ADULT UROLOGY
MAURICIO RUBINSTEIN, ANTONIO FINELLI, ALIREZA MOINZADEH, DINESH SINGH,
OSAMU UKIMURA, MIHIR M. DESAI, JIHAD H. KAOUK, AND INDERBIR S. GILL
ABSTRACT Objectives. To assess the feasibility of ambulatory laparoscopic pyeloplasty. Laparoscopic pyeloplasty aims to reproduce the excellent functional outcomes of open pyeloplasty while diminishing procedural morbidity. Methods. Six patients fulfilled specific inclusion criteria for outpatient laparoscopic pyeloplasty: informed consent, body mass index of 40 kg/m2 or less, primary ureteropelvic junction obstruction, uncomplicated laparoscopic surgery completed by 12:00 PM, and postoperative pain control by oral analgesics. All patients had a double-J ureteral stent placed cystoscopically before laparoscopic access. No drains were placed postoperatively. Results. All 6 patients successfully underwent laparoscopic dismembered pyeloplasty (3 left, 3 right) using the retroperitoneal (n ϭ 5) or transperitoneal (n ϭ 1) approach. The average patient age was 22 years. The mean surgical time was 223 minutes (range 165 to 270), the mean blood loss was 82 mL (range 10 to 250), and the mean postoperative hospital stay was 359 minutes (range 226 to 424). Postoperative analgesia comprised a mean of 6 mg morphine sulfate and 32 mg of ketorolac. No complications or readmissions occurred postoperatively. Intravenous urography and Lasix technetium-99m mercaptoacetyltriglycine renal scans documented resolution of obstruction. With long-term follow-up (mean 38.4 months), no recurrences have developed. Conclusions. We report our initial series of ambulatory laparoscopic pyeloplasty. In this well-selected patient population, outpatient pyeloplasty was feasible and safe.
UROLOGY 66: 41–44, 2005. 2005 With increasing experience and technique re- ureteropelvic junction (UPJ) obstruction. Al-
finements, select laparoscopic procedures
though antegrade or retrograde endopyelotomy is
across various surgical disciplines have been per-
a considerably less-invasive alternative, its success
formed in an ambulatory setting. Laparoscopic gy-
rates have only been 70% to 89% even in well-
necologic procedures such as pelvic adhesiolysis
(including endometriosis surgery) and general
bines the excellent functional outcomes of open
surgical procedures such as laparoscopic cholecys-
surgery with a 1 to 2-day hospital stay and dimin-
tectomy, inguinal herniorrhaphy, incidental ap-
ished morbidity. We report our experience with
pendectomy, and Nissen fundoplication have been
outpatient laparoscopic pyeloplasty.
performed in an ambulatory setting with good re-In 2000, we reported our initial series of
MATERIAL AND METHODS
Open pyeloplasty, with its success rates consis-
Six select patients underwent outpatient laparoscopic py-
tently greater than 90%, has until recently been
eloplasty. The inclusion criteria fulfilled by each patient arelisted in Specifically, each patient expressed an under-
considered the reference standard treatment for
standing of, and willingness to undergo, the proposed proce-dure in an outpatient setting. Each laparoscopic pyeloplasty
From the Section of Laparoscopic and Robotic Surgery, Glickman
was the first case in the morning (first round start), the pro-
Urological Institute, Cleveland Clinic Foundation, Cleveland,
cedure was technically uncomplicated, and was completed by
12:00 PM. All patients were hemodynamically stable intraop-
Reprint requests: Inderbir S. Gill, M.D., M.Ch., Section of
eratively and postoperatively. At the conclusion of the proce-
Laparoscopic and Robotic Surgery, Glickman Urological Insti-
dure, the operating surgeon (I.S.G.) confirmed with the staff
tute, A100, Cleveland Clinic Foundation, 9500 Euclid Avenue,
anesthesiologist that the patient had no anesthesia-related
Cleveland, OH 44195. E-mail: gilli@ccf.org
contraindications to same-day discharge. Submitted: October 26, 2004, accepted (with revisions): Feb-
Between 2000 and 2004, we have performed 55 laparo-
scopic pyeloplasties for UPJ obstruction, 35 primary (64%)
Outpatient laparoscopic pyeloplasty inclusion criteria
Six patients fulfilled the inclusion criteria for am-
bulatory laparoscopic pyeloplasty. None of the 6
Patient and family agreeable to discharge plan
patients experienced any complications or re-
quired readmission. All 6 patients were males aged
12 to 48 years (mean 22). Three patients had a
crossing vessel. The mean surgical time was 223
minutes (range 165 to 270), and all procedures
The mean postoperative hospital stay (from ad-
mission into the postanesthesia care unit to hospi-
tal discharge) was 5.9 hours (range 3.7 to 7). The
mean analgesia requirements comprised 6 mg mor-
Ambulating without significant difficulty
phine sulfate and 32 mg ketorolac. The 3 patients
Abdomen soft, tolerating liquids orallyPain under control on oral analgesics
from the Cleveland Clinic area were discharged tohome, and the 3 patients from outside Cleveland
KEY: UPJ ϭ ureteropelvic junction.
were discharged to an adjacent, geographicallyfree-standing guesthouse. At 6 weeks of follow-up,flank pain had improved in all patients. Pain had
and 20 secondary (36%). Of these patients, 24 (53%) had their
completely resolved in 3 patients and was rated as
surgery performed as the first case of the day (first round
2 in 2 patients and 3 in 1 patient. Lasix technetium-
start). Of the entire cohort, 13 patients had primary UPJ ob-struction and were first round starts. Six of the 13 patients
99m mercaptoacetyltriglycine radionuclide renal
fulfilled all preoperative, intraoperative, and postoperative cri-
scan at 2 months postoperatively confirmed reso-
teria for outpatient laparoscopic pyeloplasty.
lution of obstruction in each patient. During a me-
Laparoscopic pyeloplasty was performed using a retroperi-
dian follow-up of 38.4 months, no patient reported
toneal (n ϭ 5) or transperitoneal (n ϭ 1) approach. A three to
four-port technique was used to perform a dismemberedAnderson-Hynes pyeloplasty (3 left, 3 right). All patients hada 4.7F, 26-cm double-J stent placed cystoscopically preoper-atively. No drains or nephrostomy tubes were placed in any
patient. All patients received prophylactic intravenous antibi-otics and were discharged home with oral antibiotics and a
Several minimally invasive alternatives for repair
of UPJ obstruction have been developed to mini-
The choice of the primary anesthetic agent, dependent on
mize the usual postoperative morbidity associated
the staff anesthesiologist, included propofol in 3 patients and
with major open flank surgery. Open pyeloplasty
isoflurane in 3. Preemptive analgesia was not given. Bupiva-caine (2%) was instilled subcutaneously around the port sites
has been considered the reference standard for the
before port placement and at the conclusion of the procedure.
correction of UPJ obstruction, with success rates
Ketorolac 30 mg intravenously was administered in the oper-
exceeding 90%. Although percutaneous antegrade
ating room before completing the procedure. In the postanes-
and ureteroscopic retrograde endopyelotomy are
thesia care unit, standard monitoring, administration of par-
associated with a shorter hospital stay and more
enteral analgesics and antiemetics, and discharge to the step-
rapid recovery, these endourologic techniques
down observation unit were done at the discretion of the staffanesthesiologist. In the step-down observation unit, liquids
have lower success rates (76% to 90%), even in
were provided orally and patients ambulated. Analgesia in-
cluded parenteral ketorolac supplemented with oral oxyc-
Depending on the availability of expertise, lapa-
odone as necessary. In each instance, the operating surgeon
roscopic pyeloplasty is now a viable alternative
evaluated the clinical status 3 to 4 hours postoperatively and
for patients with UPJ obstruction. Jarrett et
consulted with the patient and family before deciding on dis-charge from the hospital. In the study group, 3 patients were
reported a 96% success rate with laparoscopic py-
from the Cleveland area and 3 lived outside Cleveland. The
eloplasty in 100 cases, with a mean clinical and
patient was given a telephone and/or pager number to directly
radiographic follow-up of 2.7 and 2.2 years, re-
contact the operating surgeon in case of an emergency. The
spectively. Similar to open surgery, laparoscopic
operating surgeon spoke with each patient by telephone on
pyeloplasty is capable of addressing various clini-
the night of hospital discharge to ensure continued well-being. Patients were required to contact the surgeon or a designated
cal situations of UPJ obstruction, including severe
clinical nurse on the first postoperative day to provide an
hydronephrosis, redundant pelvis requiring reduc-
update on their clinical status. The patient was instructed on
tion, concomitant renal pelvic calculi, high ure-
how to remove the Foley catheter on the second postoperative
teral insertion, crossing renal vessels, secondary
day. The double-J stent was removed 1 month postopera-
UPJ after prior failed intervention, and UPJ ob-
tively, and a Lasix technetium-99m mercaptoacetyltriglycinerenal scan was obtained 2 months postoperatively to docu-
struction in anatomic variants such as horseshoe
ment upper tract drainage. Patients were asked to rate their
and pelvic kidneys. Notably, laparoscopic dismem-
bered flap pyeloplasty has been performed success-
UROLOGY 66 (1), 2005
fully even for a recalcitrant, scarred, obstructed
Outpatient laparoscopic surgery may offer some
advantages for a select group of patients. With fi-
We first reported on ambulatory laparoscopic
nancial costs assuming increasing importance,
minimizing the hospital stay should lead directly
lected patients with a mean age of 53 years and
to decreased treatment costs. The cost of laparo-
average adrenal tumor size of 2 cm. The mean sur-
scopic herniorrhaphy was approximately $2000
gical time was 2.3 hours, and the mean blood loss
less when performed at an ambulatory surgical
was 53 mL. The average postoperative hospital stay
center instead of a hospital Intuitively,
was 416 minutes (range 300 to 570). The only
earlier patient ambulation and discharge should
complication was a local abscess requiring delayed
decrease postoperative complications, such as atel-
drainage at 2 weeks. Ambulatory adrenalectomy
ectasis, nosocomial infection, thrombophlebitis,
was feasible and safe, and resulted in high patient
and deep vein thrombosis. However, a prospective
randomized comparison of ambulatory versus
In this study, we extended this concept to outpa-
overnight laparoscopic pyeloplasty is necessary to
tient laparoscopic pyeloplasty. Each patient was
determine whether these potential benefits materi-
required to fulfill all preoperative, intraoperative,
alize and are statistically and clinically significant.
and postoperative inclusion criteria to qualify foroutpatient discharge The operating sur-
CONCLUSIONS
geon counseled each patient preoperatively regard-
With an experienced laparoscopic surgeon at a
ing the laparoscopic pyeloplasty experience, with
medical center accustomed to a high volume of
emphasis on patient expectations of the outpatient
laparoscopic procedures, outpatient laparoscopic
discharge criteria. Of the 13 patients who fulfilled
pyeloplasty is feasible and safe. Meticulous patient
the preoperative inclusion criteria, 7 (54%) did not
selection, careful evaluation before hospital dis-
fulfill the intraoperative and/or postoperative cri-
charge, and close follow-up are mandatory.
teria for the following reasons: pain control issuesin 4, nausea in 2, and intraoperative drain place-
ment in 1. These 7 patients were discharged home
1. Fiorillo MA, Davidson PG, Fiorillo M, et al: 149 ambu-
after a mean hospital stay of 30 hours.
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Ambulatory laparoscopic surgery expresses a
natural evolution of minimally invasive surgery.
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However, some important points must be kept in
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70% hospital admission The same study re-
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ignated study nurse and/or the referring physician
The authors should be congratulated on a well-executed
are imperative to diminish the risk of delayed di-
pilot study demonstrating the feasibility of performing laparo-
agnosis and management of postoperative compli-
scopic pyeloplasty as an outpatient procedure. The issue of
outpatient laparoscopic pyeloplasty is salient as, at centers
UROLOGY 66 (1), 2005
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ADULT UROLOGY