Conventional Laparoscopic Pyeloplasty Research Articles

Laparoscopic versus robot-assisted pyeloplasty in infants and young children

To compare the characteristics of conventional laparoscopic pyeloplasty (LP) and robotic-assisted laparoscopic pyeloplasty (RALP) in infants and young children with ureteropelvic junction obstruction (UPJO). We performed a retrospective study of patients (age: 0-36 months) who underwent dismembered pyeloplasty (Anderson-Hynes) with the fourth-generation RALP or traditional LP between April 2020 and December 2020. A total of 33 patients with UPJO were enrolled: 12 underwent RALP (9 left side; 3 right side) and 21 underwent LP (18 left side; 3 right side). In the RALP group, the median patient age was 17 months (range: 5-36 months). In the LP group, the median patient age was 9 months (range: 2-36 months) (P=0.182). The mean operation times were 120.25±37.54min (RALP) and 156.10±51.11min (LP) (P=0.042), and the mean lengths of hospital stay were 6.42±1.62 days (RALP) and 8.19±2.25 days (LP) (P=0.023). Removal of the drainage tube was performed after 3.08±0.69 days (RALP) and after 4.76±1.81 days (LP) (P=0.001). The postoperative pain showed no significant difference. The mean hospitalization costs were 61464.75±2800.53 yuan (RALP) and 22169.52±3442.15 yuan (LP) (P<0.001). The mean follow-up time was 10-18 months. Significant improvements in the anteroposterior diameter and parenchymal thickness were observed after surgery. Conversion to laparotomy was not performed. No short-term complications occurred during postoperative hospitalization and follow-up. RALP has the advantages of less trauma and faster recovery. It can be safely and effectively performed in infants and young children, and its effectiveness is similar to that of traditional LP.

A systematic review and meta-analysis of conventional laparoscopic versus robot-assisted laparoscopic pyeloplasty in infants

While there are several reports confirming the safety and efficacy of laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children there have been none comparing LP and RALP specifically in infants. In this meta-analysis, we have compared the outcomes of LP and RALP in infants. Pubmed (Medline), Publon, Index Medicus and Embase were searched using the search terms: pyeloplasty (laparoscopic OR robot-assisted) AND (infant), to identify all papers pertaining to LP and RALP. Systematic review was performed to identify information regarding number of patients/renal units, age, body weight, operating time, hospital stay, success and complications. Meta-analysis of heterogeneity was reported with I2statistics. Once heterogeneity was found low, the pooled outcomes were compared with student's t test and Fishers exact test, wherever appropriate. After screening a total of 267 articles, 18 articles were included (10 articles on LP, 7 on RALP, 1 reporting both), comprising 323 renal units for LP and 173 renal units for RALP. With low heterogeneity (I2: 0%) both groups were considered to have been conducted under similar conditions for fixed effect model. There was no significant difference between the success rates of LP or RALP (97.5% vs 94.8%; p=0.21). The mean age at operation was significantly lower for LP (5.6±1.8 months) than RALP (7.2±1.2 months, P=0.0001). The duration of surgery was 137±45min for LP while significantly higher at 179±49min for RALP (p=0.0001). The mean (s.d) time to discharge was 2.0 (1.9) days for LP while 1.3 (0.4) days for RALP. The overall complication rate was significantly higher (summary table) for RALP than LP (p=0.03), mainly due to more port-site hernias in RALP. In the present study, we found that the success of LP and RALP in infants was similar. RALP in infants had longer duration of surgery, similar hospital stay and higher Clavien-3 complications than LP. While several studies have reported favorable outcomes for RALP over LP in children, this was not the case in infants. The smaller workspace, in an infant, can significantly limit the mobility of robotic instruments and increase the chance of port-site conflicts or trocar collisions. The use of larger robotic ports and instruments in the small space of infant abdomen might have been responsible for higher complications in RALP, including significantly larger number of port-site hernias. This meta-analysis represents the early experience of most RALP in infants, and it is possible that with experience RALP outcomes in infants also will catch up with LP. Miniaturization of robotic instruments might render RALP the future standard of care for pyeloplasty in infants.

Comparison of Safety, Efficacy and Outcomes of Robot Assisted Laparoscopic Pyeloplasty vs Conventional Laparoscopy.

Pyeloplasty is considered the gold standard for the management of ureteropelvic junction obstruction in cases of flank pain, recurrent stone formation or infection, and deteriorating renal function. Over the last two decades, minimally invasive techniques such as robotic (RALP) and laparoscopic pyeloplasty (LP) have become increasingly popular and have been moderately replacing the open approach. This paper aims to provide a comprehensive up-to-date review on safety, efficacy and outcomes regarding robotic repair of UPJO compared to the conventional laparoscopic procedure. RALP represents a viable and innovative alternative to conventional LP with a comparable success and complication rate both in adult and in paediatric fields. The robotic approach seems to add further technical advantages when compared to conventional LP but sustains a higher costs. Currently, the choice to adopt one of the different minimally invasive approaches depends on the surgeon’s preference or experience, and on institutional availability.

Comparison of the initial operative experience of a single surgeon carrying out robot-assisted laparoscopic pyeloplasty, laparoendoscopic single-site pyeloplasty and conventional laparoscopic pyeloplasty.

Comparison of the initial operative experience of a single surgeon carrying out robot-assisted laparoscopic pyeloplasty, laparoendoscopic single-site pyeloplasty and conventional laparoscopic pyeloplasty.

Evaluation of the clinical value of retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction in infants: A single-center experience involving 22 consecutive patients.

Retroperitoneal laparoscopic pyeloplasty (RLP) is 1 method for treating ureteropelvic junction obstruction (UPJO) in children, but reports are more common in children than in infants younger than 2 years old. The purpose of this study was to evaluate the clinical value of RLP for infants with UPJO.From January 2015 to December 2017, a retrospective analysis of 22 infants aged 2 to 24 (11.95 ± 6.00) months with UPJO who were treated with RLP in our hospital was performed. During the same period, 14 infants who underwent conventional transperitoneal laparoscopic pyeloplasty (TLP) were compared with those who underwent RLP. Postoperative recovery and complications, including bleeding, infection, urinary leakage and anastomotic stenosis, postoperative resumption of oral feeding, postoperative hospitalization time and surgical success rate were evaluated. Drainage and function were assessed with isotope scan at 6 months and later during the yearly follow-up and by intravenous urography (IVU) and mercaptoacetyltriglycine (MAG3) renography.Both groups underwent successful surgery. The operative time in the RLP group was 88 to 205 (120.59 ± 24.59) min, and there was no significant difference compared with the TLP group (P = .767). The estimated intraoperative blood loss was 2 to 10 (3.75 ± 1.59) ml, which was not significantly different between the 2 groups (P = .386). In the RLP group, the mean postoperative resumption of oral feeding was faster than that in the TLP group (3.55 ± 0.74 vs 5.50 ± 0.85 hour, P < .001), and the postoperative hospitalization time was shorter in the TLP group than in the RLP group (6.59 ± 0.50 vs 7.07 ± 0.47 day, P = .007 < .05). Follow-up lasted from 6 months to 3 years, and there was a significant reduction in postoperative hydronephrosis in both groups (P < .05, respectively).RLP is a safe procedure for infants. This procedure is associated with relatively little trauma, a quick recovery and good cosmetic effects. RLP also has the advantages of relatively little interference with the abdominal cavity and sufficient operating space; thus, this technique is worth promoting.

Secondary Management for Recurrent Ureteropelvic Junction Obstruction after Pyeloplasty: A Comparison of Re-Do Robot-Assisted Laparoscopic Pyeloplasty and Conventional Laparoscopic Pyeloplasty

Objective: To describe and analyze our experience with secondary robot-assisted laparoscopic pyeloplasty (RALP) and conventional laparoscopic pyeloplasty (LP) in treating recurrent ureteropelvic junction obstruction (UPJO) after primary pyeloplasty. Methods: Patients who underwent secondary RALP or LP for recurrent UPJO were retrospectively analyzed. Baseline characteristics, detailed history of previous pyeloplasty, operative profile and follow-up data were collected and analyzed. Results: Among 29 patients presented with recurrent UPJO, 15 patients underwent secondary RALP. Both groups (RALP or LP) were comparable in baseline characteristics and detailed history of previous pyeloplasty. The mean operative time, suturing time, and hospitalization time of patients in RALP group were significantly less than those in LP group. The mean operative time of RALP group was 2.1 h, while the mean operative time of LP group was 3.23 h. The average suturing time of LP (62.43 min) is about 3 times that of RALP (21.47 min). The overall mean follow-up data was 23 months. The success rate of the RALP group and LP group was 87.7 and 85.7% respectively. Conclusion: Compared to LP, RALP may be a better choice for the treatment of recurrent UPJO. Further high-quality clinical studies are needed to confirm the superior nature of RALP.

Extracorporeal ureter handling during laparoscopic pyeloplasty: tips and tricks for beginners.

IntroductionLaparoscopic preparation of the ureter is a challenging part of upper urinary tract reconstruction, due to limited depth perception provided by the camera and lack of wristed motion of most laparoscopic instruments needed for adequate spatulation and scar tissue removal. One solution has been to perform the more difficult portions of the surgery in an extracorporeal manner. A hybrid intracorporeal-extracorporeal approach to upper tract ureteral reconstruction facilitates ureteral preparation at the stage of mastering the technique.Material and methodsThis retrospective study included 100 patients with primary ureteropelvic junction obstruction, who underwent laparoscopic pyeloplasty from 2014 to 2017. The patients were stratified into 2 groups: those who underwent conventional laparoscopic surgery and those who were managed with the hybrid approach. For the hybrid approach, externalizing the ureter to skin level required additional mobilization of the upper urinary tract.ResultsA total of 47 patients underwent conventional laparoscopic pyeloplasty and 53 – hybrid surgery. The maximum body mass index was 32. The hybrid approach was 8.5 minutes shorter compared to the conventional approach (p <0.001). No complications higher than Clavien-Dindo IIIb (n = 2) were observed (in both groups). Complete success (the resolution of pain and/or hydronephrosis) was observed in 92.5% in the hybrid group and in 95.7% in the conventional treatment group.ConclusionsHybrid pyeloplasty may be considered safe and effective. It has the advantage of making the surgery less challenging and time-consuming while offering improved precision. The advantages of the technique are particularly apparent during training. This technique can be recommended in the learning process of the surgeon.

Comparison of Laparoscopic Approaches for Dismembered Pyeloplasty in Children With Ureteropelvic Junction Obstruction: Critical Analysis of 11-Year Experiences in a Single Surgeon

The choice of different laparoscopic approaches of laparoscopic pyeloplasty (LP) in children remains controversial. We present a comparison of different approaches of LP in children and a critical analysis of 11-year experiences in a single surgeon. There were 1750 patients (1889 sides) who underwent LP between 2003 and 2014 reviewed. The diagnosis and outcomes of ureteropelvic junction obstruction (UPJO) were reviewed based on clinical and imaging data. Retroperitoneal laparoscopic pyeloplasty (RPLP) were performed in 451 cases (RPLP group), conventional transperitoneal laparoscopic pyeloplasty (CTLP) were performed in 311 cases (CTLP group), transumbilical single-site laparoscopic pyeloplasty (TSLP) were performed in 322 cases (TSLP group), and transumbilical multiport laparoscopic pyeloplasty (TMLP) were performed in 805 cases (TMLP group). We assessed preoperative clinical data and outcomes, and analyzed the transition experience. Data are expressed as medians for continuous variables. The start of oral feeding, hospital stay, and the operative time of RPLP group were 1.10 ± 0.10 days, 5.22 ± 1.32 days, and 138.2 ± 20.1 minutes, respectively. Compared with the other 3 groups, the start of oral feeding was the soonest, hospital stay was the shortest, and the operative time was the longest in the RPLP group (P < .01 or .05). The cosmetic result of the TMLP group was 7.07 ± 1.20 scores, and there are significant differences in cosmetic results between the TMLP group and the other 3 groups (P < .05). Although the 4 laparoscopic approaches for LP in children with UPJO are safe and efficient procedures with equivalent success rates, we recommend RPLP or TMLP as a treatment option for children with UPJO.

Laparoendoscopic single site surgery versus conventional laparoscopy for transperitoneal pyeloplasty: A systematic review and meta-analysis.

We aimed to review studies comparing the outcomes of the laparoendoscopic single site (LESS) pyeloplasty with those of conventional laparoscopic pyeloplasty (CLP). A systematic review of the literature was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria. The methodological quality of the studies was rated according validated scales. The level of evidence (LE) was reported as described by the Oxford criteria. Preoperative demographic parameters and perioperative outcomes between the two surgical techniques were assessed. A meta-analysis of the included studies was performed. A total of 5 studies were elected for the analysis, including 164 cases, 70 (42.6%) of them being LESS and 94 (57.4%) being CLP. Four studies were observational retrospective comparative studies (LE: 3a-4); one was a prospective randomized controlled trial (LE: 2b). There was no significant difference in age, body mass index, gender, side and presence of the crossing vessel, between the groups. There was no significant difference regarding the operative time (weight mean difference [WMD]: −7.02; 95% confidence interval [CI]: −71.82–57.79; P = 0.83) and length of hospital stay (WMD: 0.04; 95% CI: −0.11–0.20; P = 0.58), whereas the estimated blood loss was statistically lower for LESS (WMD: −16.83; 95% CI: −31.79–−1.87; P = 0.03). The postoperative use of analgesic favored the LESS group but without reaching statistical significance (WMD: −7.52; 95% CI: −17.56–2.53; P = 0.14). In conclusion, LESS pyeloplasty offers comparable surgical and functional outcomes to CLP while providing the potential advantages of less blood loss and lower analgesic requirement. Thus, despite being more technically challenging, LESS pyeloplasty can be regarded as a minimally invasive approach for patients seeking fewer incisional scars.

Meta-analysis of robot-assisted vs conventional laparoscopic and open pyeloplasty in children.

To critically analyse outcomes for robot-assisted pyeloplasty(RAP) vs conventional laparoscopic pyeloplasty (LP) or open pyeloplasty (OP) by systematic review and meta-analysis of published data. Studies published up to December 2013 were identified from multiple literature databases. Only comparative studies investigating RAP vs LP or OP in children were included.Meta-analysis was performed using random-effects modelling.Heterogeneity, subgroup analysis, and quality scoring were assessed. Effect sizes were estimated by pooled odds ratios and weighted mean differences. Primary outcomes investigated were operative success, re-operation, conversions,postoperative complications, and urinary leakage. Secondary outcome measures were estimated blood loss (EBL), length of hospital stay (LOS), operating time (OT), analgesia requirement, and cost. In all, 12 observational studies met inclusion criteria, reporting outcomes of 384 RAP, 131 LP, and 164 OP procedures. No randomised controlled trials were identified. Pooled analyses determined no significant differences between RAP and LP or OP for all primary outcomes. Significant differences in favour of RAP were found for LOS (vs LP and OP). Borderline significant differences in favour of RAP were found for EBL(vs OP). OT was significantly longer for RAP vs OP. Limited evidence indicates lower opiate analgesia requirement for RAP(vs LP and OP), higher total costs for RAP vs OP, and comparable costs for RAP vs LP. Existing evidence shows largely comparable outcomes amongst surgical techniques available to treat pelvi-ureteric junction obstruction in children. RAP may offer shortened LOS, lower analgesia requirement (vs LP and OP), and lower EBL (vs OP); but compared with OP, these gains are at the expense of higher cost and longer OT. Higher quality evidence from prospective observational studies and clinical trials is required, as well as further cost-effectiveness analyses. Not all perceived benefits of RAP are easily amenable to quantitative assessment.

Laparoendoscopic single‐site versus conventional laparoscopic pyeloplasty: A matched pair analysis

To compare the outcomes of laparoendoscopic single-site pyeloplasty versus those of conventional laparoscopic pyeloplasty. A total of 26 laparoendoscopic single-site pyeloplasty cases carried out in University Hospital: Kyoto Prefectural University of Medicine, Kyoto, Japan, from 2008 to 2013 were compared with a control group of 26 age-matched laparoscopic pyeloplasty cases carried out during the same study period. The mean age of the patients was 20.4 years (range 1-56 years). Laparoendoscopic single-site pyeloplasty was carried out on the right in nine cases and on the left in 17 cases. The operative time was 246 ± 68 min. Regarding the 14 pediatric patients, the mean age was 7.1 years (range 1-14 years). The operative time was 243 ± 49 min. As for the 12 adult patients, the mean age was 35.8 years (range 16-56 years). The operative time was 248 ± 86 min. The mean operative time of the control group in age-matched laparoscopic pyeloplasty was 239 ± 51 min. Times were 229 ± 54 min for the pediatric patients and 253 ± 45 min for the adult patients. There was no significant difference in the operative time between the control group and the laparoendoscopic single-site group for both adults and children. Blood loss was minimal, and no intraoperative and postoperative complications were observed in the 26 laparoendoscopic single-site pyeloplasty cases. The present findings suggest that laparoendoscopic single-site pyeloplasty can be used in both pediatric and adult patients, offering a superior cosmetic outcome than conventional laparoscopic pyeloplasty, and a lower degree of postoperative pain. A large-scale prospective, randomized study is required to confirm these findings, and to define the future role of laparoendoscopic single-site pyeloplasty.

IJU this issue

This issue deals with a wide range of clinical topics of urology, and contains one Review Article, 12 Original Articles, one Case Report and two Letters to the Editor. Urinary incontinence after radical prostatectomy is a big problem for patients with prostate cancer, and many urologists try to improve postoperative continent rates. Although recent systemic reviews and meta-analyses have shown that robot-assisted radical prostatectomy (RALP) has higher postoperative continence rates than retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP), urinary incontinence has remained one of the most bothersome postoperative complications, even after RARP. The Review Article by Kojima et al. (Fukushima, Japan) showed that the basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. They precisely reported three processes that consisted of preservation, reconstruction and reinforcement, helping us to modify our technique during RALP. Another topic regarding prostate cancer in this issue is pelvic lymph node dissection for prostate cancer. Mitsuzuka et al. (Sendai, Japan) investigated the role of pelvic lymph node dissection for low-risk prostate cancer using their medical records for 1268 patients undergoing open radical prostatectomy. Their conclusion is that pelvic lymph node dissection can be spared at radical prostatectomy for low-risk disease because of its poor diagnostic and therapeutic value, which is useful information when we carry out radical prostatectomy. Open versus laparoscopic, and partial versus radical nephrectomy (RN) for T1a renal cell carcinoma (RCC) are important topics, because the use of partial nephrectomy (PN) remains low in the community setting despite its established benefits. Bianchi et al. (Milan, Italy) examined the trends of open and laparoscopic PN and RN according to sociodemographic and tumor characteristics, using the USA Surveillance, Epidemiology, and End Results Medicare-linked database. They showed that older and female patients are less likely to undergo nephron-sparing surgery, and are more likely to have a radical nephrectomy by the laparoscopic approach instead, although utilization rates of PN are increasing. Further encouragement is required to increase PN for T1a RCC. Another topic regarding RCC in this issue is RCC extending into the inferior vena cava (IVC). Kondo et al. (Tokyo, Japan) investigated the impact of histological subtypes on the survival of patients presenting with RCC extending into the IVC, using their 68 cases who underwent RN and IVC thrombectomy. Their conclusion is that patients with RCC extending into the IVC with a papillary subtype show a considerably shorter survival compared with those with a clear cell subtype, which is helpful when we decide operative indications for patients with RCC extending into the IVC. Laparoendoscopic single site (LESS) surgery is a technical modification of conventional laparoscopy whereby the entire surgical procedure is carried out through a single abdominal wall incision. Tugcu et al. (Istanbul, Turkey) performed a prospective randomized study of LESS versus conventional transperitoneal laparoscopic pyeloplasty. A total of 39 patients were enrolled in their prospective study, and LESS pyeloplasty could offer faster recovery and higher patient satisfaction than conventional laparoscopic pyeloplasty. However, median operative time was longer in the LESS pyeloplasty group compared with the conventional laparoscopic group. Recently, a reduced port surgery using thin forceps, but not LESS, is increasing with technical advancements. In this sense, a comparison of reduced port pyeloplasty using thin forceps with LESS pyeloplasty would be interesting for evaluating the most minimally-invasive pyeloplasty. None declared.

Laparoscopic Dismembered Pyeloplasty Through Transmesocolic Approach: Point of Technique and Our Experience

Inroduction: Laparoscopic dismembered pyeloplasty is considered as the gold standard for the management of pelviureteric junction obstruction. Conventional laparoscopic pyeloplasty through a transperitoneal approach mandates colonic mobilization for access to the pathological segment. In selected individuals (with minimal mesenteric fat), a transmesocolic approach may be attempted and colonic handling can be avoided. The transmesocolic approach offers several advantages. Colonic mobilization may be attended with a prolonged procedural duration, increased blood loss, possibility of iatrogenic insults, and delayed recovery.1,2 With the transmesocolic approach, these problems can be reduced. We present a video demonstration of laparoscopic transmesocolic pyeloplasty. Port positions are depicted in the illustration. After achieving the pneumoperitoneum, the left renal pelvis and upper ureter were clearly visible through the mesocolon in this patient. This motivated us to embark on the transmesocolic approach. A transmesocolic window was created with selective generation of electrocautery. The ureter was dissected and traced upto the pelviureteric confluence. Periureteric and peripelvic adhesiolysis was performed using cold scissors, refraining from overvigorus usage of electrocautery. After delineation of the pathological segment, dismemberment was undertaken and pyelotomy was conducted. Ureter was adequately spatulated posterolaterally to ensure a wide anastomosis. Tension-free pelviureteric approxamibility was ascertained. Pelviuretreic approximation was undertaken using 4-0 polyglactin. The corner stitch was taken incorporating the apex of the spatulated ureter and the most dependent part of the pelvis. The opposite corner was approximated next followed by completion of the anterior layer of closure. The suture line was then upturned and attention directed to the posterior layer of pelviureteric approximation. A stent was inserted in an antegrade fashion. The redundant pelvis was excised and the posterior layer closure was completed by approximating the edges of the remaining pelvis. Hemostasis was achieved and a drain was inserted. The mesocolic window was closed. Materials and Methods: A 3-year-old male child was diagnosed with left pelviureteric junction obstruction after detailed evaluation. Retrograde dye delineation confirmed short segment left pelviureteric narrowing. Laparoscopic dismembered pyeloplasty through the transperitoneal route was contemplated. Operative and postoperative details were recorded. Patient was followed up at regular intervals. We analyzed the perioperative and long-term functional outcome of all patients who underwent transmesocolic pyeloplasty at our center. Results and Conclusion: Totally 41 patients underwent transmesocolic dismembered pyeloplasty at our institution. Thirty patients were of the pediatric age group and remaining were adults. The mean stricture length was 1.2 cm and a crossing vessel was present in seven patients. The mean duration of surgery was 70 minutes, mean blood loss was 100 mL. The mean time to start orals was 12 hours, mean duration of hospital stay was 36 hours, mean duration of follow up was 45 months. The success rate was 97.5%. Transmesocolic dismembered pyeloplasty is a safe and feasible procedure with less morbidity and satisfactory functional outcome. However, the transmesocolic approach may be practiced in individuals with short segment pelviureteric narrowing as the mesocolic window does not allow wide mobilization of the pelvis and upper ureter. Additionally, this approach is applicable in individuals with minimal mesocolic fat, which is typically encountered in children or thin individuals. No competing financial interests exist. Runtime of video: 4 mins 55 secs

Robot-Assisted Transumbilical Laparoendoscopic Single-Site Pyeloplasty: Technique and Perioperative Outcomes from a Single Institution

Transumbilical laparoendoscopic single-site (U-LESS) pyeloplasty may provide improved cosmesis compared with conventional laparoscopic pyeloplasty. However, U-LESS pyeloplasty can be challenging because of the need for extensive suturing. The wristed instrumentation of robot-assisted laparoendoscopic single-site (R-LESS) pyeloplasty provides improved dexterity to facilitate intracorporeal suturing. We therefore present our technique and experience with R-LESS pyeloplasty for ureteropelvic junction obstruction (UPJO). The da Vinci(®) S or Si Surgical System (Intuitive Surgical, Sunnyvale, CA) was used in all cases. Ureteral stents were placed cystoscopically at the start of each case. A 3-cm skin incision was made adjacent to the umbilicus. Three ports (12 mm, 8 mm, and 5 mm) were placed either through separate fascial incisions or into a GelPort(®) (Applied Medical, Rancho Santa Margarita, CA). Key techniques included port staggering, a "chopstick" arrangement of the instruments, and use of a 30° lens in an upward configuration. Traditional dismembered pyeloplasty procedures were performed in all cases. Patients less than 45 years of age with no prior abdominal surgery were offered this approach. Eight patients (4 female; 5 right-sided; median age, 22 years) underwent R-LESS pyeloplasty without the need for additional ports. All patients were discharged by the third postoperative day, and 5 were discharged on Day 1. One patient experienced urine leakage, which was managed with a temporary nephrostomy tube. Length of follow-up ranged from 29 to 46 months. No patients have developed symptoms or radiographic evidence of recurrent UPJO. R-LESS pyeloplasty can be safely performed for selected patients with currently available robotic equipment. Careful patient selection and case setup are key to successfully performing these procedures.

Laparoendoscopic Single-site Pyeloplasty: Outcomes of an International Multi-institutional Study of 140 Patients

To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes. LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed. The study included 140 adult patients (age 39.9 ± 15.7 years; body mass index 24.8 ± 4.2 kg/m(2); 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 ± 47 minutes with an estimated blood loss of 61.2 ± 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 ± 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 ± 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan. This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction.

V905 NEEDLESCOPIC-ASSISTED LAPAROENDOSCOPIC SINGLE-SITE PYELOPLASTY: TECHNIQUE AND OUTCOME

You have accessJournal of UrologyAdrenal and Reconstruction Teaching Techniques1 Apr 2013V905 NEEDLESCOPIC-ASSISTED LAPAROENDOSCOPIC SINGLE-SITE PYELOPLASTY: TECHNIQUE AND OUTCOME Panagiotis Kallidonis, Ioannis Georgiopoulos, Iason Kyriazis, Minh Do, Jens-Uwe Stolzenburg, and Evangelos Liatsikos Panagiotis KallidonisPanagiotis Kallidonis Patras, Greece More articles by this author , Ioannis GeorgiopoulosIoannis Georgiopoulos Patras, Greece More articles by this author , Iason KyriazisIason Kyriazis Patras, Greece More articles by this author , Minh DoMinh Do Leipzig, Germany More articles by this author , Jens-Uwe StolzenburgJens-Uwe Stolzenburg Leipzig, Germany More articles by this author , and Evangelos LiatsikosEvangelos Liatsikos Patras, Greece More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.480AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To present the technique and outcome of needlescopic-assisted Laparoendoscopic single-site surgery pyeloplasty (LESS-P). METHODS A total number of 18 patients underwent LESS-P. For the performance of the procedure, a multi-port was inserted in the umbilicus and two needlescopic instruments (3mm) were inserted under the costal margin on the mid-clavicular line and on the mid-axillary line at the level of the umbilicus. The steps of the procedure were similar to conventional laparoscopic pyeloplasty. The needlescopic instruments were used for the performance of all steps of the procedure. The multi-port was useful for inserting instruments larger than 3mm and additional instruments of larger than 3mm diameter. Peri-operative data were prospectively collected. RESULTS Peri-operative data of the patients that underwent LESS-P is summarized in Table 1. All surgical tasks were performed without significant ergonomic issues due to the triangulation of 3mm instruments. The smaller size of needlescopic instruments required more accuracy for their manipulation. The use of small suturing needle (5-0 Vicryl) for the anastomosis was possible. The andominal scars by the insertion of the needlescopic instruments were practically invisible. CONCLUSIONS LESS pyeloplasty was efficiently performed when needlescopic instruments are routinely used and shows a different perspective for “scarless” surgery. Table 1. Peri-operative and follow-up data of pyeloplasty patients. Patients/Male/Female 18/11/7 Mean age (range) years 31.4 (19-49) Mean BMI (range) kg/m2 25.1 (20.2-31.6) 6 overweight/ 1 obese Flank pain/UTI 17/7 Mean operative time (range) min 147.9 (120-180) Blood loss (ml) 202.1 (100-300) Transfusion/Conversion 0/0 Mean hospitalization (range) days 2.66 (2-4) Symptom recurrence/management 1 patient/ cold knife antegrade endopyelotomy Recurrence in renogram 1 patient/cold knife antegrade endopyelotomy Complications Complication/patient number Clavien grading/Management Fever >38°C/1 patient Grade II/Antibiotics Anastomotic leakage/1 patient Grade III/Nephrostomy placement © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e373 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Panagiotis Kallidonis Patras, Greece More articles by this author Ioannis Georgiopoulos Patras, Greece More articles by this author Iason Kyriazis Patras, Greece More articles by this author Minh Do Leipzig, Germany More articles by this author Jens-Uwe Stolzenburg Leipzig, Germany More articles by this author Evangelos Liatsikos Patras, Greece More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Renal Function After Laparoendoscopic Single Site Pyeloplasty

Outcomes after laparoendoscopic single site pyeloplasty are limited to small cohort studies with short-term followup. We evaluated the clinical and renal function outcomes of what to our knowledge is the largest laparoendoscopic single site pyeloplasty cohort to date with a mean followup of 12 months. Consecutive patients diagnosed with symptomatic ureteropelvic junction obstruction who underwent robotic or conventional laparoendoscopic single site pyeloplasty were entered into the study. Patient demographics, and preoperative and postoperative renal function outcomes were recorded. Diuretic renogram was performed after stent removal, at 6 months and yearly thereafter. The cohort included 31 conventional and 22 robotic laparoendoscopic single site pyeloplasties. Four laparoendoscopic single site surgeries (7.8%) were converted to another procedure due to failure to progress. Mean ± SD followup was 12.1 ± 10.7 months and 22 patients had at least 12 months of followup. No intraoperative complications occurred. Complications developed postoperatively in 11 patients (21%), of which 9 were Clavien grade 3 or greater. Preoperative symptoms resolved in 49 of 51 cases (96%). Severe obstruction (half-time greater than 20 minutes) was seen in 32 of 44 patients (73%) at presentation and obstruction resolved (half-time 20 minutes or less) in 41 (93%). Mean preoperative and postoperative half-time was 24.6 ± 13.4 and 8.3 ± 4.1 minutes, respectively, for an improvement of 16.3 ± 12.3 minutes (p <0.01). Laparoendoscopic single site pyeloplasty is safe and efficacious. The laparoscopic and robotic techniques provide excellent outcomes in terms of symptomatic relief and radiographic resolution of obstruction.

Laparoendoscopic single‐site versus conventional transperitoneal laparoscopic pyeloplasty: A prospective randomized study

To evaluate the potential benefits of laparoendoscopic single-site pyeloplasty over conventional laparoscopic pyeloplasty. Between October 2009 and January 2012, 39 patients were enrolled in a prospective study and randomized to undergo a laparoendoscopic single-site pyeloplasty (n = 19) or conventional laparoscopic pyeloplasty (n = 20). The outcomes in the two groups were compared by using Mann-Whitney U-test and χ(2) -test, and considering a P-value less than 0.05 as statistically significant. There was no difference in blood loss (55.67 ± 6.71 vs 45.84 ± 5.22 mL, P = 0.60), transfusion rates (0% for both) and hospitalization time (2.12 ± 0.23 vs 2.06 ± 0.34 days, P = 0.72) between the laparoendoscopic single-site pyeloplasty and conventional laparoscopic pyeloplasty groups. The time to return to normal activities was shorter (8.65 ± 1.25 vs 11.53 ± 1.28 days, P = 0.01), and median operative time (195.21 ± 12.15 vs 145.62 ± 15.34 min, P = 0.001) was longer in the laparoendoscopic single-site pyeloplasty group compared with the conventional laparoscopic pyeloplasty group. No significant intraoperative or postoperative complications occurred in either group. Compared with conventional laparoscopic pyeloplasty, laparoendoscopic single-site pyeloplasty yielded better cosmetic results and patient satisfaction. The mean follow-up period was 19.7 months (4-28 months). The success rate was 95% in both the groups. Both the visual analog scale and the postoperative use of analgesics were significantly lower in patients who underwent laparoendoscopic single-site pyeloplasty. Our findings suggest that laparoendoscopic single-site pyeloplasty can offer faster recovery and higher patient satisfaction than conventional laparoscopic pyeloplasty. Thus, this novel technique promises to become the treatment of choice in minimally-invasive management of ureteropelvic junction obstruction.

Robotic versus conventional laparoscopic pyeloplasty: A single surgeon concurrent cohort review

Introduction:The increasing availability of robotic devices has led to an increase in their use for procedures such as pyeloplasty, which have been conventionally performed laparoscopically or through open surgery. We perform both laparoscopic and robotic-assisted pyeloplasty routinely and have compared these techniques in a set of concurrent cohorts, operated by the same surgeon.Materials and Methods:A chart review was performed of all cases of Robot-assisted laparoscopic pyeloplasty (RALP) and conventional laparoscopic pyeloplasty (CLP) performed by a single surgeon, from September 2006 to July 2010. The choice of procedure depended upon the availability of the robot on the given day. A lateral transperitoneal approach was used in all cases. All anastomoses were stented antegrade. A diuretic renogram was obtained in all patients between six to twelve weeks after stent removal. Success was defined as a resolution of symptoms with non-obstructive outflow on the renogram.Results:Thirty patients underwent 31 laparoscopic pyeloplasties (20 RALPs and 11 CLPs), with one patient undergoing bilateral simultaneous robotic procedures. The robotic procedures were superior in terms of shorter operating time by 20 minutes on an average. Furthermore, 35% of the robotic procedures were performed in under 90 minutes, while the minimum time taken for laparoscopy was 110 minutes. All procedures in both cohorts were successful with no complications in either group. The surgeon recorded subjective ergonomic benefits with the use of the robot.Conclusions:Robotic assistance helps decrease the operative time for laparoscopic pyeloplasty. It seems ergonomically superior for the surgeon, allowing multiple procedures in the same list. These may be important benefits in busy centers.

Robotic-Assisted Pyeloplasty:Recent Developments in Efficacy, Outcomes, and New Techniques

Within the last decade, the adaptation of robotic urologic surgery has had a profound impact on surgical practice, with robotic upper tract reconstruction for ureteropelvic junction obstruction gaining rapid acceptance. Recent advances in robotic reconstruction demonstrate efficacious outcomes of robotic pyeloplasty, as compared with conventional laparoscopic pyeloplasty, even in the case of secondary surgery. Furthermore, efforts to continue to reduce the morbidity of laparoscopic surgery have led to the development and implementation of laparoendoscopic single-site (LESS) surgery. The recent applications of the da Vinci robotic surgical platform to LESS pyeloplasty (R-LESS) has demonstrated the potential to further decrease morbidity, improve surgeon ergonomics, and improve cosmesis.