102 © 2005 BJU INTERNATIONAL | 95, SUPPLEMENT 2, 102–105 Original Article LAPAROSCOPIC PYELOPLASTY INAGAKI et al. Laparoscopic pyeloplasty: current status TAKESHI INAGAKI, KOON H. RHA, ALBERT M. ONG, LOUIS R. KAVOUSSI and THOMAS W. JARRETT The Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA (28), Fenger plasty (11) and others (two) were used, according to the intraoperative findings. Twenty-five patients had secondary obstruction, having had previous surgery to the PUJ. The mean (range) follow-up was 24 (3–84) months; all patients were followed clinically and radiologically. RESULTS The mean operative duration time was 246 (100–480) min and estimated blood loss was 158 mL. Crossing vessels were identified in 80 cases. The success rate for all, primary and secondary patients was 95%, 98% and 84%, respectively. With one exception, all failures occurred within 6 months. Twenty- one patients (22 renal units) had simultaneous laparoscopic pyeloplasty and lithotomy; they were treated successfully and all have an intact PUJ, and 20 renal units (90%) were stone-free. The overall complication rate was 8.8%. CONCLUSIONS This series has comparable success rates to those of open pyeloplasty and the morbidity was minimal. Laparoscopic pyeloplasty may soon become the standard operation for PUJ obstruction, especially with crossing vessels. KEYWORDS laparoscopy, pyeloplasty, pelvi-ureteric obstruction OBJECTIVE To review current publications and report our results and long-term follow-up of laparoscopic transperitoneal pyeloplasty for pelvi-ureteric junction (PUJ) obstruction. PATIENTS AND METHODS In all, 147 laparoscopic transperitoneal pyeloplasties were performed between August 1993 and November 2000 (mean patient age 35.7 years, range 10–85). All patients were diagnosed with PUJ obstruction by symptoms and intravenous urography, radionuclide diuretic renography or ultrasonography. An Anderson-Hynes dismembered pyeloplasty (106), Y-V plasty INTRODUCTION PUJ obstruction (PUJO) is the most common disease in the ureter, and can lead to progressive hydronephrosis and renal dysfunction. The most common clinical symptoms of PUJO are lumbar pain, renal colic and infection. Open surgical reconstruction is the most common procedure for relieving symptoms and preventing renal dysfunction from PUJO, with a > 90% success rate reported [1–3]. To decrease the morbidity of a flank incision, minimally invasive techniques to treat PUJO have been developed, with endoscopic endopyelotomy the first such technique to be widely accepted [4–6]. However, the success rate is less than that of open pyeloplasty and there are some risk factors which decrease the success rate [6–8]. Laparoscopic pyeloplasty (LP) was initially introduced by Schuessler et al. in 1993 [9] and gives the advantages of surgical reconstruction while eliminating the morbidity of a flank incision. Numerous studies report a shorter hospital stay and with excellent surgical outcomes [10–16]. We review the results of our series of transperitoneal LPs for PUJO since August 1993 at our institution. PATIENTS AND METHODS Between August 1993 and November 2000, 147 consecutive LPs were carried out in 145 patients for PUJO (two bilateral). All patients had hydronephrosis and PUJO confirmed on radionuclide imaging or excretory pyelography. Routine preoperative laboratory tests were also used. All patients had cystoscopy and retrograde pyelography, and a double pig-tailed catheter (6 or 7 F) placed in the operating room before surgery. LP as used at our institution was described previously. Briefly, the patient was positioned with the flank up. Pneumoperitoneum was achieved in a standard manner and three trocars placed under direct vision, with a 10-mm umbilical trocar, a 10-mm trocar halfway between the umbilicus and the symphysis, and a 5-mm trocar halfway between the umbilicus and xiphoid. The peritoneum overlying the kidney was incised and the colon mobilized medially. The PUJ was freed from the surrounding tissue and the most appropriate surgical procedure selected. An Anderson-Hynes dismembered pyeloplasty was used where there were crossing vessels or redundant renal pelvis, a Y-V plasty with no crossing vessels or with a high insertion, and a Heineke-Mikulicz repair for short stenotic segments. All anastomoses were completed with a watertight running 4–0 polyglactin suture over a ureteric stent, using the EndoStich device (US Surgical, Norwalk, CO). A closed suction drain was positioned close to the repair and 16 F Foley catheter left in place. Drains were usually removed in the morning 2 days after surgery, but were occasionally left longer in cases with a high output. The ureteric stents were removed after a month. Patients were assessed at 3 months with a diuretic renogram or IVU, and were followed yearly thereafter. RESULTS The mean (range) age of the patients was 35.7 (10–85) years and the hospital stay 3.1 (1–8) days. Anderson-Hynes dismembered pyeloplasty was used in 106 patients and in the remainder a dismembered pyeloplasty was not used, being a Y-V plasty in 28, or Fenger plasty in 11, and others in two; 25 had a laparoscopic pyeloplasty after previous failed surgery. The mean operative duration, including cystoscopy, retrograde pyelography and ureteric stent placement, was 246 (100–480) min and the estimated blood loss 158 (0–1000) mL.