Impact of Extracorporeal Stent Placement during Laparoscopic Pyeloplasty on Operative Duration

Objectives: Ureteric stent insertion during laparoscopic pyeloplasty is the common practice for the reconstruction of ureteropelvic junction obstruction (UPJO). The long and hard learning curve of the method leads still controversy among surgeons. The utility of extracorporeal stent insertion in terms of shortening the length of operation time will be discussed in this study.
Methods: A total of 36 children who underwent pyeloplasty for UPJO were evaluated retrospectively. Indications for pyeloplasty were: Obstruction findings in renal scintigraphy, progressive kidney function loss, increasing in anteroposterior pelvis diameter in renal ultrasonography, and current clinical symptoms (febrile urinary tract infection and flank pain). Extracorporeal stent insertion procedure was performed as the following order: Ureteropelvic area and ureter were visualized transperitoneal by three trochars, and UPJO was excised. Thereafter, the ureter is taken out of the skin from pelvic trochar entrance and is spatulated. JJ stent is placed into the ureter. Following this move, the ureter is taken into the intra-abdominal area and first ureteropelvic suture is performed intra-abdominally.
Results: Thirteen of patients were girls and 23 were boys. Open surgery was applied for 15 patients (Group 1) and laparoscopic pyeloplasty (Group 2) to 21 patients. In Group 2, JJ stent was placed intracorporeally for six patients (Group 2a) and extracorporeally for the other 15 patients (Group 2b). The average age in Group 1 was 49.2±52 months; it was 86±29 months in Group 2a and 144±52 months in Group 2b, and the significant difference was present (p<0.001). There was statistically significant difference between Group 1 and Group 2 regarding with mean hospital stay (40 h in Group 1 and 42 h in Group 2; p=0.001). Post-operative JJ stent removal time was 58.8 days in Group 1 and 52.89 days in Group 2. In Group 2b patients, placing the stent extracorporeally took a significantly shorter operation time and the difference between the operation times of the groups (2a [192 min±3.76] and 2b [135 min±2.6] [p<0.001]) was statistically significant. No statistical difference was found between Group 1 (9.87±5.5 mm) and Group 2 (12.91±5.3 mm) in terms of renal anteroposterior diameters in the control ultrasonographic evaluation at the post-operative 2nd year (p=0.23). There was no difference between the two groups as a result of the evaluation of renal functions by scintigraphy at the post-operative 1st year (Group 1: 3.95±2%; and Group 2: 0.78±5.3%).
Conclusion: According to the consequences in this study, extracorporeally ureteric stent insertion during laparoscopic pyeloplasty shortens the length of operation duration so that extracorporeal insertion might be preferred in cases where it is difficult to place the stent during laparoscopic pyeloplasty.

Laparoskopik Pyeloplasti Operasyonunda Ekstrakorporeal Stent Yerleþtirilmesinin Operasyon Süresine Etkisi

Amaç: Laparoskopik pyeloplasti sýrasýnda üreter stenti takýlmasý, üreteropelvik bileþke darlýðýnýn cerrahi tedavisi için yaygýn olan bir uygulamadýr. Yöntemin uzun ve zor olan öðrenme eðrisi, cerrahlar arasýnda hala tartýþmalara yol açmaktadýr. Ekstrakorporeal stent yerleþtirilmesinin ameliyat süresinin kýsalmasýna katkýsý bu çalýþmada tartýþýlacaktýr.
Yöntem: Üreteropelvik bileþke obstrüksiyonu nedeniyle pyeloplasti uygulanan 36 çocuk retrospektif olarak incelendi. Pyeloplasti endikasyonlarý þunlardýr: Renal sintigrafide obstrüksiyon bulgularý, progresif renal fonksiyon kaybý, renal ultrasonografide anteroposterior pelvis çapýnda artýþ, klinik semptomlar (ateþli idrar yolu enfeksiyonu ve yan aðrýsý). Ekstrakorporeal stent yerleþtirilmesi iþlemiþu sýraya göre yapýldý: üreteropelvik alan ve üreter 3 trokar ile transperitoneal olarak diseke edildi, üreteropelvik bileþke darlýðý eksize edildi. Daha sonra, üreter pelvik trokar giriþ yerinden dýþarý alýndý ve spatüle edildi. JJ stent ekstrakorporeal olarak üretere yerleþtirildi. Takiben üreter batýn içine alýndý ve ilk üreteropelvik sütür batýn içindeatýldý.
Bulgular: Hastalarýn 13'ü kýz, 23'ü erkekti. On beþ hastaya (grup 1) açýk cerrahi, 21 hastaya laparoskopik pyeloplasti (grup 2) uygulandý. Grup 2'de JJ stent 6 hastaya (Grup 2a) intrakorporeal ve diðer 15 hastaya (Grup 2b) ekstrakorporeal olarak yerleþtirildi. Yaþ ortalamasý grup 1’de 49.2±52 ay; grup 2a’da 86±29 ay ve grup 2b’de 144±52 aydý ve anlamlý farklýlýk belirgindi (p<0.001). Ortalama hastanede kalýþ süresi açýsýndan laparoskopik ve açýk cerrahi yapýlan hastalarda anlamlý fark vardý (grup 1'de 40 saat; grup 2'de 42 saat; p=0.001). Ameliyat sonrasý JJ stent çýkarma süresi grup 1'de 58.8 gün ve grup 2'de 52.89 gündü. Grup 2’deki hastalar arasýnda stentin ekstrakorporeal olarak yerleþtirenlerde operasyon süresi belirgin kýsaydý [2a (192 dakika ± 3.76) ve 2b (135 dakika ± 2.6) (p <0.001)]. Postoperatif 2. yýlda kontrol ultrasonografik deðerlendirmede böbrek anteroposterior çaplarý açýsýndan grup 1 (9.87±5.5 mm) ve grup 2 (12.91±5.3 mm) arasýnda istatistiksel fark saptanmadý (p=0.23). Böbrek fonksiyonlarýnýn postoperative 1.yýlda sintigrafi ile deðerlendirilmesi sonucunda da iki grup arasýnda fark yoktu (grup1: %3.95±2; grup 2: %0,78±5.3).
Sonuç: Çalýþmamýza göre, laparoskopik pyeloplasti sýrasýnda ekstrakorporeal olarak üretere stent yerleþtirilmesi,ameliyat süresini belirgin kýsaltmaktadýr ve stentin yerleþtirilmesinde zorlanýldýðý durumlarda ekstrakorporeal olarak yerleþtirme yapýlmasý tercih edilebilir. (SETB-2020-06-106)