Laparoscopic strategies in complex upper urinary tract obstruction

Abstract

We enumerate the various laparoscopic strategies to resolve upper urinary tract (UUT) obstruction in the context of variations in anatomy and report their outcomes. Retrospective review of primary laparoscopic UUT reconstructions performed between May 2012 and May 2021. Anomalies included: malrotated kidney (MRK), horseshoe kidney (HSK), duplex kidney (DK), pure intrarenal pelvis (IRP) and mid-ureteric stenosis (MUS). Success was defined by postoperative resolution of symptoms, improvement of anterior-posterior renal pelvic diameter (APD) on US and drainage on Mag3. Complications were categorised by Clavien-Dindo grading. Outcomes compared using the student's t-test with P<0.05 considered statistically significant. Of the 214 laparoscopic primary UUT reconstructions, 37 (17.2%) were: 13-MRK, 12-HSK, 4-DK, 4-IRP and 4-MUS. Median age at surgery was 5-years (range 0.3-15). Dismembered pyeloplasty: 8; pyeloplasty with renal sinus dissection: 8; neo-PUJ anastomosis: 8; primary ureterocalycostomy: 7; pyeloureterostomy: 2; and uretero-ureterostomy: 4. Median follow-up was 43-months (range 8-108) with a success rate of 94.5% (35/37). Complete resolution of symptoms in 20/21 patients; improvement of hydronephrosis on US in 35/37 patients (median pre-operative APD 27mm vs. median postoperative APD 8mm) [P<0.001]; improvement of drainage on diuretic renogram in 32/34 kidneys and stable/improved DRF in 34/35 kidneys (median preoperative DRF - 45% vs. median postoperative DRF - 47%) [P>0.05]. Postoperative complications managed medically (II Clavien) included urinary tract infections - 2 patients (5%), stent-related symptoms in 2 (5%) and umbilical port site collection in 1 patient (3%). Recurrent pelvi-ureteric junction obstruction PUJO occurred in one patient (3%) requiring redo surgery (IIIb Clavien), renal stones in 1 (3%) which resolved with ESWL (IIIb Clavien); in 1 (3%) patient with a HSK there was complete loss of ipsilateral kidney function but this was managed conservatively up to date (I Clavien). Laparoscopic transperitoneal approach allows the prompt recognition of in-situ anatomical variants. UUT obstruction in such settings calls for a variety of strategies with excellent outcomes.