Evaluation of Efficiency and Safety of Transperitoneal Laparoscopic Ureterolithotomy for Treatment of Lumbar Ureteric Stones

Transcription

1 Med. J. Cairo Univ., Vol. 85, No. 3, June: , Evaluation of Efficiency and Safety of Transperitoneal Laparoscopic Ureterolithotomy for Treatment of Lumbar Ureteric Stones MOHAMED FAWZY, M.Sc.*; HUSSEIN HOSNY, M.D.**; SAYED EL-EWEEDY, M.D.**; MOHAMED ABD EL-KHALEK, M.D.**; ABD EL-BASET EL-EMAM, M.D.**; AYMAN GABR, M.D.*; SHERIF SWAR, M.D.*; ALAA EL-SHENNAWY, M.D.*; AHMED SEDIK, M.D.* and AHMED MOSTAFA, M.D.* The Department of Urology, National Institute of Urology & Nephrology* and Faculty of Medicine, Al-Azhar University** Abstract Objective: To evaluate the efficacy and safety of transperitoneal laparoscopic ureterolithotomy for treatment of lumbar ureteric stones. Patients and Methods: A prospective clinical study was conducted on 20 patients with a single upper ureteric stone with size >1cm. The patients were selected at two urological centers: Al-Azhar University Hospitals and the National Institute of Urology and Nephrology (NIUN) and they were treated by transperitoneal laparoscopic ureterolithotomy. All patients were evaluated peri-operatively and followed-up 3 months post-operatively. Patients with recurrent stone, stricture ureter below the stone, previous intraperitoneal surgery, coagulopathy, urinary tract anomalies, active UTI or pregnancy were excluded from the study. Results: Stone size: Ranges from 1.0 to 2.1cm with mean size of 1.57±0.32cm, operative time: Showed a mean of 80.3 ± 27.1, all patients in both centers had a non-significant blood loss that was <50cc, stenting: Al-Azhar group were nonstented while NIUN group were stented, drain output: Showed mean of ±340.3cc, hospital stay: Showed mean of 4.2 ± 3.1 day. Complications: 2 patients in Al-Azhar group had persistent urinary leakage that was managed by DJ fixation, postoperative pain level: By numerical rating pain scale was 2/10, hemoglobin drop: Showed mean of 0.43±0.22mg/dl. Follow-up 3 months post-operative: Pelvi-abdominal ultrasound showed improvement in the renal backpressure in 13 patients (65%) and total resolve in 7 patients (35%), all patients showed great acceptance and appreciation as regard the cosmetic outcome and the small healed incisions. Conclusion: Transperitoneal laparoscopic lumbar ureterolithotomy is an efficient safe management modality for treatment of lumbar ureteric stones with its high stone free rate, low morbidity rate, less postoperative pain, short hospital stay and good cosmetic results. Key Words: Transperitoneal laparoscopic Ureterolithotomy Ureteric stones. Correspondence to: Dr. Mohamed Fawzy, The Department of Urology, National Institute of Urology & Nephrology Introduction THE treatment of ureteric stone can now be carried out by various methods with different rates of complete stone elimination and different morbidities incidence [1]. Flexible URS and laser lithotripsy is considered as the gold standard management of all urinary stones with high efficiency and safety. It can be operated bilaterally, during pregnancy, in pediatrics and with coagulopathy. Stenting in indicated with single kidney, sever infection, bleeding disorder, aggressive manipulation or residual large fragments. It can be used antigradely in case of difficult ureteric access as urinary diversion post cystectomy [2]. Transperitoneal laparoscopic lumbar ureterolithotomy has increasingly replacing open surgery in many centers as a result of accumulated surgical experience. It has a high level of evidence (IIa) proving to be technically feasible with the advantage of being minimally access and it is mostly recommended (grade B) for large impacted ureteric stones or when ESWL and URS have failed. But it is contraindicated in severe compromised cardiopulmonary patient or with uncorrected coagulopathy [3]. Transperitoneal laparoscopic lumbar ureterolithotomy has the advantage: Over less invasive managements (ESWL and URS): Higher stone free rates [4]. Over conventional open surgery: Lower operative morbidity (due to magnification power and the ability to reach narrow areas), less blood loss, shorter hospital stay and rapid convalescence 1075

2 1076 Evaluation of Efficiency & Safety of Transperitoneal Laparoscopic Ureterolithotomy time, lower post-operative pain and better cosmetic results [5]. Over retroperitoneal laparoscopy: Surgeon's relative familiarity, wider working space, shorter learning curve and the feasibility of bilateral procedures [6]. Laparo-Endoscopic Single-Site Surgery (LESS) is the minimum invasive laparoscopic surgery with a concealed single skin incision in the umbilicus so it achieves the perfect cosmoses. Roboticassisted LESS has superior ergonomics, optical magnification, enhanced surgeon dexterity, and precision of surgical manipulation. It is considered the technological extension of laparoscopy to replace open surgery, but high costs is still the major limitation for its wide spread [7]. Patients and Methods This study was conducted on 20 patients with a single upper ureteric stone with size > 1 cm. They were managed by laparoscopic transperitoneal lumbar ureterolithotomy in Al-Azhar University Hospitals and the National Institute of Urology and Nephrology (NIUN) from January to December Patients with recurrent stone, stricture ureter below the stone, previous intraperitoneal surgery, coagulopathy, urinary tract anomalies, active UTI or pregnancy were excluded from the study. All patients were pre-operatively assessed through: A detailed medical history including cardiac, respiratory and coagulation diseases and previous intraperitoneal surgeries and a general and abdominal clinical examination. Laboratory tests including urine analysis, renal and liver function, complete blood picture and coagulation profile. Radiological investigations including pelviabdominal ultrasound, plain X-ray of the abdomen and pelvis, IVU and pelvi-abdominal multi-slice CT without contrast (when required). And all the patients had an approved written, informed consent properly explaining the aims, methods, anticipated benefits and potential hazards of the procedure. Surgical technique started by a DJ stent endoscopically fixed that was after 2 weeks postoperatively. (In NIUN group only). The patient was positioned 90º in the flank position without flexion of the operating table. After insufflation by veress needle placed in the mid-clavicular line 1 inch below the costal margin, a primary 10mm camera port was fixed blindly 2 inch lateral and superior to the umbilicus and another two secondary 10mm and 5mm working ports were fixed under vision in the anterior axillary line 1cm below the costal margin and 1cm above the iliac crest. In all patients a forth port was not needed. The colon was reflected medially by opening the posterior peritoneum at the para-colic gutter through the Toldt white line (1cm lateral to the lateral border of the colon); the incision was from the colic flexure downwards by the hook dissector or by a scissor connected to a mono-polar diathermy. Blunt dissection by two Marylands or a suction irrigator was done through the plane between the gerota's fascia and the mesenteric fat downwards till the psoas muscle. Then the ureter was identified and dissected over the stone with a Babcock grasper put above it. Vertical ureterotomy was done over the stone by the hook, and the stone was retrieved by a rightangle dissector through the 10mm port. In one patient in Al-Azhar after multiple trials the stone moved distally in the ureter and couldn't be accessed through the ureterotomy; to prevent extension of the ureterotomy a ureteroscope was introduced through the upper port passing through the ureterotomy and the stone was extracted by forceps. Then the ureterotomy was closed by intracorporeal interrupted water tight free hand suturing using 4/0 Vicryl sutures. Good hemostasis was done. And a 16 French suction drain was inserted retro-peritoneally via the upper 5mm port. Then closure of the sheath at the 10mm port sites was done. Intraoperative observation and documentation of the operative time, blood loss in the suction jar, blood transfusion if needed, stented or non-stented procedure, intraoperative complications (as open conversion). Early post-operative evaluation during hospital stay by bed-side assessment focused on: Vital signs, abdominal examination for tenderness and rigidity, postoperative pain (using the numerical rating pain scale) and the behavioral pain rating scale), need for post-operative analgesia, observation of drain output (type and amount) and the hospital stay duration. Radiological investigations on the first day post-operatively include: Plain X-ray of the abdomen and pelvis for the residual radio-opaque stones, pelvi-abdominal ultrasound for the residual radiolucent stones and for the observation of any collection due to leakage.

3 Mohamed Fawzy, et al Delayed post-operative follow-up after 3 months include: Clinical assessment (focused on the loin pain), documenting the patient acceptance about the cosmetic result, pain, duration of therapy. Urine analysis, plain X-ray of the abdomen and pelvis and pelvi-abdominal ultrasound were done. Results All patients were treated by transperitoneal laparoscopic ureterolithotomy. 10 patients were managed at Al-Azhar University Hospitals (Al- Hussein and El-Sayed Galal University Hospital) and 10 were operated in the National Institute of Urology and Nephrology (NIUN) in El-Matarya. 14 patients were males while 6 were females. There ages ranged from 28 to 65 years with mean age of 41.6±9.6y. 15 patients were medically free without any medical comorbidity (cardiac, respiratory or hepatic) but 5 patients have medical history of controlled hypertension or diabetes. Pre-operatively, 19 patients had normal serum creatinine but one patient had Chronic Renal Impairment (CRI) with serum creatinine of 2.6mg/dl due to obstructed principle kidney by a lumbar ureter stone and other atrophic hydronephrotic kidney. 17 patients had no urinary tract infection but 3 patients had pus cells >10 in their urine analysis where they receive proper preoperative antibiotic. None of the patients were anemic. 11 stones were in the right ureter while 9 were in the left ureter. 2 stones were at the level of the second lumbar vertebra (L2), 5 were at L3, 8 were at L4 and 5 were at L5. Where low lumbar ureter stones at L4 level were the most common in our study. The stone size ranges from 1.0 to 2.1cm with mean size of 1.57 ±0.32cm. Where 4 stones were from 1.0 to 1.3cm, 10 stones range from 1.4 to 1.7cm, 6 stones were between 1.8 and 2.1cm. Thus 1.4 to 1.7cm was the most common size range in our study. The stone caused moderate back pressure in 17 patients, while 3 patients suffered marked hydronephrosis but not thinned out renal parenchyma suggesting lost renal function of that kidney unit. The operative time: Showed a mean of 80.3 ± 27.1 where in Al-Azhar Hospitals operative time ranged from 42 to 65min with mean time of 51.2 ± 8.1min, while in NIUN it was from 80 to 124min with mean time of 99.7 ± 14.6min. The blood loss: All patients in both centers had a non-significant blood loss that was <50cc in the operative suction jar. None of the patients needed intraoperative or post-operative blood transfusion. Stenting: All 10 patients in Al-Azhar Hospitals were non-stented as they had water tight ureterotomy suturing, while all the 10 patients in NIUN were stented that was a preoperative decision due to the estimated lack of experience in the most skillful laparoscopic step which is the intracorporeal free hand suturing at that level of the laparoscopic learning curve. The intra-operative complications: All patients in both centers had smooth operative procedure. Post-operative vital signs: A single patient in NIUN (6.6%) who had a urinary tract infection with pus cells >100 in his urine analysis preoperatively and received a prophylactic proper antibiotic dose pre-operatively showed a low grade fever of 38ºC postoperatively that was controlled by proper antibiotic course in 2 days. Pain level: Using both the Numerical Rating Pain Scale (NRS) and the behavioral pain rating scale, all patients in both centers had low pain scales of 2/10 that didn't need analgesics all through the post-operative period. Drain output and hospital stay: Apart from 2 patients in Al-Azhar Hospitals (20%) with persistent urine leakage, other 8 non-stented patients had drain output of 100 to 1000 cc with mean of ± cc of smoky urine in the first post-operative day that decreased gradually to Nil through the hospital stay that range from 2 to 4 days with mean of 2.62±0.74 day. 10 stented patients in NIUN had drain output of Nil to 700 cc with mean of 344.4±206.8 cc of smoky urine in the first postoperative day that decreased gradually to Nil through the hospital stay that range from 1 to 3 days with mean of 2.14 ± 0.77 day. Compare the non-complicated stented laparoscopic ureterolithotomy with poor suturing skills to the non-complicated non-stented laparoscopic ureterolithotomy with water tight suturing skills in terms of the drain output and the hospital stay to stand on the value of ureteric stenting over trained water tight suturing. There was a nonsignificant difference. Thus ureteric stenting is

4 1078 Evaluation of Efficiency & Safety of Transperitoneal Laparoscopic Ureterolithotomy not indicated and has no added value provided that water tight suturing is performed in terms of drain output and hospital stay. So it is obvious that ureteric stenting during the learning curve can avoid occurrence of persistent urinary leakage in the drain thus decreasing the hospital stay. The two patients in Al-Azhar Hospitals who had persistent urinary leakage showed a mean drain output of 850± 140 cc and a mean hospital stay of 8.5±0.7 days. Post-operative imaging: All patients in both centers were stone free without any residual fragment in the plain X-ray and had no intra-peritoneal or retroperitoneal collection, urinoma or hematoma in the pelvi-abdominal ultrasonography. Hemoglobin drop: All patients showed a mild decrease that ranged from 0.1 to 0.8gm/dl with Mean ± SD of 0.43±0.22mg/dl. Post-operative complications: 18 patients had smooth post-operative hospitalization. 2 patients were non-stented in Al-Azhar Hospitals and developed a mild complication in the form of persistent urine leakage in the drain that didn't decrease over a week post-operatively so a diagnostic uretroscopy was done showing no residual stone or distal stricture but only a loose closed uretrotomy and a mucosal edema, so a DJ stent was fixed causing a decrease of the urine leakage to Nil within the next 2 days. Delayed post-operative follow-up after 3 months: All patients in both centers showed complete relief of the symptoms and loin pain. Urine analysis and plain X-ray for all patients were free. And pelvi-abdominal ultrasound showed improvement in the renal backpressure in 13 patients (65%) and total resolve in 7 patients (35%). The serum creatinine of the patient with chronic renal impairment landed from 2.6mg/dl pre-operatively to 1.9mg/dl after 3 months post relieving the obstruction. The most obvious feed-back was that all patients especially the 6 females showed great acceptance and appreciation as regard the cosmetic outcome and the small healed incisions. Discussion Over the past 2 decades many studies were carried out to assess the trans-peritoneal laparoscopic ureterolithotomy which will be mentioned in brief but the study with the largest number of cases was carried out by Simforoosh et al in 2007 on 104 patients that deserve to be a main reference to compare our results with [8]. Our study aimed to assess the efficiency and safety of transperitoneal laparoscopic ureterolithotomy. Assessing the efficiency and safety of the transperitoneal laparoscopic ureterolithotomy was done by analyzing the data from Al-Azhar Hospitals and NIUN and comparing it with other published studies. Assessment of the efficiency of laparoscopic ureterolithotomy was by focused study on the perioperative data in terms of operative time, stone free rates, post-operative pain, hospital stay and the cosmetic results. Assessing the safety was by detailed study of the blood loss and the intraoperative and the early and late post-operative complication rate. Analyzing the data retrieved from our results showed: Mean stone size: Was 1.57 ±0.32cm that was about half the stone size (3.2cm) extracted by Simforoosh, but the largest stones were 3.9 ± 1.3cm extracted from 12 patients by Al-Sayed [9]. Mean operative time: In Al-Azhar group was 51.2 ±8.1min that was nearly 2/5 achieved by Simforoosh (132 ± 52.2min), but the shortest time was 45 minutes operated on 6 patients by Flasko T et al., in Mean hospital stay: In Al-Azhar group was 2.62 ± 0.74 days which was the shortest over all published studies. All studies showed non-significant intraoperative blood loss and low post-operative pain levels. As regard the complication rate: Al-Azhar team has persistent urinary leakage in 2 patients (20%). While best results were reported by Abd El-Hakim A et al., on 25 patients in 2007 without complications. El-Moula G. et al., reported one patient with surgical emphysema. Ahmed Al-Sayed reported one patient with ureteric stricture that was managed ureteroscopically by laser incision and DJ fixation. Feyaerts et al., reported one patient with DVT that was managed conservatively by anticoagulants. Efficiency: Transperitoneal laparoscopic ureterolithotomy has short anesthesia time and low surgical burden through 50 minutes, and it has high success rate with 100% stone free rate and with low post-operative pain level of 2/10 and short hospital stay of 2.5 days. It has extreme patient satisfaction in terms of cosmetic results.

5 Mohamed Fawzy, et al Transperitoneal laparoscopic ureterolithotomy proved to be an efficient treatment modality for management of upper ureteric stones. Safety: Transperitoneal laparoscopic ureterolithotomy has the opportunity of magnification and can reach and manipulate precisely narrow areas that decrease the operative blood loss (<50cc) and the drop of hemoglobin level ( 0.4mg/dl), also that allows a very low intraoperative morbidity as vascular or gastrointestinal injuries and low late post-operative complications as ureteric stricture. Transperitoneal laparoscopic ureterolithotomy is considered a safe procedure to treat upper ureteric stones. Our results meet the results of other previously published studies. Table (1): Review of published studies results. Author Year Number of cases Stone size Mean operative time Hospital stay Open conversion Mild postoperative complication Al-Azhar & NIUN ±0.3cm 79.8±30.1min 4.15±5.11 days 0% (0) 8% (2) 0% (0) (whole group). Al-Azhar group ±0.2cm 51.2±8.1min 2.62±0.74 days 0% (0) 20% (2) 0% (0) (expert team). Moderate postoperative complication Ahmed Al-Sayed ± 1.3cm 90.1± 12.3min 2.6±1.4 days 0% (0) 0% (0) 8.3% (1) [ureteric stricture] Basiri A., et al ±3.2cm 5.8 days 4% (2) 18% (9) 0% (0) El-Moula G., et al cm 58.7min 6.4 days 12.5% (1) 12.5% (1) 0% (0) [surgical emphysema] Simforoosh N., et al cm 132±52.2min 1 % (1) 12% (12) 1 % (1) [reoperation for 1-4] Abd El-Hakim A., cm 145min 4.1 days 0% (0) 0% (0) 0% (0) et al. Flasko T., et al cm 45min 3.1 days 16.7% (1) 0% (0) 0% (0) Feyaerts A., et al min 3.8 days 4.2% (1) 0% (0) 4.2% (1) [DVT] Turk I., et al min 1-4 days 0% (0) 0% (0) 0% (0) Many further multi-center Randomized Control Trials (RCT) with a large number of patients should be held to compare the efficiency and safety of laparoscopic trans-peritoneal lumbar ureterolithotomy with the laparoscopic retro-peritoneal ureterolithotomy and the Laparo-Endoscopic Single Site ureterolithotomy (LESS) transperitoneally and reteroperitoneally to select the best laparoscopic procedure for managing lumbar ureter stone. Then comparing that best laparoscopic procedure with the less invasive ESWL, URS (flexible and laser lithotripsy) and PCNL and with the open ureterolithotomy. That will help in arranging the treatment option lines of the upper ureteric stones according to their efficiency and safety and clarifying their definite indications, contraindications, advantages and disadvantages over each other in different cases. Unfortunately in developing countries the availability of tools and equipment, the proficiency of the urologist and the costs of management play an important role in the selection of the treatment modality. Conclusion: Transperitoneal laparoscopic lumbar ureterolithotomy is an efficient safe management modality for treatment of lumbar ureteric stones with its high stone free rate, low morbidity rate, less postoperative pain, short hospital stay and good cosmetic results, and it should replace the conventional open ureterolithotomy in the developing countries. The introduction of advances in the flexible URS and laser lithotripsy with its high efficiency and safety has actually reinforced the position of endoscopy as the cornerstone and the gold standard management of all urinary stone.

6 1080 Evaluation of Efficiency & Safety of Transperitoneal Laparoscopic Ureterolithotomy The rapidly evolving technology makes us look forward in the futurity of urological laparoscopy to foresee that robotic assisted laparo-endoscopic single-site surgery will be the treatment of choice to replace all other non-calcular urological surgeries. References 1- PREMINGER G., TISELIUS H., ASSIMOS D., et al.: Guideline for the management of ureteral calculi. Eur. Urol., 52: pp , BINBAY M., YURUK E., AKMAN T., et al.: Is There a Difference in Outcomes Between Digital and Fiberoptic Flexible Ureterorenoscopy Procedures? Endo. Urol., 26: pp , ANDREAS S., ATHANASIOS G., STEFANOS A., et al.: Laparoscopic urinary stone surgery: An updated evidencebased review. Urol., 38: pp , BASIRI A., ZIAEE A., SHAYANINASAB H., et al.: Retrograde URS, antegrade URS and laparoscopic ap- proaches for the management of large, proximal ureteral stones: A randomized clinical trial. Endo. Urol., 22: pp , HONECK P., WENDT-NORDAHL G., KROMBACH P., et al.: Does open stone surgery still play a role in the treatment of urolithiasis? Data of a primary urolithiasis center. Endo. urol., 23: pp , HRUZA M., SCHULZE M., TEBER D., et al.: Laparoscopic techniques for removal of renal and ureteral calculi. Endo. Urol., 23: pp , GILL S., ARNOLD P., ARON M., CADDEDU J., et al.: Consensus statement of the consortium for Robotic LESS. Surgical Endoscopy, 24: pp , SIMFOROOSH N., BASIRI A., DANESH K., ZIAEE A., et al.: Laparoscopic management of ureteral calculi. A report of 123 cases. Urol., 4: pp , AL-SAYED A.: Laparoscopic transperitoneal ureterolithotomy for large ureteric stones. Urol. Ann., 4: pp. 34-7, 2012.