Experience with Laparoscopic Pyeloplasty, Including Robot-Assisted Laparoscopic Surgery, for Ureteropelvic Junction Obstruction

Seong Cheol Kim; Taejin Kang; Hyungkeun Park

doi:10.4111/kju.2009.50.10.996

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Kim, Kang, and Park: Experience with Laparoscopic Pyeloplasty, Including Robot-Assisted Laparoscopic Surgery, for Ureteropelvic Junction Obstruction

Original Article

Korean J Urol 2009;50(10):996-1002.

Published online: 19 October 2009

DOI: https://doi.org/10.4111/kju.2009.50.10.996

Experience with Laparoscopic Pyeloplasty, Including Robot-Assisted Laparoscopic Surgery, for Ureteropelvic Junction Obstruction

Seong Cheol Kim, Taejin Kang, Hyungkeun Park

From the Department of Urology, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to: Hyungkeun Park Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-dong, Songpa-gu, Seoul 137-736, Korea TEL: 02-3010-3737 FAX: 02-477-8928 E-mail: hkpark@amc.seoul.kr

Received 27 May 2009 Accepted 21 September 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction (UPJ) obstruction. We present our experience with the first 30 consecutive cases of laparoscopic pyeloplasty performed at our institution.

Materials and Methods

We studied 30 patients with ureteropelvic junction obstructions who underwent laparoscopic pyeloplasty between March 2004 and March 2009. Of the 30 patients, 5 patients underwent robot-assisted laparoscopic pyeloplasty (RALP) since April 2008. Patients were divided into 4 groups according to operative procedure: group 1, early laparoscopic pyeloplasty-dismembered (E/LP-D, n=9); group 2, late la-paroscopic pyeloplasty-dismembered (L/LP-D, n=9); group 3, laparoscopic pyeloplasty-Fenger’s method (LP-F, n=7); and group 4, RALP (n=5).

Results

The mean age of the patients was 34.0±12.8 years (range, 17-61 years). A crossing vessel was present in 37.9% of cases. Mean follow-up was 30±14 months (range, 11-62 months). Mean operative time was 267.3±78.7 minutes (range, 154-460 minutes), and the average length of the postoperative hospital stay was 4.6±1.6 days (range, 3-10 days). There were no intraoperative complications or transfusion. The success rate was 73.3%. The success rates of E/LP-D, L/LP-D, LP-F, and RALP were 6/9 (66.7%), 7/9 (77.8%), 5/7 (71.4%), and 4/5 (80%), respectively, without significant difference (p＞0.05). Operation time and length of hospital stay were shorter in the L/LP-D group than in the E/LP-D group.

Conclusions

Laparoscopic pyeloplasty may be an alternative treatment for an ureteropelvic junction obstruction, but the technical complexity of the procedure has made it difficult for many surgeons to adopt. RALP is a technically feasible management option for UPJ obstruction.

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Keywords: Laparoscopy, Ureteral obstruction, Robotics

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Fig. 1.

Port placement in laparoscopic pyeloplasty. (A) Laparoscopic pyeloplasty: 5 mm left working port (W) & 12 mm right working port (W) midway between the umbilicus and the xiphoid process, at least 5 cm below the umbilicus in the midline, and 12 mm camera port (C) at the umbilicus. (B) Robot-assisted laparoscopic pyeloplasty: two 8 mm working ports (W) midway between the umbilicus and the xiphoid process, pararectally below the level of the umbilicus; a 12 mm camera port (C) at the umbilicus; and a 12 mm assistant port (A) at least 5 cm below the umbilicus in the midline.

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Fig. 2.

The change in T_1/2 in ^99mTC-MAG3 for three patients who had no symptoms preoperatively. In all three patients, T_1/2 improved within 2 years after surgery.

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Fig. 3.

Recurrence-free survival. Of the 8 cases with failure, 7 cases failed before 10 months. Robot-assisted laparoscopic pyeloplasty showed the highest success rate with 80%, followed by late laparoscopic pyeloplasty-dismembered with 77.8%, laparoscopic pyeloplasty-Fenger with 71.4%, and early laparoscopic pyeloplasty-dismembered with 66.7%, but these rates were not significantly different (p＞0.05). Because the follow-up of robot-assisted laparo-scopic pyeloplasty was short, it was hard to compare to laparo-scopic surgery. RALP: robot assisted laparoscopic pyeloplasty, E/LP-D: early laparoscopic pyeloplasty-dismembered type, L/LP-D: late laparoscopic pyeloplasty-dismembered type, LP-F: laparoscopic pyeloplasty-Fenger’s type

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Table 1.

Patient characteristics

	E/LP-D (n=9)	L/LP-D (n=9)	LP-F (n=7)	RALP (n=5)	Total (n=30)
Age (year)	36.9±10.0 (20-52)	31.2±13.7 (18-61)	35.6±15.9 (17-61)	31.8±13.6 (18-48)	34.0±12.8 (17-61)
Sex (male, %)	33.3	55.6	28.6	40	40
Cross vessel (%)	55.6	44.4	0	40	36.7
Site (%)
Right	55.6	22.2	28.6	20.0	33.3
Left	44.4	77.8	71.4	80.0	66.7
Preop. renal function (%)	42.2±11.3 (29-60)	40.8±13.2 (19.4-58.6)	35.1±12.5 (21.7-52.2)	39.8±12.7 (23.5-53)	39.7±12.1 (19.4-60)
Preop. Cr (mg/dl)	0.9±0.3 (0.5-1.4)	0.9±0.2 (0.5-1.4)	0.9±0.2 (0.7-1.3)	0.8±0.1 (0.7-0.9)	0.9±0.2 (0.5-1.3)
Hydronephrosis (Gr=4, %)	11.1	33.3	42.9	40	30
Mean f/u (month)	41±15 (15-62)	26±10 (11-38)	28±13 (12-51)	18±5 (13-25)	30±14 (11-62)

E/LP-D: early laparoscopic pyeloplasty-dismembered type, L/LP-D: late laparoscopic pyeloplasty-dismembered type, LP-F: laparoscopic pyeloplasty-Fenger’s type, RALP: robot assisted laparoscopic pyeloplasty

Table 2.

Operative and postoperative outcomes

	E/LP-D (n=9)	L/LP-D (n=9)	LP-F (n=7)	RALP (n=5)	p-value
Success	6/9 (66.7%)	7/9 (77.8%)	5/7 (71.4%)	4/5 (80%)	0.936^a
Operation time (min)	334±96 (213-460)	248±39 (196-307)	199±43 (154-273)	276±41 (238-340)	0.002^b
Length of hospital stay	6.1±2.1 day (3-10)	4.0±0.9 day (3-6)	3.6±0.5 day (3-4)	4.2±0.8 day (3-5)	0.003^b
Postop./Preop. renal function	1.08±0.25 (0.58-1.38)	1.04±0.15 (0.79-1.27)	1.11±0.60 (0.04-1.90)	0.92±0.14 (0.80-1.14)	) 0.808^b

Operation time and the length of hospital stay were shorter in the L/LP-D as compared to the E/LP-D. And operation time (288±76 min vs. 199±43 min, p=0.007) and the length of hospital stay (4.9±1.7 days vs. 3.6±0.5 days, p=0.004) were in the same manner in the Fenger’s method as compared to the dismembered. E/LP-D: early laparoscopic pyeloplasty-dismembered type, L/LP-D: late laparoscopic

^a : Mann-pyeloplasty-dismembered type, LP-F: laparoscopic pyeloplasty-Fenger’s type, RALP: robot assisted laparoscopic pyeloplasty, Whitney test,

^b : chi-square test

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