| BackgroundHydronephrosis is a common urinary tract disease, which mostly due to obstruction or stenosis of urinary tract. Hydronephrosis can lead to kidney damage finally if left untreated. The ureteropelvic junction obstruction (UPJO) is characterized by impaired flow of urine from the renal pelvis to the ureter owing to blockage. UPJO is a common obstructive disease leading to hydronephrosis. There are multiple possible causes, which can be categorized as congenital versus acquired.Congenital UPJO affects approximately 1:1000-2000 live births, with a male to female ratio of 1:1 and can be detected at any time, ranging from in utero (prenatal ultrasonography) to old age. Two-thirds of congenital cases affect the left kidney, with 10-46% occurring bilaterally.The overall incidence of UPJO is 1 in 1500; adults are more likely to present with UPJO secondary to acquired causes, such as kidney stones or previous surgery history and so on.Ureteropelvic junction obstruction can be divided into two categories:(1) The mechanical obstruction may be due to external vagus vascular compression, fibrous cord membranous adhesion, high ureter outlet, but also because of the internal ureter wall stenosis, ureter valve or ureter wall wrinkles. (2) The dynamic obstruction is not due to lumen compressed or stenosis, but because of the expansion of renal pelvis and the abnormal connection between the muscle cells in ureteropelvic junction.In the course of treatment UPJO, timely and effective treatment is ritical, including early detection of suspicious symptoms or signs, definitive diagnosis and take reasonable treatment actively to save renal function maxmally.The UPJO is characterized by impaired flow of urine from the renal pelvis to the ureter owing to blockage, causing hydronephrosis and renal pelvis dilation. If left untreated, it may eventually lead to varying degrees of renal impairment. Most patients present with symptoms of abdominal or back pain or recurrent UTI; signs include persistent loin pain, renal calculi, pyelonephritis, impaired renal function, haematuria and, rarely, hypertension. UPJO is chiefly diagnosed on radiological imaging, with blood tests to assess renal impairment of the affected and contralateral kidneys and pyelonephritis. Ultrasonography can be used to evaluate hydronephrosis, the presence of renal calculi and the exact location of the obstruction. Some researchers consider that Contrast-enhanced CT of the abdomen and pelvis is the investigation of choice for diagnosis of UPJO because it has a sensitivity of 97% and specificity of 92% for renal pathology.High-resolution imaging modalities, such as CT and MRI, provide detailed anatomical information about the obstruction (including location, orientation and presence of aberrant vessels), and can identify possible underlying causes, such as calculi or urothelial tumours, both of which can provide helpful information to aid treatment decision-making. Dilatation of the collecting system on CT does not always equate to functional obstruction and, therefore, a nuclear medicine scan with an added diuretic phase is mandatory to determine the significance of renal pelvic dilatation.Diuretic renography is the most effective investigation for quantifying the degree of obstruction and assessment of renal function. Although CT provides detailed images of the urological tract anatomy and pathology of the lesion, diuretic renography also evaluates renal plasma clearance. MAG3 as a radiolabelled pharmaceutical agent used in diuretic renography is considered safer than DTPA. MAG3 used in patients with renal impairment and can be used as a sole marker in measuring renal function. Thus, 99mTc-MAG3 is the preferred pharmacological agent for diuretic renography in patients with suspected UPJO.Currently UPJO are mainly treated by surgery, especially for patients with renal impairment. Seeking the best surgical approach has troubled urologists for about a hundred years. The most widely used surgical method is open surgy of dismembered pyeloplasty or Anderson-Hynes pyeloplasty. Open dismembered pyeloplasty is considered the gold standard in the treatment of UPJO. It was first proposed by Andersen and Hynes. This kind of surgy can resec the lesion segment of PUJ, thus narrowing the renal pelvis, so the surgery is relatively simple, and its long-term operation success rate is over 95%. However, the surgery is required to make ipsilateral rib flank incision about 20cm long, with a larger and more complications of trauma and other shortcomings. After nearly twenty years of development, has appeared several minimally invasive surgical methods in treating UP JO, such as renal pelvic incision, incision inside the balloon, balloon dilatation, laparoscopic pyeloplasty.Laparoscopic pyeloplasty as a minimally invasive surgical method is firstly proposed by Schuessler in 1993. In the early stage of application, the surgical procedure lasted seven hours. The main reason may due to difficult laparoscopic pelvis anastomosis, poor laparoscopic image and lack of laparoscopic surgery experience. In 2000, Jarrett and Kavoussi summarized the experience of laparoscopic pyeloplasty with a total of 100 cases among 10 years, by comparing with open pyeloplasty in the same period. The authors believed that both laparoscopic and open surgical methods are quite similar in recent or long-term efficacy, but the trauma and postoperative disease is significantly reduced in laparoscopic group.Over the past decade, laparoscopic pyeloplasty has become a practical and reliable method of treatment. The advances in laparoscopic techniques and surgical equipment brings convenience for complex reconstructive surgery and other surgical. Laparoscopic pyeloplasty is currently gaining popularity, some scholars also believe that the procedure has less trauma, quicker recovery, similar success rate to open surgery and so on. Patients with laparoscopic surgery less postoperative morbidity, better efficacy of pyeloplasty, less postoperative pain, and shorter recovery time. It is worth mentioning that laparoscopic dismembered pyeloplasty has gradually begun to replace open surgery of dismembered pyeloplasty due to its flexibility and reliability features.Kaouk and other scholars believe that laparoscopic pyeloplasty can already be as a mature UP JO surgery. By comparing laparoscopic and open pyeloplasty, Klingler etc. believed that laparoscopic dismembered pyeloplasty better than non-dismembered of pyeloplasty. They found that the surgery effect of laparoscopic surgery consistent with open surgery and laparoscopic pyeloplasty in the future would replace the open pyeloplasty known as the gold standard for the treatment of UP JO. For complex UP JO such as horseshoe kidney, renal malrotation, pelvic ectopic kidney, abdominal surgery history or combined with kidney stones, still can adopt laparoscopic surgery. It should be noted that, due to laparoscopic pyeloplasty known as reconstructive surgery, the greater difficulty of operation requires the surgeon having a certain laparoscopic experience. At present, the number of carring laparoscopic pyeloplasty surgery cases gradually increased. Some reports have also considered the advantages were less surgical trauma, quicker recovery, and similar surgical success rates with open surgery.Laparoscopic pyeloplasty surgical approaches including abdominal and retroperitoneal approach, are similar to laparoscopic nephrectomy. Some scholars believe that retroperitoneal approach is less invasive than transabdominal approach. Comparing retroperitoneal approach with abdominal approach, the former is more direct, less impact on the abdominal organs and can take advantage of the experience of previous open surgery. The retroperitoneal approach is gradually being adopted by urologists. The success rate and long-term effect is similar to open surgery.To furtherly compare the clinical effects of dismembered pyeloplasty surgery in laparoscopic retroperitoneal with open approach, we have carried out relevant clinical research.ObjectivesTo explore the effect of laparoscopic dismembered pyeloplasty, we compared the difference between retroperitoneal laparoscopic and open pyeloplasty in the surgery effects, advantages, disadvantages and complications.MethodsThe subjects of this study were enrolled between January 1,2006 to December 31,2014 in Shenzhen Longhua New District Central Hospital. The subjects were all diagnosed as UP JO and accept surgically treatment. They were randomly divided into two groups as retroperitoneal laparoscopic and open groups. Retroperitoneal laparoscopic group included 113 cases and open group included 59 cases. Details on the grouping as follows:(1) retroperitoneal laparoscopic group:a total of 113 cases including 71 male cases and 42 female cases; mean age 35.0±8.6 years; 69 cases on the left side, 44 cases on the right side; 40 cases of hydronephrosis with 1-2 grade,73 cases of 3-4 grade; 47 cases with crossing blood vessels near the UPJ. (2) open group:a total of 59 cases, including 42 males and 17 females; mean age 34.6±8.3 years; 33 cases on the left side,26 cases on the right side; 22 cases of hydronephrosis with 1-2 grade,37 cases of 3-4 grade; 25 cases with crossing blood vessels near the UPJ.Classification of hydronephrosis in grade 1-4. Hydronephrosis grade 1: dilatation of the renal pelvis without dilatation of the calices. Prominent reflex of the renal sinus without signs of parenchymal atrophy. Hydronephrosis grade2:dilatation of the renal pelvis and calices. Attenuated sinus reflex. No signs of parenchymal atrophy. Hydronephrosis grade3:missing or marginal sinus reflex. Minor signs of organ atrophy present (flat papillae and blunt fornices). Hydronephrosis grade 4: massive dilatation of the renal pelvis and calices. Borders between renal pelvis and calyces are missing. Significant signs of renal atrophy (thin parenchyma).Inclusion criteria:(1) the progressive symptoms hydronephrosis; (2) diuretic renography confirming the existence of urinary tract obstruction or impaired renal function; (3) recurrent urinary tract infections; (4) back pain caused by UP JO; (5) the presence of UP JO in newly admitted patients to hospital should be confirmed through intravenous urography (IVU).Exclusion criteria:(1) extrarenal pelvis diagnosed according to radiological imaging; (2) the total renal function <20% on suffering side; (3) concurrent acute pyelonephritis on suffering side six weeks before surgery; (4) previous kidney or ureter surgery history on suffering side; (5) coagulopathy; (6) accompanied by other organ disease can not tolerate surgery or anesthesia.Preoperative evaluation included:(1) to understand the detailed history, physical examination and related laboratory examinations; (2) to understand the mental state of the patients, development of the body situation, with or without anemia, dehydration, cyanosis, fever or obesity; (3) assessing vital signs, related test results and the functional status of organs such as heart, lung, kidney, brain, etc; (4) to understand the personal history, previous surgeryh history, blood transfusion history and food or drug allergies, whether or not with other combined diseases.Preoperative routine examination including:(1) accessory test results:routine test of blood, urine and stool, blood biochemical test, coagulation function test, infectious disease of eight items detection, urine bacterial culture+drug susceptibility test; (2) radiological imaging:abdominal plain film (KUB), intravenous urography (IVU) and diuretic renography. If necessary, ureteropelvic retrograde pyelography, kidneys MRU, kidneys CTU and so on to confirm the location and length of the stenosis segment.Preoperative preparation including:(1) skin preparation one day before surgery; (2) fasting after 20:00 in the night before surgery; (3) forbidden to drink after 0:00 in the night before surgery; (4) cleansing enema after 20:00 in the night before surgery, and cleansing enema once again 6:00 on the morning of surgery; (5) prophylactic use of antibiotics in 30 minutes before surgery, with the choice of second-generation cephalosporin antibiotic drugs based. If the operation time was more than 3 hours, antibiotics were added once again.Two groups of patients were using the method of general anesthesia and take contralateral position. The main equipment and supplies used in surgery include:(1) retroperitoneal laparoscopic group:OLYMPUS pneumoperitoneum laparoscopic operation system includes pneumoperitoneum forming system, camera imaging system, power system, flushing and suction system, visual retroperitoneum dilator, ultrasonic scalpel, forceps, separating forceps, grasping forceps, Hem-o-lok ligating clip,6F ureteral stent (double J tube); (2) open surgery group:open operation package, 6F ureteral stent (double J tube).Retroperitoneal laparoscopic group underwent retroperitoneal laparoscopic dismembered pyeloplasty and open group underwent open dismembered pyeloplasty. For more details, see the full text of the specific part of surgical procedures in the full text. All surgery is completed by two designated physicians. The two physicians can do the job as specified laparoscopic and open pyeloplasty surgery, and previously have completed this type of surgery are more than 40 cases, in order to minimize the differences caused by the operation level.Postoperative conventional treatment include:(1) routine use of antibiotics in 3 to 5 days after surery; (2) pulling out the drainage tube if the retroperitoneal tube drainage less than 10 mL in 48 hours; (3) removing ureteral stent (double J) by cystoscopy in 4 to 8 weeks after sufgey. (4) retroperitoneal laparoscopic group incisions after 7-9 days to take out stitches, open operation group incisions after 8-10 days to take out stitches.Treatment of postoperative complications including:(1) infection: can cause anastomotic stoma adhesions or stricture. The presence of preoperative urinary tract infection should be actively treating until the infection controlled and then do plastic surgery. Postoperative management of drainage tube for strict aseptic. (2) poor emptying of UPJ:can caused by poorly designed plastic surger, ureteropelvic anastomosis not built into the lowest level in a funnel-shaped pelvis and premature removal of stent or drainage pipes. In order to ensure the smooth*evacuation ureteropelvic anastomosis, surgery should be removed completely obstructive lesion, resection excessive pelvis. To ensure well emptying of ureteropelvic anastomosis, obstructive lesions should be removed completely with resection of the excessive renal pelvis through surgery. Anastomosis should be built at the lowest level of the funnel-shaped renal pelvis. Anastomotic muscular should be fit neatly and stitched accuratly. No tension existing, anastomosis wide enough; proper separation of ureteropelvic surrounding tissue; conventional anti-infective therapy after surgery. (3) urinary fistula:mainly due to poor anastomotic suture, anastomotic stoma rupture or urinary extravasation with not timely drainage.As long as the drainage unobstructed, urinary fistula would heal under normal circumstances. If the lower ureteral obstruction exists or anastomotic gap is too large, it wounld require the reoperation.Appropriate follow-up was needed after surgery, while during hospitalization, the patient’s general information, clinical data and perioperative surgical information should be recorded. Outpatient follow-up should be make an appointment in the manner of telephone, with informing the patient about the next follow-up time and content. The specific content and follow-up arrangements including:(1) general information:recording the patient’s name, medical record number, sex, age, height, weight, address, telephone number; (2) clinical data:diagnosis, clinical manifestations (symptoms, signs), auxiliary examination (imaging and test results); (3) surgery:the operative time, estimated blood loss, time of cutting and suture, the total length of the incision, time of anal exhaust, postoperative wound drainage tube indwelling time, complications after operation, the amount of postoperative analgesic, postoperative ambulation time, postoperative hospital stay; (4) urinary ultrasonography after three months of operation; follow-up included the improvement of clinical symptoms, removal time of double J tube and IVP; (5) IVU after six months (6) urinary tract ultrasonography each year after the former mentioned; (7) diuretic renography in one year after operation to check the situation of restenosis and renal function.Criteria for evaluating the success rate of surgery including:(1) postoperative hydronephrosis symptoms were relieved or disappeared; (2) the radiological examinations showed improvement in hydronephrosis and unobstructed urinary drainage; (3) improvement of renal function.Observed contents used in this study including:(1) comparison of general information of patients in retroperitoneal laparoscopic and open groups:the number, age (years old), male & female (number), left & right (affected side), the number of patients in different grades of the classification hydronephrosis (grade 1-2,3-4), the number of combined with crossing blood vessels; (2) comparison of postoperative follow-up results in retroperitoneal laparoscopic group and open surgery group:the operative time (min), intraoperative blood loss (mL), postoperative discharge time (day), postoperative analgesic drug dosage (mg), days of postoperative hospitalization (day), incision length (cm), number of complications, the number of wound infection, the number of leakage of urine, follow-up period (month), the number of failing surgery or required secondary surgery, hospital costs (yuan).The data of results were statistically analyzed:(1) the data were expressed as mean ± standard deviation (x ± s); (2) qualitative data were analyzed mainly using Pearson chi-square test and quantitative data using independent samples t test (Independent Samples T Test); (3) application of SPSS 13.0 statistical software for analysis, P<0.05 was considered statistically significant.ResultsComparisons of general information in retroperitoneal laparoscopic group and open surgery group:both groups were successfully completed and no case in retroperitoneal laparoscopic surgery was need to convert to open surgery. Retroperitoneal laparoscopic group and open group were compared in clinical data. Two groups in age (retroperitoneal laparoscopic group:35.0±8.6 years VS. open group:34.6±8.3 years, χ2=0.260, P=0.795), male & female [retroperitoneal laparoscopic group:71 (62.8%) & 42 (37.2%) VS. open group:42 (71.2%) & 17 (28.8%),χ2=1.201, P=0.273], left & right [retroperitoneal laparoscopic group: 69(61.1%) & 44(38.9%) VS. open group:33(55.9%) & 26(44.1%),χ2=0.423, P=0.516], grades of hydronephrosis [retroperitoneal laparoscopic group:40 (35.4%) cases in 1-2 grade,73(64.6%) cases in grade 3-4 VS. open group:22(37.3%) cases in 1-2 grade VS.37 (62.7%) cases in grade 3-4,χ2=0.060, P=0.806]. The number of combined with crossing blood vessels [retroperitoneal laparoscopic group:47 (41.6%) cases VS. open group:25 (42.4%) cases,χ2=0.010, P=0.922] and other aspects were not statistically significant difference.Comparison of perioperative data in retroperitoneal laparoscopic group and open group:(1) retroperitoneal laparoscopic group was compared with the open group in operative time (108.9±28.6 min VS.142.6±13.5 min, t=-10.518, P<0.001), intraoperative blood loss (31.6±9.0 mL VS.123.1±15.0 mL, t=-42.937, P<0.001), postoperative exhaust time (1.2±0.4 day VS.1.9±0.4 day, t=-10.203, P<0.001), postoperative analgesic drug dosage (105.1±30.3 mg VS.150.4±35.2 mg, t=-8.808, P<0.001), the days of hospitalization (6.3±0.4 day VS.9.3±0.5 day, t=-42.834, P<0.001), surgical incision length (3.1±0.3 cm VS.20.7±0.9 cm, t=-148.618, P<0.001) all less than the latter; (2) follow-up time in retroperitoneal laparoscopic group was less than open patients (32.7±6.3 month VS.38.2±10.4 month,, t=-3.764, P<0.001); (3) the cost of hospitalization in retroperitoneal laparoscopic group was significantly higher than the open group (14794.7±1758.9 yuan VS.8717.6±1026.0 yuan, t=28.578, P<0.001); (4) the number of complications has no significant difference [3 (2.7%) VS.2 (3.4%), P=1.000]. The complications include wound infection and leakage of urine. The number of required secondary surgery were [2 (1.8%) VS.1 (1.7%), P= 1.000]; (5) the mean follow-up time in retroperitoneal laparoscopic group and open surgery group was 32.7±6.3 month,38.2±10.4 month respectively. Because retroperitoneal laparoscopic pyeloplasty was carried out mainly in 2008 to 2014, so the average follow-up time in the retroperitoneal laparoscopic group was shorter than the open surgery group(χ2=-3.764, P<0.001); (6) the number of complications and second operation were calculated using Fisher exact test while the age, intraoperative blood loss, postoperative exhaust time, postoperative analgesic drug dosage, the days of hospitalization, surgical incision length, follow-up time, the cost of hospitalization were calculated using t test. Except special statement, others were calculated using the Pearson chi-square test.Comparisons of surgery results in retroperitoneal laparoscopic group and open surgery group:the number of followed up loss in retroperitoneal laparoscopic group and open group has no significantly different [11 (9.7%) VS.9(15.3%),χ2=1.149, P=0.284].The number of surgical failure has no significantly different[2 (2.0%) VS. 1 (2.0%), P=1.000]. Because of the patients with surgical failure required secondary surgery, the comparing results of groups are same to the comparison of number with surgical failure.Conclusions(1) By comparing retroperitoneal laparoscopic pyeloplasty and open pyeloplasty, the success rate of retroperitoneal laparoscopic pyeloplasty is similar to open surgery. The retroperitoneal laparoscopic pyeloplasty is a feasible and effective surgical procedure; (2) compared with open pyeloplasty, retroperitoneal laparoscopic pyeloplasty has the characteristics of less bleeding, faster recovery, fewer complications and alsoits safety deserved recognition; (3) retroperitoneal laparoscopic pyeloplasty may become the new standard of treating UP JO. Especially in furtherly reducing costs of laparoscopic surgery, improved clinician laparoscopic operation level, it is more likely to replace open surgery... |
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