistant. On the contrary, we found that antegrade stenting has two major drawbacks: First, the necessity to perform at least one of the aspects of anastomosis with the Double-J stent in situ— the pigtail of the stent into the pelvis can get in the way of the running suture and the Double-J stent can slide out from the pelvis. Second, the ureteral guidewire allows one to spatulate the ureter on the guidewire, obtaining a linear section of the ureter. In our experience, the simplification of these surgical steps described above justifies the time saving that we observed with the introduction of these two technical modifications. Arumainayagam and coworkers13 described the advantages of antegrade stenting, noting that the antegrade placement of the ureteral Double-J stent led to time saving. Gaitonde and associates14 highlighted that ‘‘antegrade laparoscopic insertion of the stent can be cumbersome, and confirmation of accurate positioning of the distal end in the bladder is not always possible.’’ In our experience, the disadvantages described above have been solved, thanks to the possibility of moving, under vision, both ureteral catheter and guidewire along the ureter up the pelvis; thus, our procedure combined the advantages of performing laparoscopic dissection of the UPJ without the interference of a preplaced stent with the certainty of correct placement of the distal end of the Double-J stent. The intracorporeal suturing necessary for LP may be time consuming. For this reason, alternative tissue approximation techniques have been explored without giving an effective alternative to intracorporeal suturing.15 With regard to intracorporeal suturing, first, the posterior aspect of anastomosis can be easily performed without the Double-J stent in situ, performing a tension-free suture of ureteral and pelvic boundaries. Second, the anterior aspect of the anastomosis can be performed in the same way with a running suture, without needing additional interrupted stitches. The only two running sutures that we have performed for the anterior and posterior aspects of the anastomosis led to time saving. There are no randomized controlled trials comparing the retroperitoneal and transperitoneal approaches: the choice of the approach depends strongly on the training and preference of the surgeon. The largest series of laparoscopic dismembered pyeloplasties using a transperitonaeal approach showed a success rate of 95%, with a mean operative time of 246 minutes.16 This length of operative time in initial experiences could not encourage surgeons to perform LP even if they are conscious of the superiority of this approach. In the present study, the median operative time was 90 minutes, which is significantly shorter than the mean operative time reported in other series of transperitoneal laparoscopic dismembered pyeloplasty.16,17 It could be because of surgeon skill, but we found that the operative time in our series had been progressively reduced thanks to these tips described above (the stent placement on the same guidewire retrograde, the spatulation of the ureter on the guidewire, and the two running sutures). In each published series, the operative times decreased with increasing experience, reflecting the impact of the laparoscopic learning curve; thus, we are aware that differences in operative times among the three groups of our series can be caused by the learning curve. Our considerations could be
851 found inappropriate by surgeons who routinely perform LP with antegrade ureteral stenting; in addition, the running sutures to configure the anastomosis are not a ‘‘must.’’ Our learning curve highlights the importance of achieving a standard in each surgical procedure, and we are aware that each surgeon achieves a personal standard through personal experience. Results obtained by statistical analysis have not the power of a prospective study because of the retrospective nature of the investigation; therefore, our report simply concerns ‘‘how we did in simplifying technical challenges of this surgical procedure.’’ Our report showed that LP resulted in a durable success rate of 96.5%. Conclusion In a retrospective analysis of our series, we identified these two tips (the retrograde placement of ureteral stent and the ureteropelvic anastomosis with two running sutures) as key steps in simplifying the procedure and thus in reducing operative times. Our conclusions need to be validated by further experience from other centers. Acknowledgement Adele Dalena contributed to the editing of the manuscript. Disclosure Statement No competing financial interests exist. References 1. Eden CG, Cahill D, Allen JD. Laparoscopic dismembered pyeloplasty: 50 consecutive cases. BJU Int 2001;88:526–531. 2. Soulie´ M, Salomon L, Patard JJ, et al. Extraperitoneal laparoscopic pyeloplasty: A multicenter study of 55 procedures. J Urol 2001;166:48–50. 3. Gnanapragasam VJ, Armitage TG. Laparoscopic pyeloplasty, initial experience in the management of UPJO. Ann R Coll Surg Engl 2001;83:347–352. 4. El-Shazly MA, Moon DA, Eden CG. Laparoscopic pyeloplasty: Status and review of literature. J Endourol 2007;21: 673–678. 5. Klingler HC, Remzi M, Janetschek G, Kratzik C, Marberger MJ. Comparison of open versus laparoscopic pyeloplasty techniques in treatment of uretero-pelvic junction obstruction. Eur Urol 2003;44:340–345. 6. Jarrett TW, Chan DY, Charambura TC, Fugita O, Kavoussi LR. Laparoscopic pyeloplasty: The first 100 cases. J Urol 2002;167:1253–1256. 7. Bauer JJ, Bishoff JT, Moore RG, Chen RN, Iverson AJ, Kavoussi LR. Laparoscopic versus open pyeloplasty: Assessment of objective and subjective outcome. J Urol 1999; 162:692–695. 8. Soulie´ M, Thoulouzan M, Seguin P, Mouly P, Vazzoler N, Pontonnier F, Plante P. Retroperitoneal laparoscopic versus open pyeloplasty with a minimal incision: Comparison of two surgical approaches. Urology 2001;57:443–447. 9. Sung GT, Gill IS, Hsu TH. Robotic-assisted pyeloplasty. A pilot study. Urology 1999;53:1099–1103. 10. Gettman MT, Peschel R, Neururer R, Bartsch G. A comparison of laparoscopic pyeloplasty performed with the daVinci robotic system versus standard laparoscopic techniques: Initial clinical results. Eur Urol 2002;42:453–458.
852 11. Munver R, Sosa RE, del Pizzo JJ. Laparoscopic pyeloplasty: History, evolution, and future. J Endourol 2004;18: 748–755. 12. Schuessler WW, Grune MT, Tecuanhuey LV, Preminger GM. Laparoscopic dismembered pyeloplasty. J Urol 1993; 150:1795–1799. 13. Arumainayagam N, Minervini A, Davenport K, et al. Antegrade versus retrograde stenting in laparoscopic pyeloplasty. J Endourol 2008;22:671–674. 14. Gaitonde K, Roesel G, Donovan J. Novel technique of retrograde ureteral stenting during laparoscopic pyeloplasty. J Endourol 2008;22:1199–1202. 15. Eden CG, Coptcoat MJ. Assessment of alternative tissue approximation techniques for laparoscopy. Br J Urol 1996;78: 234–242. 16. Inagaki T, Rha KH, Ong AM, Kavoussi LR, Jarrett TW. Laparoscopic pyeloplasty: Current status. BJU Int 2005; 95(suppl 2):102–105. 17. Tu¨rk IA, Davis JW, Winkelmann B, et al. Laparoscopic dismembered pyeloplast—the method of choice in the presence
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Address reprint requests to: Giuseppe Simone, M.D. Department of Urology Regina Elena National Cancer Institute Via Elio Chianesi 53 00123, Roma Italy E-mail:
[email protected]
Abbreviations Used CT ¼ computed tomography LP ¼ laparoscopic pyeloplasty UPJ ¼ ureteropelvic junction
