Md.

Rokonuzzaman Khan et al

OUTCOME OF LAPAROSCOPIC VERSUS OPEN

PYELOPLASTY IN THE TREATMENT OF PELVIURETERIC
JUNCTION OBSTRUCTION: A COMPARATIVE STUDY.
MD. ROKONUZZAMAN KHAN1, MD. FAZAL NASER2, MD. MIZANUR RAHMAN3, MEHBUBA YASMIN4,
MD. MOSTAFIZUR RAHMAN5, MD. MUAZZAM HOSSAN6

Abstract
Background: Ureteropelvic junction obstruction leads to progressive dilatation of the
renal collecting system, and can result in pain and progressive deterioration of renal
function but may be asymptomatic and result in complication such as
pyelonephritis,calculus formation and deterioration of renal function may ensue if left
untreated.Open pyeloplasty remains the gold standard against which new technique
must be compared.we compared laparoscopic and open pyeloplasty in the treatment of
pelviureteric junction obstruction. To see the outcome of laparoscopic pyeloplasty versus
open A-H pyeloplasty in the management of pelviureteric junction obstruction.
Methods and materials: A prospective quasi experimental study was done from july
2012 to December 2013 in which a total of 30 laparoscopic and 30 open pyeloplasty
were done. All laparoscopic pyeloplasties were performed transperitoneally.Standard
open A H pyeloplasty,spiral flap or VY plasty was done depending on anatomical
consideration. Patients were followed with USG and IVU at three and six months
interval.Perioperative parameters including operative time,analgesic use,hospital stay,and
complication and success rates were compared.
Results: Mean total operative time in LP group was 115±15 min compared to 75 ±15 in
OP group, the postoperative analgesic requirement was sighnificantly less in LP
group(mean 84.73±11mg) and OP group required mean of( 274.33±39.42mg).The mean
blood loss in LP group was 118.26±110.74ml compared to open group
274.82±118.97ml.The postoperative hospital stay in LP was mean 4 days(2-7days)
sighnificantly less than the open group mean of 8 days(7-9days).
Conclusion: Lp has a minimal level of morbidity and short hospital stay compered to
open approach.Although laparoscopic pyeloplasty has the disadvantages of longer
operetive time and requires sighnificant skill of intracorporal knotting but it is here to stay
and represents an emerging standard of care.
Bangladesh J. Urol. 2019; 22(2):

1. Assistant Professor of Urology, MA Rahim Medical College Introduction

Hospital, Dinajpur Pelviureteric junction obstruction leads to progressive
2. Associate Professor of Urology Shaheed Suhrawardy Medical
dilatation of the renal collection system,and can result
College Hospital
3. Professor of Urology, Dhaka Medical College & Hospital DMCH. in pain and progressive deterioration of renal function
4. OSD, DGHS, Dhaka. but may be asymptomatic and result in complications
5. Assistant Professor of Urology, Khwaja Yunus Ali Medical such as pyelonephritis,calculus formation and renal
College, Sirajgonj
failure.Most cases are congenital in origin and most
6. Assistant Professor of Urology, Abu Naser Specialist Hospital,
Khulna. were detected before birth by prenatal
Address of correspondence: Assistant Professor of Urology, MA ultrasonography.Children who escape diagnosis in
Rahim Medical College Hospital, Dinajpur, Mobile: 01728137925, infancy can present later in life.Most common in boys
Email: dr.rokon77@gmail.com
than girls(5:2) and more common in left side(5:2) and
Received: 05 February 2019 Accepted: 10 May 2019 contralateral PUJ obstruction(10%).Most common

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Outcome of Laparoscopic versus open pyeloplasty in the treatment of pelviureteric junction obstruction: A Comparative study.

causes are intrinsic muscular defect,abnormal collagen complications,length of hospital stay, postoperative pain
tissue deposition in and around muscular fibre and return to normal activity, and radiographic outcome
cell,aberrant blood vessels and congenital narrowing at 3 months and 6 months (Bansalet al,2013).
etc.Surgical management of PUJO aims to provide
symptomatic relief and preserve remaining renal Material and methods
function.Common surgical treatment of pelviureteric A prospective randomized study was done from July
junction obstruction consists of open surgical Andersen- 2012 to december2013 in which a total of 30
Hynes pyeloplasty,laparoscopic approaches,and laparoscopic and 30 open pyeloplasty were done.All
endourologic methods,(Carr2002). procedure were perfomed in Dhaka medical college and
hospital and other private hospital in Dhaka city.In this
Open pyeloplasty has been the gold standard for surgical prospective study, sixty consecutive patients were
treatment of ureteropelvic junction obstruction,enjoining selected as per selection criteria from the patients
a long term success rate exceeding90%.This procedure attending in the out patient department of urology
requires a muscle cutting incision that entails some degree unit,Dhaka medical college hospital and other private
of morbidity. The optimum surgical correction of UPJO medical college and hospital,Dhaka.With the complaints
has been a urological challenge for over a century.Open of flank pain, flank or abdominal mass,recurrent fever
pyeloplasty originally described by Andersen and Hynes with lower urinary tract symptoms etc. The patients with
remains the gold standard against which new technique above mentioned complaints were evaluated first by
must be compared.The morbidity associated with flank details history, physical examination and investigation
incision,however, has led to development of minimally by urinalysis, urine culture and sensitivity,complete blood
invasive approachs to UPJ repair.Over the last two count,Blood urea nitrogen,serum creatinine and
decades the treatment approach to UPJ obstruction has ultrasonography of KUB region.Then suspected cases
evolved from open pyeloplasty to various minimally of PUJ obstruction were further evaluated by intravenous
invasive procedures like endopyelotomy,balloon dilatation urography and diuretic DTPA renography as out patients
and laparoscopic pyeloplasty.These minimally invasive basis.Then the patients with PUJ obstruction who fulfilled
options are reported to be less successful than open the selection criteria included in this study and admitted
pyeloplasty.Laparoscopic pyeloplasty was described first in the urology ward and numbered chronologically.Out
in 1993 by schuessler et al.Laparoscopic pyeloplasty has of the 30 patients for laparoscopy 25 presented with pain
developed worldwide as the first minimally invasive option and five presented with recurrent urinary tract
to match success rate of open pyeloplasty.only one infection.Thirty patients had pain in open pyeloplasty
randomized study to compare laparoscopic and open group while three presented with lump and one patient
pyeloplasty has been done by turk et al in 2002.In this presented with haematuria after minor trauma.All
prospective study, we see the outcome of transperitoneal patients underwent cystoscopy and RGP to comfirm the
laparoscopic pyeloplasty and open A-H pyeloplasty using diagnosis before the procedure.Urethral catheter was
a minimal flank incision with regard to operative left in situ.

Dissection of crossing vessels Holding suture through abdominal wall

Bangladesh J. Urol. 2019; 22(2): 182-187 183

Md. Rokonuzzaman Khan et al

1. Division of ureteropelvic junction 2. Lateral speculation of ureter 3. Suturing

All laparoscopic pyeloplasty were performed condition.A total 30 Laparoscopic pyeloplasty and 30
transperitonealy.Patients were placed in lateral kidney patients Open pyeloplasties were performed.Mean total
position. Three trocers were placed to enable operative time with stent placement in LP group was
dissection,retraction and identification of 115 ±15 min compared to 75 ±15 min in open group (p
PUJO.Depending on the anatomical findings at time <0.05).Total operative time did improved with
of dissection dismembered or non dismembered experience for LP patients.There was no blood
procedures were performed.In case of redundant pelvis transfusion in any patient.The mean blood loss in LP
reduction pyeloplasty was performed.Anatomoses were group was 118.26 ±110.74ml.compoared to
done with 4-0 polyglactin.After completion of posterior 274.82 ±118.97ml.in open group (p <0.05).There was
layer DJ stent was placed and then anatomosis was no mortality in either group.
completed.Drain tube was inserted adjacent to repair Compare to open pyeloplasty, the mean pain score in
and Foleys cather was left in the bladder for five first 24 hours following pyeloplasty was 13.48±2.7.In open
days.Drain was removed the fourth day if the drain group the mean pain score was 23.05±2.8 (p <0.05).
output did not increase.Internal stent was removed after Intensity of pain in first 24 hours following pyeloplasty was
the fourth week. All patients were followed with USG sighnificantly less in laparoscopic pyeloploasty group.
and IVU at 3 months and 6 months and then annully. postoperative pethedine requirement was sighnificantly
Perioperative parameters including operative less in LP group(mean 84.73±11.63mg) compared to open
time,analgesic use,hospital stay,and complication and group( mean 274.33±39.42mg).The duration of analgesic
success rate were compared.The success was defined requirement was also sighnificantly less in LP group.The
radiologically as a patent, unobstructed UPJ or postoperative hospital stay in LP was mean 3.14days(2-
improved or maintained renal function status and 7days) sighnificantly less than open group mean
symptomatic improvement. 8.29days(7-11days) (p <0.05). There was only one major
complication in laparoscopic group.That patients had
Result: prolonged drainage of urine(6 days) through the drain
The demographics of two groups were similar with which subsided with prolonged catherization.No patients
regard to sex, age.None had any significant co-morbid in open group had any complication.

Table-I
Preoperative and postoperative characteristics of the study patients.

Variables Laparoscopic Group Open Group P value

Operative time (min) (mean ± SD) 115 ± 15 75 ± 15 0.00011
Peroperative blood loss (ml) (mean ± SD) 118.26 ± 110 274.82 ±118.97 0.00011
Pain score (mean ± SD) 13.48 ± 2.7 23.05 ± 2.8 0.00011
Postoperative hospital stay (day) (mean ± SD) 3.14 8.29 0.00011
Postoperative complication (%) 3.33 0 0.00012
1Data were analyzed by using Student’s t- test.
2Data were analyzed by using Chi-square test.

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185
Outcome of Laparoscopic versus open pyeloplasty in the treatment of pelviureteric junction obstruction: A Comparative study.

Discussion: As laparoscopic surgery becomes more entrenched in

The first successful reconstruction of an obstructed resident training, the more complex skills such as
UPJO was accomplished in 1892.Since then open intracorporal suturing becomes less daunting.
pyeloplasty has been the gold standard for UPJO repair Moreover,Long operative time may be reduced by skill
and achieves success rates excedding 90% in of intracorporal knotting.
comtemporary series.In 1983 wicham and kellet .In present laparoscopic pyeloplasty, mean blood loss
described percutaneous pyelolysis(endopyelotomy) was 118 ±110.74ml.The mean blood loss in open
which subcequently gained some pyeloplasty was 274.82 ±118.97ml.Blood loss was
popularity.Subsequently evolution in endoscopic sighnificantly less in laparoscopic pyeloplasty group.In
physiology and application together with advances in a comparable study, Nihad et al,2011 had seen that
endoscopic technology fostered advances in the field. laparoscopic pyeloplasty had less blood loss,morbidity
Current approachs included antegrade percutaneous and less hospital stay than open pyeloplasty. Pain score
retrograde ureteroscopic guided laser and retrograde in first 24 hours following laparoscopic pyeloplasty was
acusize ballon dilatation.The success rate of these 13.48 ± -2.7.In open pyeloplasty,the mean pain score
minimally invasive options have consistently been less was 23.05 ±2.81.Intensity of pain in first 24 hours
than with open pyeloplasty by 10-30%.The varied following pyeloplasty was sighnificantly less in
surgical anatomy of PUJ (huge dilatation, crossing laparoscopic pyeloplasty group.In a similar comparable
vessels,high insertion of ureter) compromise all of these study,Bansal et al,2013 had compared to open
endourological procedures.These procedures are also pyeloplasty group with laparoscopic and it was revealed
associated with a risk of perioperative haemorrage and that the post operative analgesics requirement was
3-11% patients required blood transfusion. sighnificantly less in LP group.In a recent study
Laparoscopic pyeloplasty provides a minimally invasive Falahatkar et al,2012 observed that the mean dosage
alternative to repair UPJO.Laparoscopic pyeloplasty of postoperative analgesics and complication rates in
was introduced in 1993 by schussller et al and has laparoscopic (26,25mg;23.8%) were lower than open
developed worldwide as the first minimally option to pyeloplasty(38.33mg; 36%).In present study,pethedine
match success rate of open pyeloplasty.Reconstruction requirement in laparoscopic pyeloplasty was
of UPJO can be tailored to anatomical findings at the 84.73 (±)11.63mg for post operative pain
time of surgery.The feasibility of laparoscopic management.The mean pethedine requirement in open
pyeloplasty including Andersen-hynes,Fengers,Foleys A-H pyeloplasty was 274.33 ±39.42mg.Pethedine
VY plasty performed through transperitoneal and requirement was sighnificantly less in laparoscopic
retroperitoneal approach has been evaluated. Its pyeloplasty group(p<0.05).
potential advantages including less peroperative There is very small incision and tissue trauma during
bleeding, less postoperative pain,shorter hospital stay laparoscopy.So,patient can be discharged early than
and improved cosmesis have been proved.The only open surgery.Falahatkar et al,2012 revealed in their
disadvantage seems to be longer operative time.zhang study that the mean postoperative hospital
et al reported less operative time in laparoscopic group stay(LP:4.6 ±1.76 days;OP:4.3 ±1.55 days;p=0.934)
than open group.Bansal et al,2013 observed that total were similar between the two groups.In laparoscopic
operative time with stent placement in laparoscopic pyeloplasty,the mean hospital stay was 4±1 days for
pyeloplasty group was 244.2(280-300min) compared PUJ obstruction.In open pyeloplasty group,mean
to 122min (100-140min) in open pyeloplasty hospital stay was 8±2 days.Hospital stay was
group.Falahatkar et al,2012 revealed that laparoscopic sighnificantly shorter in laparoscopic pyeloplasty
pyeloplasty (28 ±095min) had a sighnificantly (p=0.003) group.It was seen that urine leakage was more in case
higher mean operating time than open (204 ±59 of laparoscopic pyeloplasty which might be due to
min)one.Nihad AA(2011) revealed that the main ligature and knotting during procedure.In open A-H
disadvantage of laparoscopic pyeloplasty was the pyeloplasty, there was more tissue handling to
longer operative time. In our study, mean operative time increased incidence of wound infection compared to
in laparoscopic pyeloplasty was 115 ±15minutes.The laparoscopic one.In present study it was revealed that
mean operative time in open pyeloplasty was 75 ±15 post operative complications were sighnificantly less
min. Operative time was sighnificantly longer in in laparoscopic pyeloplasty group except urine leakage
laparoscopic pyeloplasty group like previous studies. which was more in laparoscopic pyeloplasty.

Bangladesh J. Urol. 2019; 22(2): 182-187 185

Md. Rokonuzzaman Khan et al

If any difficulty like failure to find out renal pelvis or 6. Chen RN, Moore RG,Kavoussi LR,1998,
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Conclusion
ureteropelvic junction obstruction in children’,
The result of this study showed that laparoscopic
Journal of laparoendoscopy and advanced
pyeloplasty is a safe procedure for management of PUJ
surgical techniques,vol.21,pp.261-265.
obstruction.Laparoscopic pyeloplasty has a minimal
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