Laparoscopic strategies in complex upper urinary tract obstruction.

OBJECTIVES: We enumerate the various laparoscopic strategies to resolve upper urinary tract (UUT) obstruction in the context of variations in anatomy and report their outcomes.

PATIENTS AND METHODS: Retrospective review of primary laparoscopic UUT reconstructions performed between May 2012 and May 2021. Anomalies included: malrotated kidney (MRK), horseshoe kidney (HSK), duplex kidney (DK), pure intrarenal pelvis (IRP) and mid-ureteric stenosis (MUS). Success was defined by postoperative resolution of symptoms, improvement of anterior-posterior renal pelvic diameter (APD) on US and drainage on Mag3. Complications were categorised by Clavien-Dindo grading. Outcomes compared using the student's t-test with P < 0.05 considered statistically significant.

RESULTS: Of the 214 laparoscopic primary UUT reconstructions, 37 (17.2 %) were: 13-MRK, 12-HSK, 4-DK, 4-IRP and 4-MUS. Median age at surgery was 5-years (range 0.3-15). Dismembered pyeloplasty: 8; pyeloplasty with renal sinus dissection: 8; neo-PUJ anastomosis: 8; primary ureterocalycostomy: 7; pyeloureterostomy: 2; and uretero-ureterostomy: 4. Median follow-up was 43-months (range 8-108) with a success rate of 94.5 % (35/37). Complete resolution of symptoms in 20/21 patients; improvement of hydronephrosis on US in 35/37 patients (median pre-operative APD 27 mm vs. median postoperative APD 8 mm) [P < 0.001]; improvement of drainage on diuretic renogram in 32/34 kidneys and stable/improved DRF in 34/35 kidneys (median preoperative DRF - 45 % vs. median postoperative DRF - 47 %) [P > 0.05]. Postoperative complications managed medically (II Clavien) included urinary tract infections - 2 patients (5 %), stent-related symptoms in 2 (5 %) and umbilical port site collection in 1 patient (3 %). Recurrent pelvi-ureteric junction obstruction PUJO occurred in one patient (3 %) requiring redo surgery (IIIb Clavien), renal stones in 1 (3 %) which resolved with ESWL (IIIb Clavien); in 1 (3 %) patient with a HSK there was complete loss of ipsilateral kidney function but this was managed conservatively up to date (I Clavien).

CONCLUSION: Laparoscopic transperitoneal approach allows the prompt recognition of in-situ anatomical variants. UUT obstruction in such settings calls for a variety of strategies with excellent outcomes.