Background: To evaluate safety,
clinical efficacy, and cosmetic results after pyeloplasty using
Mini-Laparoscopic Instruments (MLP) compared with standard laparoscopic
pyeloplasty (SLP) in patients with Ureteropelvic Junction Obstruction (UPJO).
Methods: From September 2009 to September 2014, 29 extroperitoneal MLPs
were performed, and in the corresponding period, 22 extroperitoneal SLPs were conducted in patients with UPJO in our
hospitals. The data from two groups were reviewed and studied.
Results: Baseline characteristics were similar between
the groups. There were no conversions to open procedures in groups. There were
no differences in operative duration, blood loss, day of catheter removal, time
for backing to normal diet, and perioperative complications in two groups（P>0.05）. The average postoperative hospital stays,
postoperative analgesics required and the pain Numerical Rating Scale (NRS)
scores at first postoperative day were less or lower for group MLP than that
for the group SL（P<0.05). Mean follow-up time was 23（6-36）months. The values of anteroposterior pelvic diameter
on Ultrasound within each group were decreased significantly（P<0.05), but were similar between the two groups
at 1 year after surgery（P>0.05）. The GRFs of impaired split renal function in both
group were significantly elevated, whereas there was no significant difference
in mean values of GRF between the two groups at 1 postoperative year (GRF,
MLP:45±18ml/min vs SLP:47±16 ml/min, P>0.05). The
questionnaires showed that patients in group MLP were significantly more
satisfied with their cosmetic
Conclusions: Our initial experiences suggest that pyeloplasty
using mini-laparoscopic instruments appears to be safe, feasible and effective
in the treatment of PUJOs. Cosmetically, it is better than standard
Keywords: Mini-Laparoscopy; Operation Instruments;
Pyeloplasty; Ureteropelvic Junction Obstruction
Abbreviations: MLP: Mini-Laparoscopic Instruments;
SLP: Standard Laparoscopic Pyeloplasty; UPJO: Ureteropelvic Junction
Obstruction; NRS: Numerical Rating Scale; ECT: Emission Computed Tomography
With the continuous innovation and development of the
laparoscopic instruments, there are more and more tiny instruments being
invented, which leads the pyeloplasty less invasive. Tan, et al. reported that the needle-scope (or we call mini-laparoscopic) with 2.0mm
diameter was used for children Ureteropelvic Junction Obstruction (UPJO) . Here we improved the
mini-laparoscopic: 5.5mm trocar on the observation lens, 3.0mm trocar on the
reflective lens, and 2.8mm operation instruments. We performed series of
Urology surgery using the improved min-laparoscopic, and it demonstrated an
ideal clinical efficacy. All surgeries were taking place from September of 2011
to September of 2014. Among them, 29 cases of UPJO were conducted by the
mini-laparoscopic mentioned above, while 22 were by conventional ones. We
compared the results and got this report.
2.1. Clinical Data
The sample contains 51 patients of UPJO. One group of
29 patients were treated with mini-laparoscopic (MLP group) while the other
group of 22 treated by standard laparoscopic (SLP group). In MLP group there
were 18 males and 11 females. Their age ranged from 9 to 64 with an average age
of 27.5. Correspondingly, SLP group contains 14 males and 8 females. The age
ranged from 9 to 65 with an average of 29.5. The comparative data of two
groups’ age, gender composition, BMI and left & right distribution of UPJO.
There is no statistical significance in terms of two groups index difference.
Two groups patients were diagnosed with UPJO and the diagnosis was confirmed by
Urography, CT and Urinary system imaging. Emission Computed Tomography (ECT)
and/or Diuretic kidney diagram were used to judge the level of Urinary tract
infarction. Two groups applied the same inclusion criteria and exclusion
criteria. Inclusion criteria: (1) Patients with obvious expansion of Renal
Pelvis and Calendula, or the diameter of Renal Pelvis is larger than 3.0cm, or
those whose bad kidney was still functional despite of badness with an
GRF>10%; (2) Renal Pelvis and Calendula expanded progressively; (3) Patients
with symptoms of bellyache and urinary tract infection but not caused by gastrointestinal
diseases. Exclusion criteria: (1) Patients with the multiple surgical history
at side of waist abdomens before the pyeloplasty and those whom we think would
be difficult to be established retroperitoneal cavity, separation and adhesion;
(2) Patients with severe cardiopulmonary disease, arrhythmia, heart failure,
pulmonary ventilation disorders and those who cannot or do not accept the
2.2. Surgery Instruments
MLP group: 5.00 mm high definition mini-laparoscopic (Olympus
Company produces two types: 0° and 30°), 5.5mm and 3.0mm trocar (Made by Hangzhou Kangji Medical Device
Company), 2.8mm separation clamp, needle holders, hook electrodes, scissors,
and irrigation aspirators and other reusable equipment (Figure 1).
SLP group: 10mm high definition laparoscopic (Made by
Olympus Company), 10.5mm and 5.5mm trocar (Made by Hangzhou Kangji Medical
Device Company), 2.8mm separation clamp, needle holders, hook electrodes,
scissors, and irrigation aspirators and other reusable equipment (Image 1).
2.3. Surgical Methods
Surgeries were operated in abdominal cavity while
patients were fully anesthetized. Two groups’ patients were treated with the
same operator. The establishment of retroperitoneal space: Abdominal wall
puncture was made by piercing cone with trocar. Through observation lens, we
used direct separation method to establish it. Patients were in lateral
position and raised their waist with their shoulder leaning forward around 10°-15°. Then we
cut and left a 2cm incision above axillary line skeleton (Make sure it reaches
subcutaneous fascia). The direction of puncture was vertical with the skin
surface. Stop piercing at the moment when you felt a sudden drop. Normally the
depth is 3-5cm. then removing the piercing cone, inserting observation lens, adjust to just below the back
fascia (with visible yellow fat) and finally swing the lens to produce the gap.
Under straight look when the lens was closely stuck to outer fat we proved that
once CO2 enters in retroperitoneal space, keep swinging the lens will push
forward peritoneum to axillary line and push backward peritoneum to separate it
from abdominal wall and psoas muscle. If we press the abdomen from outside,
there would be a safer and better effect because the gap will grow bigger and
bigger. All methods mentioned above were used in both groups. The only
difference is that the cut depth in MLP group was 3-4mm using 5.5mm trocar and
mini-laparoscopic while in SLP group the depth was 7-8mm using 10.5mm trocar
and traditional laparoscopic.
Under the direction of observation lens, in MLP group
we pierced two 3.0mm trocars blow 2-3cm of 12th flange front and backside of
auxiliary line respectively (Figure 2a).
In SLP group we did pierced 5.5mm and 10.5mm trocar
respectively. Post-cavity pressure maintained between 12-14mmHg in both groups
and so as the junction obstruction. Cut the perirenal fascia vertically using
electrodes to exposure the underneath of the back side of kidney, separate
upper side of pelvis and ureter exposed in air then we identify the proposition
of obstruction and figured out the reason. We cut the pelvis parenthetically in
accordance with its feature to prevent inner part from being separated with
ureter. There was 1 patient of pelvis stones in each group and we tried to take
it out. We cut ureter vertically below the obstruction around 0.1-1.0cm first.
In MLP group we use 5-0 absorbable line to stitch the lowest part which was cut
before (In SLP group 4-0 or 5-0 absorbable line was used). Then we cut the
ureter at remote end of obstruction. Continuous suture method was used at one
side, leaving sewing length around 0.8-1.0cm. If pelvis was cut deeper than the
stated lengths, stitch longer until the pylon opening. Patients without putting
double J tube by Cystoscope should be put the tube through cutting point and
then suture the other end (Figures 2b-2f).
Put 1 same drainage tube through ridge by trocar for
both groups. In SLP group we used 10.5mm trocar to insert the tube and stitched
1-2 needles at all cuts. In MLP group we used 2.8mm champ insert the tube
through 3mm trocar after going through 5.5mm trocar. After this, remove 5.5mm
trocar. There is no need to sew the 3.0mm wound because of its short diameter
and less repairing needles (Figure 2f). Double J tube will be removed after 4
weeks of the surgery.
2.4. Evaluation Factors for Efficacy
We marked down surgery duration, complications, open
transfer rate, estimated bleeding, duration of in-hospital stay, pain level,
urine wilt, the possibilities wound infection, and satisfaction of body
recovery. Continuous observation on diameter before and after separation, the
change of GRE, evaluation on obstruction improvement is required by ultrasound
(or water Image on urinary tract when necessary), MRU and Diuretic reprogram
examination after 3 months, 6months, 1 year and 2 years. NRS methods was
adopted to evaluate the pain level. Survey was used to evaluate patients
2.5. Statistical Analysis
SPSS17.0 was utilized for helping analyse. The data
difference was compared by**, measurement difference was compared by
Mann-Whitney level. P<0.05 is statistically significant.
Two groups’ surgeries were operated successfully
without any Interim open surgery patients, intestinal damage or organ damage
cases. There is no statistical significance (P>0.5) in surgical blood loss,
duration of drainage tube, postoperative recovery time, urinary atrophy and
wound infection rate. Though the operation duration in MLP was longer than that
of SLP, there is no statistical significance neither. However, in-hospital time
and demand of medicine after the surgery in MLP group is significantly less
than those of SLP group. One case in MLP group: we took out two kidney stones
from a female patient after smashing them and transferred another one
(1.0cm*0.8cm*0.5cm) into Retroperitoneal cavity. The patient doesn’t fell any
discomfort until now. One case in SLP group as demonstrated: we took out one
kidney stone from one male patient with obesity by means of Choledochoscope and
remained the other 3 in the body. There is no severe complication, neither no
death rate.51patients were investigated for a continuous period of time
(average 23 months). We found one patient from each group diagnosed with
Anastomotic obstruction and we conducted Ureteral balloon dilation for them
after 6 and 9 months respectively under full anaesthesia. They were cured after
3-month double J tube in the body. All patients had no more Urinary tract
infection and feelings of back pain. Ultrasound Image suggested that there is
no increasingly separation of pelvis and that AP value decreased dramatically.
1 year later, the average AP value of two groups has no more statistical
significance (MLP: 2.4+-0.8cm vs SLP: 2.5+-0.9cm) but the value is lower than
before. The average GRE in Diuretic kidney diagram (14 from MLP and 9 from SLP)
show the result of 45+-18ml/min vs 47+-16ml/min. Compared with before, there
was a significant increase in GRE (P<0.5). The survey we conducted suggested
that MLP patients are more satisfied with the results that that of SLP group.
Currently, MLP gets recognised by the filed to conduct
surgery for UPJO patients and is chosen as the first choice and highest
standard. However, the medical professions are still finding a better
substitute. With the invention of mini-Laparoscopy, we are entering a boom
period of mini-equipment. Previously Tan reported that 2.0mm laparoscopy was
used to cure a child patient, resulting a lower definition/contrast and less
wide scope of the Image than conventional one .
Besides, it was only available for Acupuncture without 2mm Set folder, hook
electrode and needle holder. 2mm is not proper to hold the equipment and the
attractor flow is not high. When some device stuck in the tube, smoke caused by
electrode cannot be discharged out of body. That’s why Acupuncture is limited.
Our study shows that improved laparoscopy works better and provides the same
quality Image as the conventional
laparoscopy. Besides, it has two types to choose (0 and 30 degree). Therefore,
2.8mm tube is safer together with Set folder, hook electrode and needle holder.
Cheng, etc,  reported that infant UPJO patients can
also be treated with mini-laparoscopy as long as make them lie down. Puncture
at 11-4 umbilicus point, insert observation lens, then put the tube(3mm/5mm) at
5-7 umbilicus point. Doing this make it easy insert Single-hole laparoscopy.
Simforoosh etc,  proved that MLP for infants is
safer than SLP with less trauma and more satisfying efficacy. In Fiori etc, ‘s  study, they treated 12 adult patients with 3mm laparoscopy. Compared
with 24 patients cured by CLP, they concluded that those 12 had less
in-hospital days and were more satisfied. One difference from our study is that
all references mentioned above the patients lied down while we required
patients lied at one side but all puncture point are the same.
Ureteropelvic angioplasty through multiple entries of
umbilical hole caused less trauma. It only requires one cut which hides
secretly below the umbel can minimises the width of the wound. Therefore, it
appears a better Postoperative cosmetic result and leads a less painful effect.
Ureteropelvic angioplasty cannot work perfectly with Single-hole laparoscopy
because the laparoscopy is easy to be bent and cause crash with another device
in the tube, which increases risks. Curvable needle is distinct from
traditional laparoscopy during the operation. Compared with Single-hole
laparoscopy, we chose a more convenient one, which leads less trauma. Three
cuts we made are 5.5mm, 3mm, and 3mm respectively while the former one made a
cut within 20-30mm. Our study suggested that MLP has a less trauma than SLP,
less than half in terms of the length despite of the same operation manner.
Duration of operation, blood loss during the surgery, duration of drainage tube
and time required of recovery of normal diet have no statistical significance.
MLP appears a less pain effect, a shorter in-hospital duration and more
satisfying efficacy. In long term run, we conclude that there will be no
significantly medical difference for UPJO patients’ improved kidney function
between MLP and SLP. MLP turns out to be a more operation accuracy oriented
medical equipment especially when it comes to ureter cut and suture compared
with SLP and Single-hole laparoscopy with multi channels. 2.8mm needle holder
can hold the 5-0 absorbable line better. However, if it is used to hold 5-0
needle tube, it will lead to the structure change of the needle and stuck in
the tube. That is not recommendable for us. Our key study point is to find how
to insert trocar and to establish Retroperitoneal with 5.5mm trocar. There have
already been reference books talking about direct puncture method to establish
Retroperitoneal. They did it like this: first cut 1.0-1.5cm in length under
skin with a lean of 0-30 degree and 5-7cm in depth; then swing the laparoscopy
to establish it under straight sight. On the contrast, we only cut 3-4 mm and
used 5.5mm trocar to do the same work, which minimised the trauma of celiac
wall. Trocar normally was fixed by the skin tension, so we do not need to fix
it ourselves. Puncture depth is around 3-5cm, reaching the boarder of
Extramembranous fat and abdominal fascia. At this moment we swing the
laparoscopy. To realize this project, we strong recommend that the puncture
depth shall not exceed our limit because once we puncture too deep, the sight
will be blocked by yellow fat due to inflatable expansion. In SLP group study
we also used the same method (cut 7-8mm) to establish Retroperitoneal. The
duration to establish it in two groups has no statistical significance.
Nowadays there is no MLP 2.8mm set folder and ultrasound knife, in order to
stop blood loss, we must use Electrocoagulation. Leaving trocar open (one
air-in and two air-out) can accelerate emission of smoke caused by
Electrocoagulation when necessary [8-11].
Our clinical research suggests that
mini-laparoscopy is safe for UPJO surgeries and that can get the same clinical
efficacy compared with those conducted by conventional laparoscopy but a
minimal trauma and painful feelings and a faster recovery and better
satisfaction for patients.
Figure 1: Result of follow-up during after surgeries.