Laparoscopic Reconstruction of Pathologies Involving Solitary/Predominantly Solitary Functioning Kidney- Feasibility, Safety and Outcome Analysis

Case Report

Austin J Clin Case Rep. 2017; 4(2): 1120.

Laparoscopic Reconstruction of Pathologies Involving Solitary/Predominantly Solitary Functioning Kidney- Feasibility, Safety and Outcome Analysis

Das K¹*, Abraham GP1,2, Siddiaiah AT¹, Abraham JJ¹, Ramaswami K², Thampan OS² and George PD³

¹Lakeshore Hospital, Kochi, India

²PVS Memorial Hospital, Kochi, India

³AIMS, Kochi, India

*Corresponding author: Krishanu Das, Plot Senior Specialist Urology, Lakeshore Hospital, Kochi, India

Received: March 20, 2017; Accepted: June 15, 2017; Published: July 06, 2017


Purpose: To evaluate the feasibility, safety and outcome of laparoscopic reconstruction of various urological pathologies in patients with Solitary Kidney (SK) or predominantly Solitary Functioning Kidney (PSK) (contralateral unit glomerular filtration rate <10 millilitres/minute/m²).

Materials and Methods: Data of patients operated between January 2005 and December 2012 for similar scenarios was evaluated retrospectively. Preoperative imaging included Ultrasound (USG), Intravenous Pyelogram (IVP), CT or Magnetic Resonance Urogram (CTU or MRU), Diuretic Renogram (DR), Retrograde Urogram (RGU), Voiding Cystourethrogram (VCUG). Operative and postoperative profile was recorded. Follow-ups were scheduled 3 monthly. CTU or MRU and DR were repeated at 1 year post procedure. No intervention during intervening period (ureteral stent, nephrostomy or redo surgery) and improvement in clinical and radiological parameters was considered as successful outcome.

Results: Ten patients underwent laparoscopic reconstruction-3 dismembered pyeloplasty (intrinsic pelviureteric dysfunction), 2 ureteroureterostomy (midureteric stricture), 1 Boari flap ureteroneocystostomy (long lower ureteral stricture), 1 tailoring and non-refluxing reimplantation (obstructive megaureter), and 3 non-refluxing ureteric reimplantation (grade IV vesicoureteric reflux). 5 patients revealed SK and 5 patients PFSK. Mean operative time was 160.5 minutes, mean blood loss was 52.5 ml and mean hospital stay was 100.2 h. There were no significant intraoperative and postoperative complications. Mean follow-up duration was 22 months. Significant improvement was noticed in last follow-up GFR (p 0.00, Paired t test).

Conclusion: Reconstruction of urological pathologies in SK or PSK through laparoscopic approach is feasible and safe. Satisfactory outcome can be achieved preserving the goals of minimally invasive access.

Keywords: Laparoscopy; Pyeloplasty; Pelviuretric junction obstruction; Kidney; Postoperative complications; Ureteral obstruction; Reconstruction


Since its inception laparoscopic surgery has become an integral part of almost all urological ablative procedures [1]. Contrastingly in the field of reconstructive urology, the adoption of this approach was considerably delayed, probably due to the technical concerns [2]. Refinements in technique and increasing familiarity with the approach have resulted in more liberal application of this approach in the field of reconstructive urology in the present decade [3]. Laparoscopic pyeloplasty currently ranks as the most commonly performed urological reconstruction. The reported long term outcomes following this approach have been at par with the conventional open approach and this is currently considered the standard of care approach for pelviureteric rehabilitation [4,5]. In recent times, other reconstructive surgeries like ureteroureterostomy, Boari flap and ureteric reimplantation have also been increasingly performed via laparoscopic or robotic assisted laparoscopic access. However there is paucity of data in the literature about laparoscopic reconstructions for various urological pathologies in patients with solitary or predominantly solitary functioning kidney. Although laparoscopic approach is not absolutely contraindicated in these scenarios, in view of circumstantial challenges probably incisional approach remains the favored modality in such circumstances.

We narrate our experience in laparoscopic reconstruction of various urological pathologies in solitary or predominantly solitary functioning kidney and analyse the feasibility, safety, morbidity profile and renal function outcome.

Materials and Methods

Patients with SK/PSFK who underwent reconstructive procedures for various urological pathologies between January 2005 and December 2012 were included in the patient cohort. Permission was obtained from institutional review board. All procedures were performed by a single surgeon proficient in laparoscopic surgeries (GPA) and were conducted in two centers. Pre procedure evaluation included assessment of presenting complaints, previous clinical profile and previous surgical intervention. Routine blood investigations and renal function tests were carried out. All patients underwent preliminary ultrasound screen. Patients with suspected PUJ obstruction, ureteric stenosis or obstructive megaureter underwent CTU or MRU (in patients with altered renal profile at presentation), DR and RGU. Ureteric stenosis were classified as distal (distal to sacroiliac joint to vesicoureteric junction), middle (over the sacroiliac joint) or proximal (above the sacroiliac joint to pelviureteric junction) based on location of the pathology. Patients with a history suggestive of Vesicoureteric Reflux (VUR) were evaluated with Voiding Cystourethrogram (VCUG) and DR. In lower ureteric and vesicoureteric pathologies, cystoscopy was performed to rule out coexistent bladder pathologies. Patients revealing gross pelvicaliceal dilatation and altered renal profile at presentation underwent urinary diversion (Double J ureteral stent or percutaneous nephrostomy) prior to definitive correction. All laparoscopic procedures were undertaken via transperitoneal access.

Operative exercise

Laparoscopic pyeloplasty: A dismembered pyeloplasty was performed in all scenarios. If tension was apprehensed during pelviureteric approximation, the entire renal unit was mobilized following the intra-Gerotas’ fascia plane and displaced caudally. Pelviureteric anastomosis was undertaken employing interrupted sutures of 4-0 polyglactin. Any additional closure of the excised redundant pelvis was conducted in a continuous manner. Ureteral stent was inserted antegrade prior to anastomotic completion.

Laparoscopic ureteroureterostomy: Ureteric mobilisation was performed and pathological segment delineated. Dismemberment, exclusion of the culprit segment, spatulation of opposite ends and tension free reunion remained the subsequent exercises. Meticulous attention was paid to preservation of periureteral vascularity and optimum spatulation was conducted to ensure a wide anastomosis. A Double J ureteral stent was inserted in antegrade fashion and interposed across the anastomosis.

Laparoscopic boari flap: Our technique of laparoscopic Boari flap has been previously demonstrated [6]. Meticulous attention was paid to preserve ureteral and flap vascularity. Ureterovesical anastomosis and flap tubularisation was conducted with 3-0 polyglactin suture and bladder closure with 2-0 polyglactin suture.

Laparoscopic antireflux surgery: Our technique of laparoscopic antireflux surgery has been previously demonstrated [7]. Care was taken to preserve the vas deferens that lies in the vicinity of vesicoureteric junction. Detrusorraphy was conducted using interrupted 3-0 polyglactin sutures.

Laparoscopic ureteral tailoring: Our technique of laparoscopic ureteric tailoring has been previously demonstrated [8]. The ureter was dismembered immediately proximal to the pathological segment and all tortuosities straightened. The ease of approximation of the dismembered ureter to the bladder was ascertained. Thereafter, the lower 5 centimeters of the straightened ureter was tailored. The ureteral circumference was reduced to a size that just accommodates a 6 F ureteral stent. Ureteroneocystostomy was performed using 3-0 polyglactin followed by extravesical antireflux creation using 3-0 polyglactin.


Operative and postoperative details were recorded. Renal profile was assessed on first postoperative day and then at periodic intervals. Ureteral stent was removed 6 weeks post procedure. The followup protocol included 3 monthly revisits with evaluation of clinical parameters, renal profile and ultrasound. CTU or MRU and DR were repeated at 1 year post procedure.

Outcome analysis

No intervention during the follow-up period (ureteral stent, nephrostomy or redo surgery), stabilization or improvement in renal profile, stabilization or improvement in hydronephrosis and drainage parameters at 1 year was considered a successful outcome. Statistical interpretation.

Statistical analysis was done by using SAS software 9.2 version. A p value <0.05 was inferred as statistically significant.


Demographic details are projected in Table 1. At time of definitive reconstruction, 5 patients revealed SK and 5 patients revealed PSK. The patient with lower ureteric stricture underwent preoperative nephrostomy drainage 3 months prior to definitive correction. In all other cases definitive procedure was undertaken without any temporary urinary diversion. All 10 patients underwent laparoscopic reconstruction successfully-3 dismembered pyeloplasty (intrinsic pelviureteric dysfunction), 2 ureteroureterostomy (midureteric stricture), 1 Boari flap ureteroneocystostomy (long lower ureteral stricture) and 1 tailoring and non-refluxing reimplantation (obstructive megaureter) and 3 non-refluxing ureteric reimplantation (pediatric vesicoureteric reflux, Grade III-IV). The operative, postoperative and follow-up profile is depicted in Table 2. There were no remarkable intraoperative and postoperative events. A significant elevation was appraised in first postoperative day creatinine from preprocedure values (p 0.00). Till last follow-up, all patients reported an improved clinical profile. 9 patients completed 1 year followup. No patients required any intervention during the intervening period. Figure 1 potrays the comparative analysis of preoperative and postoperative creatinine and GFR. Last follow-up creatinine was statistically equitable to the preprocedure levels (p=0.07, t test). A significant improvement was remarked in last follow-up GFR in comparison to the preoperative profile (p=0.001, t test).