Hybrid laparoendoscopic single-site (LESS) pyeloplasty: Initial experience in children

25 février 2017

Auteurs : M. Ben Dhaou, M. Zouari, S. Ammar, H. Zitouni, M. Jallouli, R. Mhiri
Référence : Prog Urol, 2017, 2, 27, 87-92




 




Introduction


In the field of pediatric surgery, single port surgery using a transumbilical approach has gained popularity during the last few years [1, 2, 3, 4, 5, 6]. The application of this procedure in the ureteropelvic junction obstruction (UPJO) management is technically challenging. However, many studies suggested that laparoendoscopic single-site (LESS) pyeloplasty has equivalent or better short-term outcomes than conventional laparoscopy (CL) with superior cosmesis and reduced postoperative pain [7, 8, 9, 10]. Our aim was to overcome technical difficulties of the LESS pyeloplasty using a hybrid procedure and to compare hybrid pyeloplasty (HP) to LESS pyeloplasty and to open pyeloplasty (OP).


Materials and methods


We retrospectively reviewed records of patients with UPJO aged<14 years undergoing pyeloplasty at our institute from January 2011 to December 2015. Demographic data, laterality, operative time, length of hospital stay, drainage tubes, and postoperative complications were recorded. Classification of postoperative complications was performed using the Clavien-Dindo classification (Table 1) [11]. Surgical outcomes were evaluated based on renal sonography and Lasix diuretic renography. We divided patients into open, LESS, and hybrid pyeloplasty cohorts. We compared patient demographics, total operative times, length of stay and complication rates. Statistical significance was set at a P <0.05 using the Kruskal-Wallis and Chi2 tests for continuous and categorical variables, respectively.


All patients were operated by the same surgeon. For patients treated with the open method (group I), children were put in the lateral position. A lumbotomy incision was performed (Figure 1) and a traditional pyeloplasty was performed using interrupted 5-O chromic catgut sutures (Ethicon, Inc., Johnson & Johnson Company, New Jersy, USA). For LESS pyeloplasty and HP (group II and III, respectively), children were placed in semi-flank position with the affected side up (Figure 2). Transperitoneal approach was used. A single glove port was introduced through the umbilical incision into the abdominal cavity. This glove port is composed of a flexible ring, a rigid larger ring and one powder free surgical glove (Figure 3). The flexible ring covered by the glove was placed through a middle umbilical incision. Then, the open end of the glove surrounded closely the rigid ring. Standard straight laparoscopic instruments were introduced through the fingers of the glove port for the dissection and the mobilisation of the ureteropelvic junction (Figure 4).


Figure 1
Figure 1. 

Operating view of the ureteropelvic junction through a lumbotomy incision.




Figure 2
Figure 2. 

Children were placed in semi-flank position with the affected side up.




Figure 3
Figure 3. 

Instruments required for the confection of the glove port: a flexible ring, a rigid larger ring and one powder free surgical glove.




Figure 4
Figure 4. 

Glove port and conventional rigid instruments.




For group III patients, a sterile atraumatic cord was placed around the ureter and used to tract it up in order to facilitate dissection (Figure 5). The obstruction site was clearly identified, a 1-cm flank incision was made and an ureteropyeloplasty was performed under direct vision using interrupted 5-O chromic catgut sutures (Ethicon, Inc., Johnson & Johnson Company, New Jersy, USA) (Figure 6). All patients in groups I, II and III had double-J stenting. A perirenal drainage tube was placed in all patients.


Figure 5
Figure 5. 

A sterile atraumatic cord was placed around the ureter and used to tract it up in order to facilitate dissection.




Figure 6
Figure 6. 

Operating view of the ureteropelvic junction externalized through a 1-cm flank incision.





Results


Initially, a total of 43 children (35 boys and 8 girls) were enrolled. Five patients were excluded because of associated congenital urinary tract anomalies. Among the 38 patients, 17 underwent open OP (group I) from January 2011 to May 2013, 10 had LESS pyeloplasty from June 2013 to May 2014 and 11 had HP from June 2015 to december 2015. Patients' characteristics are summarized in Table 2. The mean age at the time of operation was 55 months. In group II and group III patients, the disorder was mostly detected by prenatal sonography. Group I patients presented with abdominal pain in most cases probably because of their higher age. The operative time in group III was shorter than that in group I and II (P <0.001). There was no statistically significant difference in the operative time between groups I and II (P =0.637). None of group II or group III patients required conversion to open pyeloplasty. Postoperative complications occurred in 4 children. In the open surgery group, two patients had prolonged ileus. Recurrent ureteropelvic junction stenosis was noted in one group I patient and was managed by repeat pyeloplasty. One patient in group II had postoperative urine leakage, which was resolved with prolonged drainage. All patients required paracetamol postoperatively. Perioperative details and outcomes in the three groups are summarized in Table 3. Group III patients had a shorter hospital stay (P <0.001), with good cosmetic results (Figure 7) and early return to normal activity. The mean follow-up period was 26 months (range: 6-52 months). Successful resolution of UPJO was noted in 37 patients. Resolution of UPJO was confirmed by improvement in ultrasound and diuretic renography.


Figure 7
Figure 7. 

Wound appearance at the end hybrid pyeloplasty.





Discussion


Congenital UPJO is one of the most common congenital abnormalities of the ureter in pediatrics; this causes a progressive dilatation of the renal collecting system and may lead to progressive deterioration of renal function [12, 13, 14, 15, 16]. Traditionally, the standard of treatment has been open pyeloplasty, with success rates exceeding 90%. This was first described by Trendelenburg in 1886. Several variations have since evolved, and today the Anderson-Hynes dismembered pyeloplasty is the most commonly employed open surgical approach [17, 18, 19, 20].


Laparoscopic pyeloplasty (LP) is a minimally invasive surgical option that aims to adhere to the surgical principles of OP. It provides the desirable aspects of open surgery, including the precise mucosal approximation, excision of redundant renal pelvis tissue, and anterior transposition of the UPJ for lower pole crossing vessels. It offers advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, reduced complications and equal success rate [17, 21, 22, 23, 24]. However, CL may be rendered difficult by various problems and technical challenges encountered during surgery, such as the limited working space in infants, the difficulty of performing the anastomosis and the ureteral spatulation which is one of the most difficult, time-consuming, and critical steps of laparoscopic pyeloplasty [8, 25, 26].


LESS pyeloplasty is a novel and innovative technical modification of CL based on the idea that entire surgical procedures are performed via a single abdominal wall incision [7, 8, 10, 27]. The potential benefits reported using LESS technique were decreasing morbidity with reduction of iatrogenic vascular or digestive injuries resulting from port placement, lower blood loss, short recovery, cosmetic improvement and lower risk of wound healing complications [7, 8, 10]. However, LESS has not been broadly adopted into mainstream urologic practices because of technical challenges including limited triangulation, difficulty in maintaining tensile strength to adequately dissect the tissues and suturing necessary for intracorporeal reconstruction of the ureteropelvic junction [7, 8, 28]. Some technical modifications were proposed to overcome these difficulties. Rizkala and Franco [25] proposed an ex vivo ureteral spatulation and a placement of apical anastomotic sutures as an alternative to the technically demanding laparoscopic ureteral spatulation. The procedure was performed to five pediatric patients without any operative complication. Huang et al. [29] proposed HP using CL and suggested that this procedure is safe and secure in infants and young children with UPJO. In 2010, Caione et al. [30] reported good results using a one-port retroperitoneoscopic assisted pyeloplasty with extracorporeal sutures.


In our study, we used LESS pyeloplasty with extracorporeal reconstruction in infants and children with UPJO. This procedure was safe and effective with a short operative time, a short hospital stay and good cosmetic results. LESS surgery is still in the early stages of development and further follow-up and long-term data are required to determine its role in the field of urologic surgery, particularly in the repair of UPJO.


Our study has several limitations. The retrospective nature in data collection, the small patient numbers in each group and the nonrandomized selection of surgical approach may all add to the bias. No objective assessment of pain management, cosmesis, patient/family satisfaction, or cost analysis was performed. Moreover, the learning curve factors of the operating surgeon who performed open pyeloplasty, LESS pyeloplasty and hybrid pyeloplasty have made the 3 groups not ideally comparable and may incur drawbacks in our comparative analysis.


Conclusion


The hybrid pyeloplasty using LESS combines the successful outcomes of open surgery and advantages of minimally invasive surgery. It offers small incision surgery, good working space, short operation time, secure anastomosis and good cosmetic results.


Disclosure of interest


The authors declare that they have no competing interest.




Table 1 - Clavien-Dindo grading system for the classification of surgical complications [11].
Grades  Definitions 
Grade I  Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions. Acceptable therapeutic regimens are: drugs such as antiemetics, antipyretics, analgesics, diuretics and electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside 
Grade II  Requiring pharmacological treatment with drugs other than those allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included 
Grade III  Requiring surgical, endoscopic or radiological intervention 
Grade III-a  Intervention not under general anaesthesia 
Grade III-b  Intervention under general anaesthesia 
Grade IV  Life-threatening complication (including CNS complications: brain haemorrhage, ischaemic stroke, subarachnoid bleeding, but excluding transient ischaemic attacks) requiring IC/ICU management 
Grade IV-a  Single organ dysfunction (including dialysis) 
Grade IV-b  Multi-organ dysfunction 
Grade V  Death of a patient 





Table 2 - Characteristics of patients in the three groups.
  GroupI (open)  Group II (LESS)  Group III (hybrid) 
Number of patients   17  10  11 
Number of renal unit   17  10  11 
Sex (M/F)   16/1  7/3  8/3 
Laterality (R/L)   5/17  2/8  1/10 
Mean operative age (months)   81  38  46 
Mean follow-up (months)   40  13  12 
Presentation        
Prenatal sonography 
UTI 
Flank abdominal pain  10 



Légende :
M: male; F: female; R: right; L: left; UTI: urinary tract infection.



Table 3 - Operative results in the three groups.
  Group I (n =17)  Group II (n =10)  Group III (n =11)  P  
Mean operative time (minutes)   146±3.39  160±3.01  98±16.35  <0.001 
Aberrant vessels    
Use of extra-port    
Mean hospital stay (days)   5±0.61  2,4±1.38  2±0.71  <0.001 
Complications          
Stenosis (grade III)a   
Urinary leakage (grade I)a   
Prolonged ileus (grade I)a   



Légende :
Data are presented as mean±SD.

[a] 
Grading using Clavien-Dindo classification of surgical complications.


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