Page 21 - Journal of Laparoscopic Surgery

WJOLS

Laparoscopic vs Open Pyeloplasty

than in pediatric kidneys with PUJO (30%) and absent in pelvis is not completely exposed as the renal artery and vein
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prenatally detected PUJO. Thus, there may be a time- cross ventrally. In Rasweiler’s experience, this approach is
dependent relation between the development of adult PUJO also more invasive as reflected by the higher postoperative
and the presence of crossing vessel. The identification of morbidity rates relative to the retroperitoneoscopic
crossing vessels tends to be higher in laparoscopic than in nephrectomy. However, we did not experience any technical
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open surgery. The explanation for this difference may lie in difficulty or increased morbidity in the postoperative period in
the minimal mobilization of the kidney needed during the our series of transperitoneal pyeloplasty. Fourteen out of
laparoscopic procedure to access the PUJ, in contrast to the 15 patients did not suffer from ileus or distention of abdomen
open pyeloplasty in which the entire kidney needs to be and we started oral sips from the evening of the surgery which
mobilized and rotated medially to expose the pelviureteric was tolerated well by all patients. One out of 15 patients
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segment. Van Cangh et al showed the negative association developed urinary peritonitis due to leak from the anterior suture
between the presence of crossing vessel and the success rate line of the ureteropelvic anastomosis and required open
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of endopyelotomy. Crossing vessels are an important exploration. Others have reported shorter operative times but
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consideration in managing PUJO even though the relative higher complication rates for the retroperitoneoscopic
contribution of crossing vessels to the pathophysiology of the approach. The success rates seem to be better with
individual PUJO will probably always be difficult to quantify as transperitoneal pyeloplasty (97 to 99%) than with the
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there are subtle differences in vessel size, distance from and retroperitoneoscopic approach (87 to 98%). Long-term
relation to the PUJ, degree of hydronephrosis, level of kidney outcomes need to be assessed because in rare cases PUJ
function and the presence of periureteric and perivascular bands obstruction can recur a year or more postoperatively. Several
and adhesions. Incidence of crossing vessels reported in investigators recommend assessment of outcome by at least 1-
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retroperitoneal series is lower than those reported in most year follow-up with diuretic renal scan or IVP. Jarrett et al 16
transperitoneal studies. And a retroperitoneal surgeon is less reported the results of 100 laparoscopic pyeloplasties with a
likely to transpose the anterior crossing vessel arguing that the mean clinical and radiographic follow-up of 2.7 and 2.2 years
ureter is lying naturally and anatomically as the most posterior respectively. The overall success rate was 96% and no late
structure in the retroperitoneum as evidenced in the series of failure (after 1 year) was observed. We intend to follow all our
Eden CG et al. Still, there is no apparent difference in the success patients for a period of 1 year after surgery with IVP and DTPA
rate of transperitoneal or retroperitoneal LP. Precise plastic repair renal scan. At the present time, eight patients are under follow-
of the PUJ is most important for the success rate of pyeloplasty up and seven patients have completed the 1 year follow-up and
with the crossing vessel either transposed or translocated there was only one failure.
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cephalad from the PUJ area, as per the individual case. The
necessity for reduction of the renal pelvis might be CONCLUSION
controversial. We do not reduce the pelvis when it is small and LP is a safe and effective minimally invasive treatment option
has active peristalsis. However, in a large pelvis with poor that duplicates the principles and techniques of definitive open
movement, we actively consider reduction, particularly when surgical repair. The success rates associated with LP are
the reduction is necessary to give the PUJ, a funnel-like shape. comparable to those of the gold standard, open pyeloplasty.
All patients in our series had primary PUJ obstruction. LP has LP is associated with significant reductions in overall morbidity,
been used even in patients in whom previous endoscopic and/ including less discomfort, shorter hospital stay, lower
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or open pyeloplasty had failed. Sundaram CP et al reported an complication rate, and shorter time to convalescence and is
overall success rate of 94% in a series of 36 patients with cosmetically superior to the open pyeloplasty. Varied surgical
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secondary PUJO. Siqueria et al also reported success in eight anatomy associated with PUJ like the crossing vessels and
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out of nine patients. Jarrett reported 17 laparoscopic high insertion of the ureter in the pelvis can be successfully
pyeloplasties with secondary PUJO with a success rate of 88%. repaired with LP which have been shown to compromise the
Notable point recorded in these studies was the longer mean results of other endourological procedures. The disadvantage
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operative time. Soulie et al and Lachkar et al report that any includes the longer operative duration as compared to open
previous retroperitoneoscopic procedure makes a new pyeloplasty, steep learning curve and requires technical
retroperitoneoscopic pyeloplasty unlikely. So, a transperitoneal expertise. With the steady increase in worldwide laparoscopic
approach is preferred for such cases over the retroperitoneal experience and education, LP is indeed emerging as the new
approach. We used transperitoneal approach in all our patients. gold standard of care for symptomatic PUJ obstruction.
This approach offers more working space and a better field of
view which is important for a reconstructive surgery. However, REFERENCES
several disadvantages have been reported for this approach. 1. Thomas HS, Stevan B Streem, Stephen Y Nakada. Campbell-
For access to the retroperitoneum, the colon has to be mobilized walsh urology (9th ed). Management of upper urinary tract
and separated from the Gerota’s fascia. In addition, the renal Obstruction 2007.

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