Laparoscopic Pyeloplasty In Secondary Ureteropelvic Junction Obstruction Due To Failed Open Or Laparascopic Surgery

Background and purposeUreteropelvic junction(UPJ) obstruction leads to progressive dilation of the renal collecting system and can result in pain and progressive deterioration of renal function. Historically,open dismembered pyeloplasty has been the gold-standard treatment for primary UPJ obstruction,capable of correcting all forms of obstruction with success rates >90%.Over the past decade,laparoscopic pyeloplasty,as a technique offering the success rate of open surgery through a minimally invasive approach,since reported initially by Schuessler et al.,has become a viable option for the treatment of select patients with primary UPJ obstruction.More and more literature showed that laparoscopic pyeloplasty is moving rapidly toward replacing open surgery as the gold standard in the treatment of UPJ obstruction.Although success rates are high,failures do occur and necessitate additional interventions.However,little has been written on the application of this technique for secondary ureteropelvic junction obstruction due to failed open or laparoscopic pyeloplasty.Prior open or laparoscopic pyeloplasty has been considered a relative contraindication to laparoscopic surgery because of the likelihood of adhesion formation and perinephric scarring,which results in difficulty during surgical dissection.The purpose of this study was to examine the feasibility and morbidity of laparoscopic pyeloplasty in patients with secondary UPJO due to failed open or laparoscopic-pyeloplasty .All the patients were operated by a single skilled urologic surgeon. MethodsBetween September 2004 and May 2008,11 patients with secondary UPJ obstruction due to failed open surgery(9) and laparoscopic pyeloplasty(2) who had undergone laparoscopic pyeloplasty were enrolled in this study(group A).The mean interval from the last surgery to redo laparoscopic pyeloplasty was 26.1 months(ranging from 3 months to 65 months).Laparoscopy was carried out in all cases using a transperitoneal approach.When the trocars were introduced,we mobilized the colon by incising Toldt's lines,the posterior peritoneum was divided.Because there was severe fibrosis and attachments to neighboring structures in some cases,we spent a lot of time releasing the upper ureter and renal pelvis.After the ureter and the kidney were subsequently found,we performed disembersd laparoscopic pyeloplasty and passed a Double-J stent from the renal pelvis to the bladder.At the same period,15 patients were performed primary laparoscopic pyeloplasty(group B).Two groups are similar in age,sex,laterality and degree of hydronephrosis.The mean operation time,blood bleeding,perioperative complications,hospital stay and success rate were also recorded and compared between 2 groups.All patients visited our clinic at 1 week,1 and 3 months after surgery and every 3 months thereafter.Success was defined as the symptomatic relief and improved radiographic imaging at the latest follow-up. Statistical analyses included the unpaired Student t-test for normallydistributed data groups and the chi-square test for bivariate tabular analysis where appropriate.A p value less than 0.05 was considered significant.ResultsNo difference was observed between the 2 groups in patient hospital stay, perioperation complication and success rate.Overall success rates were also equivalent(10/11 vs 14/15)(P>0.05).No intraoperative complication occurred,and no one needed a blood transfusion during or after surgery.In addition,no conversion to open surgery was necessary.Because there was severe fibrosis and attachments to neighboring structures in some cases after failed open surgery,we spent a lot of time releasing the upper ureter and renal pelvis,so the average operative time of laparoscopic pyeloplasty for secondary UPJO was significantly longer than the time of laparoscopic pyeloplasty for primary UPJO(145.2 vs 113.5 min)(P<0.05),and the average blood loss during secondary laparoscopic pyeloplasty was more than that in primary laparoscopic pyeloplasty(245.6 vs 118.5)(P<0.05).Compared with which was reported,in literature, the mean operative time in our study was significantly shorter(P<0.05).The blood loss in our study was also similar to that in open surgery(245.6 vs 245.3)(P>0.05).ConclusionsFor secondary ureteropelvic junction obstruction,laparoscopic pyeloplasty can be performed safely with a success rate comparable to that of primary laparoscopic pyeloplasty.The patient benefits of laparoscopic ureteropelvic junction repair of secondary ureteropelvic junction obstruction are similar to the benefits of laparoscopic repair of primary ureteropelvic junction obstruction.we believe the transperitoneal approach is superior for reoperative procedures.