Abstract  OBJECTIVE:
To compare laparoscopic with open pyeloplasty.  METHODS:
The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of patients who underwent surgical correction of ureteropelvic junction obstruction between during January 2008 and December 2012. Patients with laparoscopic pyeloplasty were placed in group 1 and those with open pyeloplasty in group 2.The groups were compared for operative time, hospital stay, perioperative complications, blood loss, duration of surgery, outcome and follow-up. Data was analysed using SPSS 19.  RESULTS:
Of the 73 patients, 29(40%) were in group 1, and 44(60%) in group 2. A crossing vessel could be identified in 25(86.2%) in group 1 and in 33(75 %) in group 2. Laparoscopic procedures were associated with a longer mean operating time (p=0.04), median estimated blood loss (p\u3c0.001) and a shorter mean hospital stay (p\u3c0.001). Follow-up mercaptoacetyltriglycinescan was done in 21(74.5%) patients in group 1 and 23(52.2%) in group 2. Only 2(7%) patients in group 1 and 2(4.5%) in group 2 had poor response on mercaptoacetyltriglycine scan. Mean follow-up was 2.71±1.2 months. Postoperative complications were 5(13%) in group 1 and 9(20%) in group 2(p=0.141).  CONCLUSIONS:
Laparoscopic pyeloplasty was associated with shorter hospital stay, less pain and less blood loss. The efficacy in term of success rate and perioperative complications of laparoscopic pyeloplasty was comparable to that of open pyeloplasty

Aziz, Wajahat

Ghirano, Rajab

Memon, Mazhar Ali

Mutahir Siddiqui, Khurram

Raziuddin Biyabani, Syed

English

Ali, Mazhar

Ghirano, Rajab Ali

Siddiqui, Khurram Mutahir

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryMarch 2016Is laparoscopic pyeloplasty a comparable option totreat ureteropelvic junction obstruction (UPJO)? acomparative study.Mazhar AliAga Khan University, mazhar.ali@aku.eduSyed Raziuddin BiyabaniAga Khan University, raziuddin.biyabani@aku.eduRajab Ali GhiranoAga Khan UniversityWajahat AzizAga Khan University, wajahat.aziz@aku.eduKhurram Mutahir SiddiquiAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Surgery Commons, and the Urology CommonsRecommended CitationAli, M., Raziuddin Biyabani, S., Ghirano, R., Aziz, W., Siddiqui, K. (2016). Is laparoscopic pyeloplasty a comparable option to treatureteropelvic junction obstruction (UPJO)? a comparative study.. JPMA: Journal of the Pakistan Medical Association, 66(3), 224-227.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/595IntroductionUreteropelvic junction obstruction (UPJO) is a conditionwhere flow of urine from the renal pelvis to the proximalureter is hindered. The incidence of congenital (primary)UPJO is approximately 1 in 500 with a male-to-female ratioof 2:1.1 If left untreated, UPJO may lead to loss of renalfunction. The surgical correction of UPJO is essential toprevent further damage of nephrons. Open surgicalpyeloplasty is the traditional gold standard for thetreatment of UPJOwith success reported inmore than 90%cases. Minimally invasive endoscopic management hasbeen reported with variable success rate, but highrecurrence rate has been reported for endoscopiccorrection of primary UPJO and thus this modality oftreatment has little place in the current management ofthis anomaly.2,3 Open pyeloplasty (OP) is associated withmorbidity like pain and prolonged convalescence from aflank incision. Laproscopicpyeloplasty (LP) has beenshown to duplicate the high success rates achieved withOP.4,5 Since 1993, when the first LP was performed,published reports have shown comparable results,complication rates and recovery time with OP.6 LP is nowconsidered the new gold standard with better successratio than endopyelotomy, and equal functional outcomescompared to OP.2,7,8 Use of laparoscopy in urology is notnew. However, LP is a technically challenging operationwhich involves intracorporeal suturing.The current study was planned to compare the outcomesof LP compared to OP.Materials and MethodsThe retrospective study was conducted in January 2013 atAga Khan University Hospital, Karachi, and comprisedrecords of patients who underwent surgical correction ofureteropelvic junction obstruction either through LP orOP between January 2008 and December 2012. Patientswith missing or incomplete data were excluded and sowere those having secondary UPJO.Patients whose records were included in the study weredivided into two groups; LP in group 1 and OP in group 2.LP was performed by a single surgeon, while OP wasperformed by other surgeons with at least >5-yearexperience in urology.For LP, first of all rigid cystoscopy was performed inlithotomy position and ureteric orifice was cannulatedwith 5 Fr ureteric catheter. Retrograde pyelography wasdone to see the obstruction and ureteric catheter was leftJ Pak Med Assoc324ORIGINAL ARTICLEIs laparoscopic pyeloplasty a comparable option to treat Ureteropelvic junctionobstruction (UPJO)? A comparative studyMazhar Ali Memon, Syed Raziuddin Biyabani, Rajab Ghirano,Wajahat Aziz, KhurramMutahir SiddiquiAbstractObjective: To compare laparoscopic with open pyeloplasty.Methods: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised recordsof patients who underwent surgical correction of ureteropelvic junction obstruction between during January 2008and December 2012. Patients with laparoscopic pyeloplasty were placed in group 1 and those with openpyeloplasty in group 2.The groups were compared for operative time, hospital stay, perioperative complications,blood loss, duration of surgery, outcome and follow-up. Data was analysed using SPSS 19.Results: Of the 73 patients, 29(40%) were in group 1, and 44(60%) in group 2. A crossing vessel could be identifiedin 25(86.2%) in group 1 and in 33(75 %) in group 2. Laparoscopic procedures were associated with a longer meanoperating time (p=0.04), median estimated blood loss (p<0.001) and a shorter mean hospital stay (p<0.001). Follow-up mercaptoacetyltriglycinescan was done in 21(74.5%) patients in group 1 and 23(52.2%) in group 2. Only 2(7%)patients in group 1 and 2(4.5%) in group 2 had poor response onmercaptoacetyltriglycine scan. Mean follow-upwas2.71±1.2 months. Postoperative complications were 5(13%) in group 1 and 9(20%) in group 2(p=0.141).Conclusion: Laparoscopic pyeloplasty was associated with shorter hospital stay, less pain and less blood loss. Theefficacy in term of success rate and perioperative complications of laparoscopic pyeloplasty was comparable to thatof open pyeloplasty.Keywords: Laparoscopy, Hydronephrosis/congenital, Minimally invasive surgical procedures. (JPMA 66: 324; 2016)Department of Surgery, Section Urology, Aga Khan University Hospital,Karachi, Pakistan.Correspondence:Mazhar Ali Memon. Email: drmazharmemon110@gmail.comat the level of obstruction or beyond that and then thedistal end of ureteric catheter was fixed with 16Fr Foley.Position was changed to semi-lateral with ipsilateral sideup. Anderson-Hynes (AH) dismembered pyeloplasty wasthe preferred choice in all but one patient with UPJO. LPwas performed using three ports in all the patientsthrough transperitoneal approach. Using the Hassontechnique,9 a 10mmport was placed above the umbilicus,second port (5mm) was placed at the angle between thecostal margin and the lateral border of the ipsilateralrectus muscle, and third port (10mm) was placed midwaybetween the umbilicus and the anterior superior iliacspine at the level of the umbilicus.Colon was mobilised medially by identifying and incisingLine of Toldt, and dissection was done to identify theureter. Gonadal vessel and psoas were the landmarks forthe identification of ureter. The ureter could bedistinguished from the gonadal vessels by peristalsis andby the presence of ureteric stent. After identification ofureter it was traced upwards towards the pelvis. Peripelvicfat dissection was done to allow for optimal visualizationand enough mobility for a tension free anastomosis withthe ureter (Figure). If the crossing vessel was identified,then ureter was divided and transposed anteriorly. Thescissors were used to divide the ureter at the ureteropelvicjunction (UPJ). The ureter was then spatulated on itslateral aspect (facing the medial aspect of the kidney).Corner sutures were taken first then posterior wallanastomosis was performed in a running fashion with 4-0polydioxanone suture. Double J stent was passedantegradely and anastomosis completed. Further, 10Frradivac drain was placed and 10mm port sheath wasclosed with vicryl 2-0 and skin with polypropylene 2-0.For open dismembered pyeloplasty, a standardretroperitoneal approach through the subcostal incisionwas used.Postoperative management was similar in both groups.Prophylactic antibiotics (third-generation cephalosporin)were routinely prescribed. The Foley catheter wasremoved 2 days postoperatively. The closed suction drainwas subsequently removed if the drain output was lessthan 30ml in 24 hours after Foley catheter removal.Postoperatively patients were given intravenous (IV)paracetamol and opioid analgesia. Ultrasonography andrenal scintigraphy were performed 02 monthspostoperatively. Double J stent was removed after 06weeks in both groups.Operative time, intraoperative estimated blood loss,presenting complaint, preoperative imaging, analgesicuse, postoperative hospital stay, crossing vessel,complications and success rates based on postoperativemercaptoacetyltriglycine (MAG3) scan at 6 months werecompared for both groups. The operative time wasrecorded from the time of the initial skin incision to thefinal skin suture.Statistical analysis was done using SPSS 19. Continuousvariables were analysed by using student t test or MannWhitney test, where applicable, and p<0.05 was taken asstatistically significant.ResultsThere were 84 patients identified initially, but 11(13%)patients were excluded for missing or incomplete data. Ofthe 73(87%) patients in the study, LPrepair was performedon 29(40%) and OP on 44(60%)(Table 1).Crossing vessel was identified in 33(75%) in group 2 and25(86.2%) in group 1. Mean operative time in group 2was153±45 min and 178±60 min in group 1. Mean blood lossin group 1was 54±17ml compared to 110±78ml in group2 (p=0.059).Mean length of stay was 2.7±0.5 days in group 1compared to 4.5±0.9 days in group 2 (p<0.000).Therewere 7(16%) complications in group 2 against 5(17%)in group 1. Mean follow-up was 2.7±1.2 months (range: 1-6 months). Postoperative radionuclide scan on follow-upVol. 66, No. 3, March 2016Is laparoscopic pyeloplasty a comparable option to treat Ureteropelvic junction obstruction (UPJO)? A comparative study 325Table-1: Demographics and operative parameters.Characteristic Open % Laparoscopic %Approach ApproachN=44 (60%) M=29 (40%)Median Age (years) 28 30Male (n) 17 38.6 13 44.8Female (n) 27 61.4 16 55.2Right (n) 24 54.5 06 20.6Left (n) 20 44.5 23 79.4PresentationIncidental 5 11.3 2 6.8Flank Pain 39 88.6 27 93.1Pre-operating ImagingRidionuclide Scan 32 72.7 29 100Intra-venous Urography 15 34 3 10.3Computed Tomography Scan 16 36.3 15 51.7Ultra Sound 21 47.7 19 65.5Types of PyeloplastyCulp DeWeerd 8 18.2 0 0YV-Foley 2 4.5 1 3.4Anderson Hyne 34 77.3 28 96.5Crossing Vessel 33 75 25 86.2Operative time (Min) 153±45 178±60Estimated Blood Loss (mls) 110±78 54±17revealed success in 42(95%) in group 2 compared to i95%(n=42) for OP vs 27(93%) in group 1 (Table-2).DiscussionTo our knowledge, this is the first study from our regiondemonstrating safety and efficacy of laparoscopicapproach. The first LP was described in 1993.8 initially, OPwas considered the gold standard with high success rateand acceptable outcome.10,11 The advancement intechnology led to widespread use of minimally invasivesurgical techniques. A reflection of this trend was thedevelopment of LP which is now the preferred treatmentmodality,11,12 with advantages of reduced access-relatedmorbidity, improved visualisation, decreased blood loss,less postoperative pain, quicker recovery and bettercosmesis. With respect to success rate, LP has providedequivalent results when compared to open surgery.A crossing vessel is identified as one of the common causesof UPJO irrespective of the choice of surgical approach.13-16In our study the LP group it was the case in had 86.2%patients. The standardised procedure of Anderson-Hynesrepair is ideally suitable for crossing vessel.Existing literature presents contradictory findingswith regardto duration of surgical intervention in LP vsOP approach.Thismaybe a reflection of the learning curve of reconstructivelaparoscopy. Some studies showed that LP is a demandingprocedure and requires longer duration of time.8,17Conversely, others identified no significant difference indurationof surgery forOPversus LP.18Our study revealed thatit took on average 25 min more to perform LP, and thisdifferencewas statistically significant.This review includes theexperience of our first 30 cases and the increased operativetime maybe a reflection of our learning curve. Literature alsosupports this finding as LP is a difficult procedure anddemands technical expertise compared to OP. Reducedoperative time can be achieved by increasing experience ofsurgeons and by standardisation of operative steps.19,20 Onthe other hand, the significantly shorter length of hospitalstay (2.7 days) required for LP group is an obvious advantage.This finding can be attributed to the fact that patientsundergoing LP experience less postoperative pain, and havequicker recovery.8,16,19,21,22 Similarly, the reduced blood loss isanother advantage of minimally invasive approach and isduplicated in our study. There was a female predominance inour study which is contrary to literature.16,19 As LP offersunparalleled cosmetic advantage, this may be a reflection ofpatient's preference or referral pattern.Existing literature also supports that LP has lowermorbidity compared to OP. In general, the reportedoverall complication rate of the LP ranges from 4% to12.7%. In the present study the complication rate LP ingroup was 17% (n=5). There was no intraoperativecomplications, but there were 2 cases converted to opensurgery due to the technical problems that has beenreported in earlier studies as well.15,17,21,23,24In the current study the main strength was preoperativerenal scintigraphy (MAG-3) in the LP group done in 93%(n=27). Preoperative renal scintigraphy is important toidentify patients whowill benefit most from repair and alsohelps in comparison during postoperative follow-up.8,21In our study, 75% (n=22) LP patients got the postoperativeMAG-3 in follow-up. Relatively less data is available forradionuclide scan during follow-up.8 We recommendpostoperative radionuclide scan routinely in all patientsundergoing LP. As reduction of renal pelvis is not routinelyperformed during LP, imaging modalities likeintravenouspyelogram (IVP) or ultrasonography (USG)may provide erroneous result in this setting.J Pak Med Assoc326 M. A. Memon, S. R. Biyabani, R. Ghirano, et alTable-2: Postoperative findings.Open Approach Laparoscopic ApproachN=44 N=29Length of stay (days) 4.5+0.9 2.7+0.5Complications n % n %Urinary Tract Infections 4 9 1 3JJ displaced 0 0 1 3Perinephric Haematoma 0 0 1 3Anastomosis Leak 1 2 1 3Recurrent PUJO 1 2 1 3Wound Infection 1 2 0 07 15 5 17Success 42 95 27 93Recurrence 2 4 2 6Figure: Black arrow renal pelvis and white arrow narrow part of UPJO.Conversion to OP is a recognised complication of LP.8,16,21,22All patients should be informed about this technicalproblem. In our series, 3 patientswere converted from LP toOP. In all 3 of these cases, the reasonwas technical difficultyin achieving a tension-free anastomosis.Despite initial concerns, the success rate of LP iscomparable to OP. Previous studies are limited by variablefollow-up strategies and definition of success.12,20,25 Wereport a success rate of 93% in our LP cohort usingradionuclide scan as the primary modality for follow-up.Our study is limited by a few considerations. Firstly, thesmall sample size of each group did not allow for subgroupanalysis. Secondly, the duration of follow-up was short, sothe long-term results of LP could not be inferred.ConclusionLP had equivalent success rate compared to OP butoffered all the advantages of minimally invasive treatment.With shorter hospital stay and better cosmetic results,laparoscopic dismembered pyeloplasty has the potentialto replace open surgery and, provided there is availabilityof expertise, it should be considered the first option for thetreatment of ureteropelvic junction obstruction.References1. Khan F, Ahmed K, Lee N, Challacombe B, Khan MS, Dasgupta P.Management of ureteropelvic junction obstruction in adults.Nature Rev Urol 2014; 11: 629-38.2. Penn HA, Gatti JM, Hoestje SM, DeMarco RT, Snyder CL, Murphy JP.Laparoscopic versus open pyeloplasty in children: preliminaryreport of a prospective randomized trial. J Urol 2010; 184: 690-5.3. Zhang X, Li H-Z, Ma X, Zheng T, Lang B, Zhang J, et al.Retrospective comparison of retroperitoneal laparoscopic versusopen dismembered pyeloplasty for ureteropelvic junctionobstruction. J Urol 2006; 176: 1077-80.4. Shahnawaz AS, Shahzad I, Baloch MU. Our experience with opendismembered pyeloplasty for uretero-pelvic junction obstruction.Pak J Med Sci 2014; 30: 153.5. Eden C, Gianduzzo T, Chang C, Thiruchelvam N, Jones A.Extraperitoneal laparoscopic pyeloplasty for primary andsecondary ureteropelvic junction obstruction. J Urol 2004; 172:2308-11.6. Golda N, Kapoor A, DeMaria J. Laparoscopic pyeloplasty: role ofpreoperative retrograde pyelography. J Pediatr Urol 2008; 4: 162-4.7. Bauer JJ, Bishoff JT, Moore RG, Chen RN, Iverson AJ, KavoussI LR.Laparoscopic versus open pyeloplasty: assessment of objectiveand subjective outcome. J Urol 1999; 162: 692-5.8. Klingler HC, Remzi M, Janetschek G, Kratzik C, Marberger MJ.Comparison of open versus laparoscopic pyeloplasty techniquesin treatment of uretero-pelvic junction obstruction. Eur Urol 2003;44: 340-5.9. Poole GH, Frizelle FA. Modifications ToThe HassonTechnique. AustN Z J Surg 1996; 66: 770.10. Psooy K, Pike J, Leonard M. Long-term followup of pediatricdismembered pyeloplasty: how long is long enough? J Urol 2003;169: 1809-12.11. Schuessler W, Grune M, Tecuanhuey L, Preminger G. Laparoscopicdismembered pyeloplasty. J Urol 1993; 150: 1795-9.12. Jarrett TW, Chan DY, Charambura TC, Fugita O, Kavoussi LR.Laparoscopic pyeloplasty: the first 100 cases. J Urol 2002; 167:1253-6.13. Srivastava A, Singh P, Maheshwari R, Ansari MS, Dubey D, KapoorR, et al. Laparoscopic pyeloplasty: a versatile alternative to openpyeloplasty. Urol Int 2009; 83: 420-4.14. Stern JM, Park S, Anderson JK, Landman J, Pearle M, Cadeddu JA.Functional assessment of crossing vessels as etiology ofureteropelvic junction obstruction. Urology 2007; 69: 1022-4.15. Boylu U, Basatac C, Turan T, Onol FF, Gumus E. Comparison ofsurgical and functional outcomes of minimally invasive and openpyeloplasty. J Laparoendosc Adv Surg Tech A 2012; 22: 968-71.16. Hao G, Xiao J, Yang P, Shen H. Laparoscopic retroperitonealdismembered pyeloplasty: single-center experience in China. JLaparoendosc Adv Surg Tech A 2013; 23: 38-41.17. Bonnard A, Fouquet V, Carricaburu E, Aigrain Y, El-Ghoneimi A.Retroperitoneal laparoscopic versus open pyeloplasty in children.J Urol 2005; 173: 1710-3.18. Mei H, Pu J, Yang C, Zhang H, Zheng L, Tong Q. Laparoscopicversus open pyeloplasty for ureteropelvic junction obstruction inchildren: a systematic review and meta-analysis. J Endourol 2011;25: 727-36.19. Singh O, Gupta SS, Arvind NK. Laparoscopic pyeloplasty: ananalysis of first 100 cases and important lessons learned. Int UrolNephrol 2011; 43: 85-90.20. Abuanz S, Gamé X, Roche J-B, Guillotreau J, Mouzin M, Sallusto F,et al. Laparoscopic pyeloplasty: comparison betweenretroperitoneoscopic and transperitoneal approach. Urology2010; 76: 877-81.21. Calvert R, Morsy M, Zelhof B, Rhodes M, Burgess N. Comparison oflaparoscopic and open pyeloplasty in 100 patients with pelvi-ureteric junction obstruction. Surg Endoscop 2008; 22: 411-4.22. Simforoosh N, Basiri A, Tabibi A, Danesh A, Sharifi-Aghdas F, ZiaeeSA, et al. A comparison between laparoscopic and openpyeloplasty in patients with ureteropelvic junction obstruction.Urol J 2004; 1: 165-923. Zhang X, Li HZ, Wang S-G, Ma X, Zheng T, Fu B, et al.Retroperitoneal laparoscopic dismembered pyeloplasty:experience with 50 cases. Urology 2005; 66: 514-7.24. Braga LH, Pace K, DeMaria J, Lorenzo AJ. Systematic review andmeta-analysis of robotic-assisted versus conventionallaparoscopic pyeloplasty for patients with ureteropelvic junctionobstruction: effect on operative time, length of hospital stay,postoperative complications, and success rate. Eur Urol 2009; 56:848-58.25. Umari P, Lissiani A, Trombetta C, Belgrano E. Comparison of openand laparoscopic pyeloplasty in ureteropelvic junctionobstruction surgery: report of 49 cases. Arch ital Urol Androl 2011;83: 169-74.Vol. 66, No. 3, March 2016Is laparoscopic pyeloplasty a comparable option to treat Ureteropelvic junction obstruction (UPJO)? A comparative study 327

Is laparoscopic pyeloplasty a comparable option to treat ureteropelvic junction obstruction (UPJO)? a comparative study.

eCommons@AKUDepartment of Surgery Department of SurgeryMarch 2016Is laparoscopic pyeloplasty a comparable option totreat ureteropelvic junction obstruction (UPJO)? acomparative studyMazhar Ali MemonAga Khan University, drmazharmemon110@gmail.comSyed Raziuddin BiyabaniAga Khan University, raziuddin.biyabani@aku.eduRajab GhiranoAga Khan University, rajab.ghirano@aku.eduWajahat AzizAga Khan University, wajahat.aziz@aku.eduKhurram Mutahir SiddiquiAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Urology CommonsRecommended CitationMemon, M. A., Raziuddin Biyabani, S., Ghirano, R., Aziz, W., Mutahir Siddiqui, K. (2016). Is laparoscopic pyeloplasty a comparableoption to treat ureteropelvic junction obstruction (UPJO)? a comparative study. JPMA: Journal of Pakistan Medical Association, 66(3),324-327.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/135IntroductionUreteropelvic junction obstruction (UPJO) is a conditionwhere flow of urine from the renal pelvis to the proximalureter is hindered. The incidence of congenital (primary)UPJO is approximately 1 in 500 with a male-to-female ratioof 2:1.1 If left untreated, UPJO may lead to loss of renalfunction. The surgical correction of UPJO is essential toprevent further damage of nephrons. Open surgicalpyeloplasty is the traditional gold standard for thetreatment of UPJOwith success reported inmore than 90%cases. Minimally invasive endoscopic management hasbeen reported with variable success rate, but highrecurrence rate has been reported for endoscopiccorrection of primary UPJO and thus this modality oftreatment has little place in the current management ofthis anomaly.2,3 Open pyeloplasty (OP) is associated withmorbidity like pain and prolonged convalescence from aflank incision. Laproscopicpyeloplasty (LP) has beenshown to duplicate the high success rates achieved withOP.4,5 Since 1993, when the first LP was performed,published reports have shown comparable results,complication rates and recovery time with OP.6 LP is nowconsidered the new gold standard with better successratio than endopyelotomy, and equal functional outcomescompared to OP.2,7,8 Use of laparoscopy in urology is notnew. However, LP is a technically challenging operationwhich involves intracorporeal suturing.The current study was planned to compare the outcomesof LP compared to OP.Materials and MethodsThe retrospective study was conducted in January 2013 atAga Khan University Hospital, Karachi, and comprisedrecords of patients who underwent surgical correction ofureteropelvic junction obstruction either through LP orOP between January 2008 and December 2012. Patientswith missing or incomplete data were excluded and sowere those having secondary UPJO.Patients whose records were included in the study weredivided into two groups; LP in group 1 and OP in group 2.LP was performed by a single surgeon, while OP wasperformed by other surgeons with at least >5-yearexperience in urology.For LP, first of all rigid cystoscopy was performed inlithotomy position and ureteric orifice was cannulatedwith 5 Fr ureteric catheter. Retrograde pyelography wasdone to see the obstruction and ureteric catheter was leftJ Pak Med Assoc324ORIGINAL ARTICLEIs laparoscopic pyeloplasty a comparable option to treat Ureteropelvic junctionobstruction (UPJO)? A comparative studyMazhar Ali Memon, Syed Raziuddin Biyabani, Rajab Ghirano,Wajahat Aziz, KhurramMutahir SiddiquiAbstractObjective: To compare laparoscopic with open pyeloplasty.Methods: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised recordsof patients who underwent surgical correction of ureteropelvic junction obstruction between during January 2008and December 2012. Patients with laparoscopic pyeloplasty were placed in group 1 and those with openpyeloplasty in group 2.The groups were compared for operative time, hospital stay, perioperative complications,blood loss, duration of surgery, outcome and follow-up. Data was analysed using SPSS 19.Results: Of the 73 patients, 29(40%) were in group 1, and 44(60%) in group 2. A crossing vessel could be identifiedin 25(86.2%) in group 1 and in 33(75 %) in group 2. Laparoscopic procedures were associated with a longer meanoperating time (p=0.04), median estimated blood loss (p<0.001) and a shorter mean hospital stay (p<0.001). Follow-up mercaptoacetyltriglycinescan was done in 21(74.5%) patients in group 1 and 23(52.2%) in group 2. Only 2(7%)patients in group 1 and 2(4.5%) in group 2 had poor response onmercaptoacetyltriglycine scan. Mean follow-upwas2.71±1.2 months. Postoperative complications were 5(13%) in group 1 and 9(20%) in group 2(p=0.141).Conclusion: Laparoscopic pyeloplasty was associated with shorter hospital stay, less pain and less blood loss. Theefficacy in term of success rate and perioperative complications of laparoscopic pyeloplasty was comparable to thatof open pyeloplasty.Keywords: Laparoscopy, Hydronephrosis/congenital, Minimally invasive surgical procedures. (JPMA 66: 324; 2016)Department of Surgery, Section Urology, Aga Khan University Hospital,Karachi, Pakistan.Correspondence:Mazhar Ali Memon. Email: drmazharmemon110@gmail.comat the level of obstruction or beyond that and then thedistal end of ureteric catheter was fixed with 16Fr Foley.Position was changed to semi-lateral with ipsilateral sideup. Anderson-Hynes (AH) dismembered pyeloplasty wasthe preferred choice in all but one patient with UPJO. LPwas performed using three ports in all the patientsthrough transperitoneal approach. Using the Hassontechnique,9 a 10mmport was placed above the umbilicus,second port (5mm) was placed at the angle between thecostal margin and the lateral border of the ipsilateralrectus muscle, and third port (10mm) was placed midwaybetween the umbilicus and the anterior superior iliacspine at the level of the umbilicus.Colon was mobilised medially by identifying and incisingLine of Toldt, and dissection was done to identify theureter. Gonadal vessel and psoas were the landmarks forthe identification of ureter. The ureter could bedistinguished from the gonadal vessels by peristalsis andby the presence of ureteric stent. After identification ofureter it was traced upwards towards the pelvis. Peripelvicfat dissection was done to allow for optimal visualizationand enough mobility for a tension free anastomosis withthe ureter (Figure). If the crossing vessel was identified,then ureter was divided and transposed anteriorly. Thescissors were used to divide the ureter at the ureteropelvicjunction (UPJ). The ureter was then spatulated on itslateral aspect (facing the medial aspect of the kidney).Corner sutures were taken first then posterior wallanastomosis was performed in a running fashion with 4-0polydioxanone suture. Double J stent was passedantegradely and anastomosis completed. Further, 10Frradivac drain was placed and 10mm port sheath wasclosed with vicryl 2-0 and skin with polypropylene 2-0.For open dismembered pyeloplasty, a standardretroperitoneal approach through the subcostal incisionwas used.Postoperative management was similar in both groups.Prophylactic antibiotics (third-generation cephalosporin)were routinely prescribed. The Foley catheter wasremoved 2 days postoperatively. The closed suction drainwas subsequently removed if the drain output was lessthan 30ml in 24 hours after Foley catheter removal.Postoperatively patients were given intravenous (IV)paracetamol and opioid analgesia. Ultrasonography andrenal scintigraphy were performed 02 monthspostoperatively. Double J stent was removed after 06weeks in both groups.Operative time, intraoperative estimated blood loss,presenting complaint, preoperative imaging, analgesicuse, postoperative hospital stay, crossing vessel,complications and success rates based on postoperativemercaptoacetyltriglycine (MAG3) scan at 6 months werecompared for both groups. The operative time wasrecorded from the time of the initial skin incision to thefinal skin suture.Statistical analysis was done using SPSS 19. Continuousvariables were analysed by using student t test or MannWhitney test, where applicable, and p<0.05 was taken asstatistically significant.ResultsThere were 84 patients identified initially, but 11(13%)patients were excluded for missing or incomplete data. Ofthe 73(87%) patients in the study, LPrepair was performedon 29(40%) and OP on 44(60%)(Table 1).Crossing vessel was identified in 33(75%) in group 2 and25(86.2%) in group 1. Mean operative time in group 2was153±45 min and 178±60 min in group 1. Mean blood lossin group 1was 54±17ml compared to 110±78ml in group2 (p=0.059).Mean length of stay was 2.7±0.5 days in group 1compared to 4.5±0.9 days in group 2 (p<0.000).Therewere 7(16%) complications in group 2 against 5(17%)in group 1. Mean follow-up was 2.7±1.2 months (range: 1-6 months). Postoperative radionuclide scan on follow-upVol. 66, No. 3, March 2016Is laparoscopic pyeloplasty a comparable option to treat Ureteropelvic junction obstruction (UPJO)? A comparative study 325Table-1: Demographics and operative parameters.Characteristic Open % Laparoscopic %Approach ApproachN=44 (60%) M=29 (40%)Median Age (years) 28 30Male (n) 17 38.6 13 44.8Female (n) 27 61.4 16 55.2Right (n) 24 54.5 06 20.6Left (n) 20 44.5 23 79.4PresentationIncidental 5 11.3 2 6.8Flank Pain 39 88.6 27 93.1Pre-operating ImagingRidionuclide Scan 32 72.7 29 100Intra-venous Urography 15 34 3 10.3Computed Tomography Scan 16 36.3 15 51.7Ultra Sound 21 47.7 19 65.5Types of PyeloplastyCulp DeWeerd 8 18.2 0 0YV-Foley 2 4.5 1 3.4Anderson Hyne 34 77.3 28 96.5Crossing Vessel 33 75 25 86.2Operative time (Min) 153±45 178±60Estimated Blood Loss (mls) 110±78 54±17revealed success in 42(95%) in group 2 compared to i95%(n=42) for OP vs 27(93%) in group 1 (Table-2).DiscussionTo our knowledge, this is the first study from our regiondemonstrating safety and efficacy of laparoscopicapproach. The first LP was described in 1993.8 initially, OPwas considered the gold standard with high success rateand acceptable outcome.10,11 The advancement intechnology led to widespread use of minimally invasivesurgical techniques. A reflection of this trend was thedevelopment of LP which is now the preferred treatmentmodality,11,12 with advantages of reduced access-relatedmorbidity, improved visualisation, decreased blood loss,less postoperative pain, quicker recovery and bettercosmesis. With respect to success rate, LP has providedequivalent results when compared to open surgery.A crossing vessel is identified as one of the common causesof UPJO irrespective of the choice of surgical approach.13-16In our study the LP group it was the case in had 86.2%patients. The standardised procedure of Anderson-Hynesrepair is ideally suitable for crossing vessel.Existing literature presents contradictory findingswith regardto duration of surgical intervention in LP vsOP approach.Thismaybe a reflection of the learning curve of reconstructivelaparoscopy. Some studies showed that LP is a demandingprocedure and requires longer duration of time.8,17Conversely, others identified no significant difference indurationof surgery forOPversus LP.18Our study revealed thatit took on average 25 min more to perform LP, and thisdifferencewas statistically significant.This review includes theexperience of our first 30 cases and the increased operativetime maybe a reflection of our learning curve. Literature alsosupports this finding as LP is a difficult procedure anddemands technical expertise compared to OP. Reducedoperative time can be achieved by increasing experience ofsurgeons and by standardisation of operative steps.19,20 Onthe other hand, the significantly shorter length of hospitalstay (2.7 days) required for LP group is an obvious advantage.This finding can be attributed to the fact that patientsundergoing LP experience less postoperative pain, and havequicker recovery.8,16,19,21,22 Similarly, the reduced blood loss isanother advantage of minimally invasive approach and isduplicated in our study. There was a female predominance inour study which is contrary to literature.16,19 As LP offersunparalleled cosmetic advantage, this may be a reflection ofpatient's preference or referral pattern.Existing literature also supports that LP has lowermorbidity compared to OP. In general, the reportedoverall complication rate of the LP ranges from 4% to12.7%. In the present study the complication rate LP ingroup was 17% (n=5). There was no intraoperativecomplications, but there were 2 cases converted to opensurgery due to the technical problems that has beenreported in earlier studies as well.15,17,21,23,24In the current study the main strength was preoperativerenal scintigraphy (MAG-3) in the LP group done in 93%(n=27). Preoperative renal scintigraphy is important toidentify patients whowill benefit most from repair and alsohelps in comparison during postoperative follow-up.8,21In our study, 75% (n=22) LP patients got the postoperativeMAG-3 in follow-up. Relatively less data is available forradionuclide scan during follow-up.8 We recommendpostoperative radionuclide scan routinely in all patientsundergoing LP. As reduction of renal pelvis is not routinelyperformed during LP, imaging modalities likeintravenouspyelogram (IVP) or ultrasonography (USG)may provide erroneous result in this setting.J Pak Med Assoc326 M. A. Memon, S. R. Biyabani, R. Ghirano, et alTable-2: Postoperative findings.Open Approach Laparoscopic ApproachN=44 N=29Length of stay (days) 4.5+0.9 2.7+0.5Complications n % n %Urinary Tract Infections 4 9 1 3JJ displaced 0 0 1 3Perinephric Haematoma 0 0 1 3Anastomosis Leak 1 2 1 3Recurrent PUJO 1 2 1 3Wound Infection 1 2 0 07 15 5 17Success 42 95 27 93Recurrence 2 4 2 6Figure: Black arrow renal pelvis and white arrow narrow part of UPJO.Conversion to OP is a recognised complication of LP.8,16,21,22All patients should be informed about this technicalproblem. In our series, 3 patientswere converted from LP toOP. In all 3 of these cases, the reasonwas technical difficultyin achieving a tension-free anastomosis.Despite initial concerns, the success rate of LP iscomparable to OP. Previous studies are limited by variablefollow-up strategies and definition of success.12,20,25 Wereport a success rate of 93% in our LP cohort usingradionuclide scan as the primary modality for follow-up.Our study is limited by a few considerations. Firstly, thesmall sample size of each group did not allow for subgroupanalysis. Secondly, the duration of follow-up was short, sothe long-term results of LP could not be inferred.ConclusionLP had equivalent success rate compared to OP butoffered all the advantages of minimally invasive treatment.With shorter hospital stay and better cosmetic results,laparoscopic dismembered pyeloplasty has the potentialto replace open surgery and, provided there is availabilityof expertise, it should be considered the first option for thetreatment of ureteropelvic junction obstruction.References1. Khan F, Ahmed K, Lee N, Challacombe B, Khan MS, Dasgupta P.Management of ureteropelvic junction obstruction in adults.Nature Rev Urol 2014; 11: 629-38.2. Penn HA, Gatti JM, Hoestje SM, DeMarco RT, Snyder CL, Murphy JP.Laparoscopic versus open pyeloplasty in children: preliminaryreport of a prospective randomized trial. J Urol 2010; 184: 690-5.3. Zhang X, Li H-Z, Ma X, Zheng T, Lang B, Zhang J, et al.Retrospective comparison of retroperitoneal laparoscopic versusopen dismembered pyeloplasty for ureteropelvic junctionobstruction. J Urol 2006; 176: 1077-80.4. Shahnawaz AS, Shahzad I, Baloch MU. Our experience with opendismembered pyeloplasty for uretero-pelvic junction obstruction.Pak J Med Sci 2014; 30: 153.5. Eden C, Gianduzzo T, Chang C, Thiruchelvam N, Jones A.Extraperitoneal laparoscopic pyeloplasty for primary andsecondary ureteropelvic junction obstruction. J Urol 2004; 172:2308-11.6. Golda N, Kapoor A, DeMaria J. Laparoscopic pyeloplasty: role ofpreoperative retrograde pyelography. J Pediatr Urol 2008; 4: 162-4.7. Bauer JJ, Bishoff JT, Moore RG, Chen RN, Iverson AJ, KavoussI LR.Laparoscopic versus open pyeloplasty: assessment of objectiveand subjective outcome. J Urol 1999; 162: 692-5.8. Klingler HC, Remzi M, Janetschek G, Kratzik C, Marberger MJ.Comparison of open versus laparoscopic pyeloplasty techniquesin treatment of uretero-pelvic junction obstruction. Eur Urol 2003;44: 340-5.9. Poole GH, Frizelle FA. Modifications ToThe HassonTechnique. AustN Z J Surg 1996; 66: 770.10. Psooy K, Pike J, Leonard M. Long-term followup of pediatricdismembered pyeloplasty: how long is long enough? J Urol 2003;169: 1809-12.11. Schuessler W, Grune M, Tecuanhuey L, Preminger G. Laparoscopicdismembered pyeloplasty. J Urol 1993; 150: 1795-9.12. Jarrett TW, Chan DY, Charambura TC, Fugita O, Kavoussi LR.Laparoscopic pyeloplasty: the first 100 cases. J Urol 2002; 167:1253-6.13. Srivastava A, Singh P, Maheshwari R, Ansari MS, Dubey D, KapoorR, et al. Laparoscopic pyeloplasty: a versatile alternative to openpyeloplasty. Urol Int 2009; 83: 420-4.14. Stern JM, Park S, Anderson JK, Landman J, Pearle M, Cadeddu JA.Functional assessment of crossing vessels as etiology ofureteropelvic junction obstruction. Urology 2007; 69: 1022-4.15. Boylu U, Basatac C, Turan T, Onol FF, Gumus E. Comparison ofsurgical and functional outcomes of minimally invasive and openpyeloplasty. J Laparoendosc Adv Surg Tech A 2012; 22: 968-71.16. Hao G, Xiao J, Yang P, Shen H. Laparoscopic retroperitonealdismembered pyeloplasty: single-center experience in China. JLaparoendosc Adv Surg Tech A 2013; 23: 38-41.17. Bonnard A, Fouquet V, Carricaburu E, Aigrain Y, El-Ghoneimi A.Retroperitoneal laparoscopic versus open pyeloplasty in children.J Urol 2005; 173: 1710-3.18. Mei H, Pu J, Yang C, Zhang H, Zheng L, Tong Q. Laparoscopicversus open pyeloplasty for ureteropelvic junction obstruction inchildren: a systematic review and meta-analysis. J Endourol 2011;25: 727-36.19. Singh O, Gupta SS, Arvind NK. Laparoscopic pyeloplasty: ananalysis of first 100 cases and important lessons learned. Int UrolNephrol 2011; 43: 85-90.20. Abuanz S, Gamé X, Roche J-B, Guillotreau J, Mouzin M, Sallusto F,et al. Laparoscopic pyeloplasty: comparison betweenretroperitoneoscopic and transperitoneal approach. Urology2010; 76: 877-81.21. Calvert R, Morsy M, Zelhof B, Rhodes M, Burgess N. Comparison oflaparoscopic and open pyeloplasty in 100 patients with pelvi-ureteric junction obstruction. Surg Endoscop 2008; 22: 411-4.22. Simforoosh N, Basiri A, Tabibi A, Danesh A, Sharifi-Aghdas F, ZiaeeSA, et al. A comparison between laparoscopic and openpyeloplasty in patients with ureteropelvic junction obstruction.Urol J 2004; 1: 165-923. Zhang X, Li HZ, Wang S-G, Ma X, Zheng T, Fu B, et al.Retroperitoneal laparoscopic dismembered pyeloplasty:experience with 50 cases. Urology 2005; 66: 514-7.24. Braga LH, Pace K, DeMaria J, Lorenzo AJ. Systematic review andmeta-analysis of robotic-assisted versus conventionallaparoscopic pyeloplasty for patients with ureteropelvic junctionobstruction: effect on operative time, length of hospital stay,postoperative complications, and success rate. Eur Urol 2009; 56:848-58.25. Umari P, Lissiani A, Trombetta C, Belgrano E. Comparison of openand laparoscopic pyeloplasty in ureteropelvic junctionobstruction surgery: report of 49 cases. Arch ital Urol Androl 2011;83: 169-74.Vol. 66, No. 3, March 2016Is laparoscopic pyeloplasty a comparable option to treat Ureteropelvic junction obstruction (UPJO)? A comparative study 327

Is laparoscopic pyeloplasty a comparable option to treat ureteropelvic junction obstruction (UPJO)? a comparative study

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Is laparoscopic pyeloplasty a comparable option to treat ureteropelvic junction obstruction (UPJO)? a comparative study

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