INTRODUCTION: In the last 15 years, the role of laparoscopic surgery has progressively increased to include reconstructive procedures such as pyeloplasty and management of ureteral stricture, in addition to being a field in continuous development, this refers to the improvement of ergonomics, new instruments and new techniques. We present a review on basic features of laparoscopic reconstructive surgery in urology.ACQUISITION OF EVIDENCE: For this review, an exhaustive literature search was performed in PUBMED, MEDILNE, BioMed central and others, with the keywords: reconstructive surgery, urology, laparoscopy. Only articles including urologic procedures in the adult and published in the last 6 years, were selected for this review.SYNTHESIS OF EVIDENCE: One of the objectives of any urological reconstructive procedure is to treat any segment of the genitourinary tract that is obstructed due to scar tissue following trauma or iatrogenic causes. After the excision of such segment or scar, a mobilization of the 2 healthy extremities of the urinary tract must be performed in order to proceed with a tension-free anastomosis. Occasionally, if there is tension, a mobilization of the organs at each side of the lesion should be performed to reduce the tension of the anastomosis; also, it should be a water-tight anastomosis to ensure good functional results. Another type of procedure is to perform laparoscopic repair surgery of pelvic organ prolapse in which the vaginal anatomy should be adequately restored, with good function maintained (sexual, urinary, intestinal) and durability.CONCLUSIONS: With the worldwide expansion of minimally invasive surgery in the area of laparoscopy and robotics, it has been possible to reproduce many of the reconstructive techniques that have followed the evolutionary course of surgery from the open to the robot assisted technique, which has made clear that such therapeutic options exist and are reproducible with good results.
OBJECTIVES: To review the role of robot-assisted laparoscopic colposacropexy (RALCS) as atreatment for pelvic organ prolapse (POP) accordinglywith the available literature and our own experience.METHODS: We have analyzed the studies with theresults of robot-assisted colposacropexy (RALCS) andothers in which this technique is compared with theabdominal (ACS) and/or the laparoscopic approach(LCS), including our own series. The main data collectedare surgical time, blood loss, complications, clinicaloutcomes, quality of life and the different costs of LCSversus RALCS. We have reviewed the last systematicreviews and meta-analysis.RESULTS: Clinical outcomes were similar within bothRALCS and LCS, surgical time was a bit longer for therobot-assisted compared with laparoscopy, blood losswas similar, as complications. The costs of RALCS weresignificantly higher than those of LCS, although we must conseconsiderthat the different studies used different variablesto measure them.CONCLUSIONS: Considering that comparative studiesare necessary, it is reasonable to assume that RALCS isa feasible and secure technique for the treatment of POP.
OBJECTIVES: Surgical restoration of pelvicfloor anatomy in pelvic organ prolapse (POP) shouldavoid extensive areas that may injure healthy tissues andlead to scar fibrosis producing dysfunctional rigidity.Laparoscopic sacrocolpopexy corrects POP by liftingpelvic elements with a minimally invasive procedure. Various current strategies and approaches make it a diverseprocedure.METHODS: We performed a bibliographic review onthe published experience about abdominal sacrocolpopexyover the last 20 years. We analyze the philosophyof each technique, advantages, disadvantages, andresults.RESULTS: Among current theories that explain how is theanatomy and function of the pelvic floor, the comprehensivetheory of the pelvic floor announces that anatomicaldeviation produces pelvic dysfunction (diagnostic algorithm)(1). Surgical invasion with reconstructive purposesmay hide results if the true physiopathology of the defectsfound is not known. Although current diagnostic toolscannot solve the problem as a whole, results of differenttechniques are much better than those of previous times.CONCLUSIONS: Laparoscopic sacrocolpopexy is anadequate strategy that restores anatomy in POP, mainlyapical, and function with minimal invasion. Technicaldevelopment and better knowledge of the female pelvisfunctional anatomy is enabling today a more preciseunderstanding of its physiopathology, so it facilitatesthe design of site-specific operations. Various surgicalapproaches and techniques are offered depending onthe defect, where combined procedures give good solutions.It is necessary to have an appropriate surgicaltraining to obtain the better competence, and a safe andcorrect repair.
Although the laparoscopic ureteralreimplantation (LUR) has a history of over 20 years, itspresence in the literature is relatively sparse, almost alwaysin the form of small case series with low statistical power,which has prevented consistent results. It has proven tobe a safe and effective technique, improving the safetyprofile and perioperative complications compared toopen ureteral reimplantation (OUR). The few long-termresults suggest a similar success rate between the openand laparoscopic approaches. Although we do notfound in the literature a strong evidence of the benefitsof anti-reflux reimplantation techniques in adults, most ofthe published series include these procedures.Ureteral reimplantation is considered the treatment ofchoice in ureteral injuries below the iliac vessels. Thisis its main indication now. Intraoperative recognition ofthe injury and immediate LUR avoid other complications,but most of ureteral injuries are diagnosed in the early postoperative period. Although the classicalrecommendations advise urinary diversion and delayedtreatment, the immediate approach is feasible, andindeed seems to improve results in complications, stayand long-term renal function. In situations of postoperativeperitonitis secondary to a ureteral fistula, immediate LURoffers specific advantages, at least theoretically, for theprotective effect of pneumoperitoneum in abdominalsepsis.
OBJECTIVES: Laparoscopic ureteral reconstructive surgery is routinely performed , because it demonstrated efficacy and safety profiles similar to open surgery in expert hands. The most frequent surgical complications after transplant are urological, appearing in up to 12,5% of the cases; they can compromise graft function and mortality. The most frequent ones include ureterovesical anastomosis stenosis (2,5-7,5%) and vesicoureteral reflux (0,4-2,2), which present in up to 80% of the cases. METHODS: Technical description of the Lich–Gregoire ureteral reimplantation technique in renal transplant patients. RESULTS: From October 2012 we performed 14 Lich-Gregoire laparoscopic ureteral reimplantations in transplant patients, 9 due to distal ureteral stenosis and 5 for vesicoureteral reflux. There were not open conversions. CONCLUSIONS: Laparoscopic surgery has evolved much allowing the performance on techniques that we could not think of years ago. Renal transplant patients present frequent postoperative complications, so they benefit of minimally invasive surgery such as endoscopy or laparoscopy. The Lich-Gregoire laparoscopic reimplantation in transplant patients is reproducible in Centers with experience both in laparoscopic surgery and transplantation.
OBJECTIVES: The most frequent ureterallesions are iatrogenic, mainly due to gynecologicand urologic procedures. The resolution and repair ofthese lesions, when they require surgery, is often theperformance of ureteroneocystostomy.We describe the technique for the repair of distal ureterlesions that preserves both anatomy and function of theurinary tract (1).The operation consists in dissection and extraction ofthe distal ureteral stump from its intramural tract to getat least 1 cm of free ureter, percutaneous insertion of aureteral stent, checking the absence of tension between proximal ureter and distal dissected stump, end to endanastomosis and reinsertion of the distal ureter in thepreviously dissected bladder muscle layer.We present 4 cases of ureteral injury after laparoscopicsimple total hysterectomy for uterine myomas withcomplete section of the distal ureter, that were operated3-5 days after injury, performing laparoscopic repairsurgery.We performed clinical and radiological control withintravenous urography demonstrating ureteral continuitynormalization and good renal function. We believethat repair of the urinary tract with anatomical andphysiological preservation must be the first option in thelaparoscopic treatment of complete distal ureteral injuries,and intramural ureter dissection when needed avoids theperformance of ureteroneocystostomy. It is necessary tokeep progressing in the technique improvement, and toincrease the number of cases and experience
OBJECTIVES: To report our initial experiencewith laparoscopic Boari flap ureteral reimplantationand to review the main technical elements in ureteralreconstructive surgery.METHODS: In a 10-year period we performed 23 laparoscopicureteral reimplantations. Three cases requireda Boari flap. Two patients presented ureteral stenosisabove the iliac vessels and the third one a urothelialtumor of the pelvic ureter.RESULTS: Two cases were completed laparoscopically;the third one was electively converted to open surgeryto avoid prolonged OR time. Mean operative time was276 minutes (270-290 min). There were no intraoperativecomplications. Mean hospital stay was 6.6 days. One patient presented postoperative UTI (Clavien 2).One patient developed with history of sever arteriopathyand aortorenal by pass developed ureteral stenosisproximal to the ureteral reimplantation eight months afterthe operation.CONCLUSIONS: Laparoscopic Boari flap ureteral reimplantationis an affective technique for ureteral reconstruction,safe and reproducible, reserved for cases ofureteral pathology in which the distance to bridge betweenthe bladder and the ureteral stump is long.
OBJECTIVE: To perform a literature review on the use of buccal mucosa graft (BMG) in the treatment of extensive ureteral stenosis, according to the criteria of Evidence Based Medicine.METHODS: Pubmed search of published studies with the following keywords: “ureteral stricture treatment”, “buccal mucosa graft ureteral treatment” and “buccal mucosa graft ureteroplasty”, without time limits, in English and Spanish; 12 articles were identified with a total of 48 cases (46 patients) of BMG use in ureteral repair.RESULTS: The main etiologies of ureteral stenosis, where BMG has been applied, have been iatrogenic and inflammatory strictures. This graft has been usedmainly in proximal or middle ureter stenosis, as a patch according to onlay technique or as a tubularized graft. Early and late complications of the procedure have been reported in 16.7% and 10.4%, respectively, with a restenosis rate of 6.25%. A 91.6% success rate was observed with this technique, with an average follow-up time of 22 (3-85) months.CONCLUSIONS: The findings of the present review do not justify the universal use of BMG in all ureteral strictures, particularly in the absence of long-term followup, but still provide evidence that BMG can be effectively used in extensive ureteral strictures.
OBJECTIVES: Uretero-pelvic junction (UPJ) obstruction has been classically treated by open dismembered pyeloplasty. Recently, laparoscopic (LP) and robotic pyeloplasty (RP) have become the techniques of choice for the treatment of UPJ stenosis in adult andpediatric population. Our objective in this paper is to review the results of minimally invasive surgery as the treatment of UPJ obstruction, the trend to use these approaches and the current limits of LP and RP. METHODS: A review of most relevant papers and meta-analysis about LP and RP in pediatric and adult population was performed using PubMed.RESULTS: In pediatric population, comparative studies and meta-analysis of relevant series show an overlap of results between LP, RP and open surgery in terms of success rate, rate of complications and hospital stay, being operating time shorter in open pyeloplasty compared to minimally invasive techniques. In infants and pre-school age open surgery remains as technique of choice for pediatric surgeons.In adults, comparative studies and meta-analysis of the most relevant series show also an overlap of results in terms of success rate and complication rate between LP and RP. Nonetheless, minimally invasive techniques seem to offer a significant shortening of hospital stay and need for analgesics compared to open surgery, reason why laparoscopic techniques are recommended over open pyeloplasty in adult population.CONCLUSIONS: In view of published literature, minimally invasive surgery has been postulated as the standard treatment in UPJ stenosis, with superimposable results to open surgery. The high cost of robotic approach limits its use in this type of pathology.
OBJECTIVE: Renal transplant surgery hasnot undergone any major changes until a few yearsago, probably due to the technical difficulty involvedin performing a laparoscopic transplant. With theintroduction of robotic technology, the difficulties derivedfrom laparoscopic surgery in certain procedures havebeen reduced, so we can now offer a minimally invasiveapproach to kidney recipients.METHODS: Review of published literature on robotickidney transplantation.RESULTS: Since the first robot-assisted renaltransplantation in 2009, several hundred cases havebeen performed. The different series of published cases,although with different surgical techniques, show initialfunctional results comparable to conventional opensurgery. Despite this evidence, there are no comparativequality studies that confirm this hypothesis. CONCLUSIONS: Robotic renal transplantation is afeasible surgical technique with interesting functionalresults. As a minimally invasive route, it is a promisingoption to reduce the surgical morbidity inherent to therenal transplant.
OBJECTIVES: Retroperitoneal fibrosis is a disease that may condition a severe involvement of various organs, mainly upper urinary tract, even causing renal insufficiency. It was first described by Albarran in 1905 and it is also known as Ormonds disease. The correct diagnosis includes, in many cases, the performance of one or more tests: CT scan, MRI, renal scan, etc. It is often necessary the insertion of double J catheters on percutaneous nephrostomy tubes with the aim to preserve renal function. Initial treatment is medical, based on corticoids, and , less frequent, immunosuppressive or chemotherapy drugs. Surgery is the treatment of choice when ureteral entrapment by the fibrous plaque is not solved with medical treatment. Such operation may be performed with a conventional open approach (laparotomy) or by pure, hand assisted laparoscopic surgery, or robotic surgery. In all cases, the technique involves freeing the ureters from the fibrous plaque that entraps them, leaving them intraperitoneal, and it is recommendable to wrap them with an omental flap. The implantation of minimally invasive techniques has made that, in groups with experience in laparoscopy, open surgery is being abandoned and the laparoscopic approach indication is increasing. Our group has performed 10 laparoscopic ureterolysis from 2005. In two patients, it was bilateral. Despite surgical repair, two renal units were lost, keeping the rest with different levels of renal function depending on the preoperative level of disease. We did not have major complications and the mean hospital stay was 5.5 days. Although, there is not important published scientific evidence about this technique and it is unlikely we will have it in an immediate future, due to the rarity of this disease, and the different degree of involvement that conditions,. It is not unreasonable to propose that, based on the literature reviewed and our own experience, laparoscopic approaches, despite being complex, may solve the ureteral entrapment with similar results to open surgery but less morbidity and shorter hospital stay.
Continued progresses in the field of laparoscopy have been introduced in urological surgery. With the development of smaller instrumental mini- laparoscopy was born seeking to reduce abdominal trauma and improve cosmetic scars, obtaining similar or better results than conventional laparoscopy. OBJECTIVE: The objective of this paper is to evaluate the results and reproducibility of mini-laparoscopic pyeloplasty. METHODS: A literature review and a bibliographic search in PubMed were performed. We describe the technique used in the “Hospital Marqués de Valdecilla” (HUMV), Santander (Spain). RESULTS: 60 articles about mini-laparoscopy were found. Although there are few reported minilap pyeloplasty series, they offer excellent cosmetic and functional results. We analyze operative time, complications, post- operative hospital stay, conversion rate, functional and cosmetic results, and we compare them with conventional laparoscopic pyeloplasty. CONCLUSIONS: More reported series are necessary but it has been proved that minilap pyeloplasty is a reproducible and safe technique with excellent results.
OBJECTIVE: To present in detail our surgical technique and to show our initial experience with ureteral reimplantation using the transumbilical LESS approach to treat patients with ureteral stenosis secondary to various diseases and surgical complications.METHODS: We performed 7 ureteral reimplantations from February 2012, using the multichannel RichardWolf (KeyPort) platform placed transumbilical by a small 2-2,5 cm transversal incision. We always use a 3.5 mm minilaparoscopy accessory trocar in the right iliac fossa, that is crucial to perform the laparoscopic suturing safely for the patient and in an optimal time. The etiology of ureteral lesions was: 1 endometriosis, 1 symptomatic ureterocele not responding to endoscopic treatment, 1 ureteral lesion after ureteroscopy for lithiasis, 1 ureteral lesion after radical prostatectomy and 3 gynecologic iatrogenic lesions (1 laparoscopically assisted vaginal hysterectomy, 2 radical hysterectomies with double anexectomy for cervix carcinoma). 5 ureteral reimplantations were left and 2 right sides. Before surgery, 5 patients had nephrostomy tubes inserted and the patient with endometriosis had a double J catheter. The patient with ureterocele did not require urinary diversion before the operation and endoscopic intraoperative catheterization was not feasible.RESULTS: We present the operative and postoperative results of the patients undergoing surgery. They had a mean age of 49.3 [28-78] years. Mean intraoperative estimated blood loss was 132.1 [100-250] ml, with no transfusions required. Mean operative time was 127.4 [120-210] minutes, with no conversions to laparoscopic or open surgery required. Mean hospital stay was 2.1 [2-3] days and all patients had drainage removed at 48 hours. There were minor Clavien-Dindo complications in one patient presenting urinary tract infection 10 days after the operation. All patients had double J catheters that were removed with a mean of 34.3 [30-45] days. Mean time for bladder catheter removal was 7.8 [7-10] días. With a mean follow up of 32.6 [14-54] months no ureteral stenosis recurrence has been observed.CONCLUSIONS: LESS ureteral reimplantation, in our initial experience, shows a low complication rate, similar to current laparoscopic series, offering less postoperative pain and abdominal wall aggression with great cosmetic results that are perceived by patients very positively, in addition to rapid recovery and return to normal daily life.
OBJECTIVE: To describe the laparoscopicapproach for uretero-ileal anastomosis strictures and toanalyse our long term series.METHODS: A retrospective review was performedevaluating our series of patients with benign ureteroilealanastomosis strictures treated laparoscopicallyfrom 2011 to 2017. Demographics and perioperativedata were obtained and analyzed. Complications weredescribed with the Clavien-Dindo classification. Thesurgical technique was described and a literature reviewwas performed.RESULTS: Eleven procedures were performed inten patients. Mean blood loss was 180 ml. All theoperations were performed laparoscopically without conversion. Mean hospital stay was 10 days (4-23).Early complications were Clavien-Dindo I y II: Two casesof limited anastomosis leakage, one lymphorrea, oneparalitic ileum and one accidental descent of the ureteralcatheter . Mean follow-up was 56 months (12-179) Nolate complications have been described.CONCLUSION: Based on our series with 5 yearfollow up, the laparoscopic approach for uretero-ilealanastomosis strictures is feasible and safe.