TITLE: Laparoscopic versus open pyeloplasty: Comparison of two surgical approaches- a single centre experience of three years

  ABSTRACT.BACKGROUND:
Ureteropelvic junction obstruction (UPJO) causes hydronephrosis and progressive renal impairment may ensue if left uncorrected. Open pyeloplasty remains the standard against which new technique must be compared. We compared laparoscopic (LP) and open pyeloplasty (OP) in a randomized prospective trial.

ABSTRACT.MATERIALS AND METHODS:
A prospective randomized study was done from January 2004 to January 2007 in which a total of 28 laparoscopic and 34 open pyeloplasty were done. All laparoscopic pyeloplasties were performed transperitoneally. Standard open Anderson Hynes pyeloplasty, spiral flap or VY plasty was done depending on anatomic consideration. Patients were followed with DTPA scan at three months and IVP at six months. Perioperative parameters including operative time, analgesic use, hospital stay, and complication and success rates were compared.

ABSTRACT.RESULTS:
Mean total operative time with stent placement in LP group was 244.2 min (188-300 min) compared to 122 min (100-140 min) in OP group. Compared to OP group, the post operative diclofenac requirement was significantly less in LP group (mean 107.14 mg) and OP group required mean of (682.35 mg). The duration of analgesic requirement was also significantly less in LP group. The postoperative hospital stay in LP was mean 3.14 Days (2-7 days) significantly less than the open group mean of 8.29 days (7-11 days).

ABSTRACT.CONCLUSION:
LP has a minimal level of morbidity and short hospital stay compared to open approach. Although, laparoscopic pyeloplasty has the disadvantages of longer operative time and requires significant skill of intracorporeal knotting but it is here to stay and represents an emerging standard of care.

BODY.INTRODUCTION:
Open pyeloplasty has been the gold standard for surgical treatment of ureteropelvic junction (UPJ) obstruction, enjoying a long-term success rate exceeding 90%.[1] This procedure requires a muscle incision that entails some degree of morbidity. UPJO causes hydronephrosis and progressive renal impairment may ensue if left uncorrected.[2] The optimum surgical correction of UPJO has been a urological challenge for over a century.[3] Open pyeloplasty originally described by Andersen and Hynes[4] remains the gold standard against which new technique must be compared. The morbidity associated with flank incision, however, has led to development of minimally invasive approaches to UPJ repair. Over the last two decades the treatment approach to UPJ obstruction has evolved from open pyeloplasty to various minimally invasive procedures like endopyelotomy, acucise catheter incision, balloon dilatation and laparoscopic pyeloplasty. These minimally invasive options are reported to been less successful than open pyeloplasty.[5] Laparoscopic pyeloplasty was described first in 1993 by Schuessler et al. Laparoscopic pyeloplasty has developed worldwide as the first minimally invasive option to match success rate of open pyeloplasty. Only one randomised study to compare Laparoscopic and open pyeloplasty has been done by Turk et al in 2002.[6] We analysed the comparison of Laparoscopic and open pyeloplasty in a randomised prospective trial.

BODY.MATERIALS AND METHODS:
A prospective randomised study was done from January 2004 to January 2007 in which a total of 28 Laparoscopic and 34 open pyeloplasty were done. All procedures were performed at our institute. The patients had radiographic evidence of UPJO on diuretic renography or hydronephrosis with delayed function on IVP in conjunction with signs and symptoms or deterioration of renal function. Out of the 28 patients for laparoscopy 25 presented with pain and three presented with recurrent urinary tract infection. Thirty patients had pain in open pyeloplasty group while three presented with lump and one patient presented with haematuria after minor trauma. All patients underwent cystoscopy and RGP to confirm the diagnosis before the procedure. Ureteric catheter was left in situ.  All laparoscopic pyeloplasties were performed transperitoneally. Patients were placed in lateral kidney position. Four to five trocars were placed to enable dissection, retraction and identification of PUJO. Depending on the anatomical findings at time of dissection dismembered or non dismembered procedures were performed. In case of redundant pelvis reduction, pyeloplasty was performed. Anastomoses were done with 4-0 polyglactin. After completion of posterior layer DJ stent was placed and then anastomosis was completed Drain was inserted adjacent to repair and Foleys catheter was left in the bladder for two days. Drain was removed the next day if the drain output did not increase. Internal stent was removed after the fourth week.  Standard open Anderson Hynes pyeloplasty, spiral flap or VY plasty was done depending on anatomic consideration. The patients were randomly admitted for pyeloplasty under four different surgeons. All laparoscopic cases were performed by a single surgeon dedicated to laparoscopy while open cases were performed by different surgeons' expert in open surgery. Ethics committee approval was obtained prior to the study.  Patients were followed with DTPA scan at three months and IVP at six months. Thereafter, patients were followed at six months and then annually. The patients were radiologically investigated with DTPA scan depending on symptoms and signs.  Peri-operative parameters including operative time, analgesic use, hospital stay, and complication and success rates were compared. Postop patients received transdermal patch 100 mg or 200 mg (Diclofenac) according to severity of pain. Patients were assessed in postop period regarding pain according to the requirement of transdermal diclofenac patch (duration and quantity).  The success was defined radiologically as a patent, unobstructed UPJ or improved or maintained renal functional status and symptomatic improvement. Formal chart review was completed with all peri-operative data completed and statistical analysis was done using Fisher exact test, unpaired t test and Marn-Whitney U test.

BODY.RESULTS:
The demographics of two groups were similar with regard to sex, age, laterality. None had any significant co-morbid condition. The mean follow-up in open cases was 33.5 months and in Laparoscopic cases was 34.5 months.  A total of 28 Laparoscopic pyeloplasties and 34 open pyeloplasties were performed [Table 1]. Two patients in laparoscopic group had VY plasty due to high insertion of ureter and less dilated renal pelvis.   Table 1 Details of cases of pyeloplasty Total cases 62 Laparoscopic pyeloplasty 28 Dismembered 26 Vy plasty 2 Associated stone 2 Crossing vessel 4 Open pyeloplasty 34 Dismembered 31 Vy plasty 2 Spiral flap 1 Associatd stone 3 Crossing vessel 4   Mean total operative time with stent placement in LP group was 244.2 min (188-300 min) compared to 122 min (100-140 min) in open group. Total operative time did improve with experience for LP patients as average time reduced to 202 min for last five patients. There was no blood transfusion in any patient. There was no mortality in either group.  Compared to open pyeloplasty, the postoperative diclofenac requirement was significantly less in LP group (mean107.14 mg) compared to open group mean (682.35 mg). The duration of analgesic requirement was also significantly less in LP group. The postoperative hospital stay in LP was mean 3.14 Days (2-7 days) significantly less than open group mean 8.29 days (7-11 days) [Table 2].  Table 2 Comparison of laparoscopic and open pyeloplasty Open LP P  value Age 29.58 31.64 N.S Sex m/f 20/12 17/11 n.S Side r/l 18/14 16/12 n.S Operating time (min) 122.411 ± 10.60 244.21 ± 41.73 <0.01 Analgesic(mg) 682.35 ± 123.66 107.14 ± 73.00 <0.01 Duration analgesic (days) 3.41 ± 0.61 1.00 ± 0.67 <0.01 Hospital stay (days) 8.29 ± 1.35 3.14 ± 1.29 <0.01 Success 34/34 26/28 N.S   We had two cases of UPJO secondary to failed endopyelotomy which required operative duration of 300 minutes. Both patients had a successful outcome.  There was only one conversion in laparoscopic group to open surgery as we were unable to remove associated calculus by laparoscopy. There was only one major complication in laparoscopic group. That patient had prolonged drainage of urine (six days) through the drain which subsided with prolonged catheterisation. He had recurrence of symptoms at three months and an obstructive DTPA curve. This was probably secondary to fibrosis caused by leakage of urine that occurred earlier. The patient was managed with endopyelotomy after six months. No patient in open group had recurrence.

BODY.DISCUSSION:
The first successful reconstruction of an obstructed UPJO was accomplished in 1892.[7] Since then open pyeloplasty has been the gold standard for UPJO repair and achieves success rates exceeding 90% in contemporary series.[8–10] In 1983 Wicham and Kellet described percutaneous pyelolysis (endopyelotomy) which subsequently gained some popularity.[11] Subsequent evolution in endoscopic physiology and application together with advances in endoscopic technology fostered advances in the field. Current approaches include antegrade percutaneous, retrograde ureteroscopic guided laser and retrograde acusize ® balloon dilatation. The success rate of these minimally invasive options have consistently been less than with open pyeloplasty by 10-30%.[12–14] The varied surgical anatomy of PUJ (huge dilatation, crossing vessels, high insertion of ureter) compromise all of these endourological procedures. These procedures are also associated with a risk of peri-operative haemorrhage and 3-11% patients' required blood transfusion.[1516]  Laparoscopic pyeloplasty provides a minimally invasive alternative to repair UPJO. Laparoscopic pyeloplasty was introduced in 1993 by Schussller et al and has developed worldwide as the first minimal option to match success rate of open pyeloplasty.[3] Reconstruction of UPJO can be tailored to anatomical findings at the time of surgery.[17] The feasibility of Laparoscopic pyeloplasty including Anderson Hynes, Fengers, Foleys VY plasty performed through transperitoneal and retroperitoneal approach has been evaluated.[18] Its potential advantages including less postoperative pain, shorter hospital stay and improved cosmesis have been proved in previous comparative series.[19–21] The only disadvantage seems to be longer operative time in published series.[1920] However, Zhang et al,[18] reported less operative time in Laparoscopic group (retroperitoneal) than open group. As laparoscopic surgery becomes more entrenched in resident training, the more complex skills such as intracorporeal suturing become less daunting. Moreover, long operative time may be reduced by skill of intracorporeal knotting and development of new robotic equipment.[21] The performance enhancing feature of Da Vinci robot seems to decrease the difficulty of intra corporeal suturing. In general the reported overall complications rate of laparoscopic pyeloplasty ranges from 4% - 12.7%.[18] In the present study there was only one major complication and only one conversion to open surgery. This is possibly the result of the experience of the surgeon who did laparoscopic cases. Siguriea et al[22] reported success rate in eight of nine patients with secondary PUJO while Sundaram et al[23] reported 89% success rate in secondary procedure and a longer mean operating time of 6.3 h(2.7-10) In our series, we had two secondary cases with operative duration of 300 min. Both patients had a successful outcome. Ram Kumar et al, reported a series of 20 LPs with stone extraction through Laparoscope port. We had five patients with associated stone disease. Three were managed by open approach. One patient being managed laparoscopically had to be converted to open as stone could not be retrieved by laparoscopy. Zhang et al,[18] reported that analgesic requirement was significantly less in LP than open pyeloplasty. The duration and amount of analgesic requirement is significantly less than that in open pyeloplasty in our series. The success rate of laparoscopic pyeloplasty has been reported to be consistently high, at 87-98%.[3] In the present series, we had a success rate of 92.3%. We considered conversion to open as a failure.

BODY.CONCLUSION:
LP is a technically sound operation which uses well established principles familiar to urologist. The only disadvantage of Laparoscopic pyeloplasty is longer operative time and requires significant skill of intracorporeal knotting This procedure has a minimal level of morbidity, short hospital stay, better cosmesis compared to open approach. Laparoscopic pyeloplasty has emerged as the standard of care and is here to stay.

Question: Compared to pyeloplasty (OP) what was the result of laparoscopic (LP) on Mean total operative time with stent placement?
Evidence: The duration of analgesic requirement was also significantly less in LP group.
Answer: significantly increased