Page 20 - Journal of Laparoscopic Surgery

10.5005/jp-journals-10007-1133
Ahmed Nihad Abtar
REVIEW ARTICLE
Laparoscopic vs Open Pyeloplasty

Ahmed Nihad Abtar
Specialist in Urology, Director, Rania General Hospital, Rania, Sulaimaniyah, Iraq

ABSTRACT

This review article compares open versus laparoscopic management of pelviureteric junction obstruction (PUJO). Untreated PUJO will
cause hydronephrosis and gradual renal impairment. Using PubMed, Google, Journal of Minimal Access Surgery (JMAS), Medscape,
European Urology Journal and SpringerLink internet search engines, I reviewed several articles that have tried to find out which way is
better. Most of the articles I reviewed showed that laparoscopic pyeloplasty (LP) is as good as open pyeloplasty (OP) and has additional
advantages. The parameters that were evaluated included operative time, the use of pain killers (analgesic), period of hospitalization and
complications.
Conclusion: Most of the studies agreed on that LP had less morbidity and less hospital stay than OP, but the main disadvantage was the
longer operative time.
Keywords: Laparoscopic pyeloplasty, Management of PUJ obstruction, Laparoscopic PUJ surgery.

INTRODUCTION versus laparoscopic (or robotic) techniques, actual application
of the methods.
Many procedures have been described for the management of
Pelviureteric Junction Obstruction (PUJO) including open, DISCUSSION
laparoscopic and endourological approaches. The first
reconstructive procedure was performed by Trendelenburg in LP has developed worldwide as the first minimally invasive
1886 and in 1891, Kuster performed the first successful option to match the success rates of open pyeloplasty while
1
dismembered pyeloplasty. The first laparoscopic pyeloplasty achieving the added goals of low morbidity, short hospital stay
2
(LP) was described by Schuessler et al in 1993. Many and convalescence. The success rate of Piyush Singhania et
7
procedures exist for correction of PUJ obstruction, but surgical al was 86.66% with a median follow-up period of 10.6 months
management of PUJ obstruction has recently been improved which compares favorably with other series. The operative time
by the introduction of minimally invasive surgical techniques decreased with increasing surgeon’s experience and
as alternative to standard open surgery in an effort to reduce standardization of the operative steps. LP allows the surgeon
the morbidity of the treatment. Initially, minimally invasive to perform the operative steps similar to those in open
approaches included antegrade and retrograde endoscopic pyeloplasties, such as dissection, transection and suturing.
endopyelotomy, but there is increasing evidence that However, it is a difficult procedure that requires careful ureteral
laparoscopic dismembered pyeloplasty is becoming the dissection and considerable proficiency in the intracorporeal
8
preferred option for treatment of PUJO and it can be performed suturing. Standardization of a surgeon’s steps and introduction
by transperitoneal, retroperitoneal or hand-assisted techniques, of additional techniques specific for laparoscopic surgery can
3,4
having a success rate of more than 95%. These outcomes are help to overcome the difficulties and enhance the performance.
better than other minimally invasive approaches to PUJO, Toward this end, we placed a transcutaneous suture in the
including retrograde and antegrade endopyelotomy or balloon medial edge of the redundant renal pelvis just below the renal
5
dilation. Patients suffering from PUJO present with a wide range vein. We found this step very useful in the transection and
of symptoms. Only a small percentage present with pain severe suturing as it tends to open up the pelvis and acts as a stay
enough to necessitate insertion of ureteric stent until the suture holding the anterior and the posterior walls of the pelvis
definitive surgery is prepared. 6 apart. We also tried taking a stay suture on the ureter in our
initial cases, but it caused entanglement of the sutures and so
to avoid confusion this step was omitted in the subsequent
MATERIALS AND METHODS
cases. Crossing vessels were observed in 7 out of 15 (46.7%)
A search for literatures and articles was performed using Google patients. The contribution of crossing vessels to the functional
search engine, SpringerLink, eMedicine, WebMD and PubMed. obstruction of the PUJ is an area of controversy. There is a
The following search terms were used: Laparoscopic versus higher incidence of crossing vessels as detected by color
open pyeloplasty, pyeloplast repair, advanced management of Doppler ultrasonography, in relation to kidneys with known
9
PUJ obstruction, robotic pyeloplasty. Multiple articles were PUJO (79%) than in kidneys with no PUJO (35%). Crossing
found. Selection criteria included those articles comparing open vessels are common in adult kidneys (50 to 80%) with PUJO

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