World Journal of Laparoscopic Surgery
Volume 12 | Issue 3 | Year 2019

Laparoscopic Ureterolysis without Omentoplasty in the Management of the Uropathy Secondary to Idiopathic Retroperitoneal Fibrosis

Miguel A Bergero1, Patricio A Garcia Marchiñena2, Guillermo Gueglio3, Carlos David4, Fernando Dipatto5, Alberto Jurado6

1,4,5Department of Urology, Sanatorio Privado San Geronimo, Santa Fe, Argentina
2,3,6Department of Urology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

Corresponding Author: Miguel A Bergero, Department of Urology, Sanatorio Privado San Geronimo, Santa Fe, Argentina, Phone: +54 34299960, e-mail:

How to cite this article Bergero MA, Garcia Marchiñena PA, Gueglio G, et al. Laparoscopic Ureterolysis without Omentoplasty in the Management of the Uropathy Secondary to Idiopathic Retroperitoneal Fibrosis. World J Lap Surg 2019;12(3):126–129.

Source of support: Nil

Conflict of interest: None


Introduction: Obstructive uropathy (OU) secondary to idiopathic retroperitoneal fibrosis (IRF) is an infrequent disease, and the standard treatment has not been established. However, ureterolysis with ureteral intraperitonealization is an effective therapeutic alternative. We present the successful management of OU secondary to an IRF by laparoscopic ureterolysis without omentoplasty (LUWO).

Materials and methods: A retrospective descriptive study of 5 patients with IRF treated with LUWO was performed.

Results: The average age was 60.4 years. The average creatinine was 3.86 mg/dL. There were no intraoperative or major postoperative complications. In a follow-up period of 31.2 months, all patients are asymptomatic, with an average creatinine level of 1.52 without dialysis requirement. No patients required corticosteroid therapy after surgery.

Conclusion: Laparoscopic ureterolysis without omentoplasty is a safe and feasible option to treat the OU caused by IRF that provides good results in the medium-term follow-up, as we describe it in our series of cases.

Keywords: Hydronephrosis, Laparoscopy, Retroperitoneal fibrosis, Ureteral obstruction.


Obstructive uropathy (OU) related to idiopathic retroperitoneal fibrosis (IRF) is a rare disease characterized by retroperitoneal fibrosis. The pathology has theorized to be an inflammatory response to oxidized low-density lipoproteins.1,2 Because IRF has a very low prevalence, no treatments have been standardized.35 Surgical ureterolysis with intraperitonealization (SUWI) has been considered as a definitive treatment for ureteral obstruction caused by IRF. Usually, SUWI has been done open (open ureterolysis with intraperitonealization (OUWI)), with a high success rate, >90%. But, with a high morbidity rate, ≥60%. Laparoscopic ureterolysis with intraperitonealization (LUWI) of the ureter with or without omental wrapping has also shown a high success rate, >90% with a low morbidity rate <30%.49 However, there is still no prospective randomized study comparing both techniques.79


A retrospective multicenter descriptive study of 5 patients with OU secondary to retroperitoneal fibrosis treated surgically with laparoscopic ureterolysis without omentoplasty (LUWO) during the years 2012 and 2017 was performed.

The variables for the study were age, sex, symptoms at the time of pathology’s presentation, blood analysis [erythrocyte sedimentation rate (ESR), tumor markers, autoimmune disease markers, creatinine], imaging studies (ultrasound, computed tomography or magnetic resonance, renal scintigraphy, positron emission tomography), corticoids treatment, ureteral catheter or nephrostomy. In addition, the variables related to the surgical intervention were evaluated: surgical time (minutes), intraoperative and postoperative complications (Clavien scale), bleeding (mL), pain management with pain ladder of the World Health Organization (WHO) and time of hospitalization (hour).

The follow-up was performed with creatinine and renal scintigraphy 1 month after surgery and then at 6 months. The correct functioning of the kidney was considered an adequate renal function without requiring a urinary neither stent or dialysis treatment.

Surgical Technique

Ureteral stenting was performed preoperatively. The patient was placed in an extended plank position. Four ports sites were placed according to the surgical technique (Fig. 1).

In the first step of the procedure, the line of told was incised, and the colon was deflected. The aorta and the external iliac artery were clearly exposed. Close to the aorta and riding the iliac artery, the encased ureter was identified and released from the fibrotic mass using a blunt instrument (Figs 2 and 3). Once the ureter has been completely released from the fibrotic tissue, along the full length between the renal pelvis and iliac vessels, we proceeded with the intraperitonealization of the ureter (Figs 3 and 4).

Fig. 1: Disposition of laparoscopic ports in laparoscopic ureterolysis: the initial port of 10 mm is placed pararectal at the level of the umbilicus (laparoscopy). The second port of 10 mm is placed in the iliac fossa. The other two remaining 5 mm ports are placed in the hemiclavicular line and the anterior axillary line in the upper abdominal quadrant

Figs$$$2A to E: (A) Ectasia of the renal pelvis; (B) Ureter compromised by retroperitoneal fibrosis; (C) Retroperitoneal fibrosis; (D) Muscle psoas; (E) Kidney

Figs$$$3A to D: (A) Riding the external iliac artery (EIA), the encased ureter was identified; (B and C) Ureter was release from the fibrotic mass using a blunt instrument; (D) Pericolonic fat was interposed between the ureter and the fibrosis. Ao, aorta; Co, colon; EIA, external iliac artery; FM, fibrotic mass; P, psoas muscle; U, ureter

Figs$$$4A to D: (A) Kidney; (B) Intraperitonealization of the ureter; (C) Interposition of pericolonic fat with its fascia between the ureter and the fibrosis; (D) Bladder

In our cases, the peri-colonic fat was interposed between the ureter and the fibrosis (transposition of the ureter) without an omental wrapping. 6 weeks after surgery, the ureteral stent was removed.


Of the 5 patients analyzed, the average age was 60.4 years (55–67), and 80% were female. Sixty percent of patients had back pain and 40% oliguria. The average creatinine was 3.86 (1.2–8.6). All patients had negative autoimmune disease markers and tumor markers. The patient’s characteristics were described in Table 1. All patients underwent ULIP without omentoplasty. There were no intraoperative or postoperative complications major to Clavien 2 (1 patient presented a wound infection that required oral antibiotics). The average surgical time was 137 minutes (97–215) with an average blood loss of 84 (10–110) mL, without requiring transfusions. The average time of hospitalized was 51 hours (36–62), and all had mild pain that was controlled with non-steroidal analgesics.

Table$$$1: Patient’s characteristics
67*Left RN (2005)Back pain, oligoanuria (2013)ÇCr 8.6CT: right RF, OUNoUSRight LUWI WOIRF2018:Ç
ESR: 80MRI: IDEMNo symptoms
TM (−)RS: OUCr 1.9
MAD (−)RS: no OU
No CTh
63*Cholecystectomy 2014:Ç, right IRF + OU OUWIBack pain (2016)ÇCr 3.7CT: left RF, OU MRI: IDEMPrednisoneUSLeft LUWI WOIRF2018:Ç
ESR: 95RS: OUIntoleranceNo symptoms
TM (−)PET: PAMCr 2.1
MAD (−)RS, no OU
No CTh
52*AHBack pain (2015)ÇCr 1.3CT: right RF, OU. MRI: IDEMPrednisoneUSLeft LUWI WOIRF IG4 (+)2018:Ç
ESR: 78RS: OUTamoxifenNo symptoms
TM (−)PET: PAMCr 1
MAD (−)RS: no OU
No CTh
65*CholecystectomyOligoanuria (2016)ÇCr 4.5CT: bilateral RF, OU. MRI: IDEMPrednisoneUSLeft LUWI WOIRF2018:Ç
ESR: 87RS: OUIntoleranceNo symptoms
TM (−)RK no RPCr 1.7
MAD (−)RS, no OU
No CTh
55*NoAsthenia weight loss (2017)ÇCr 1.2CT: right RF
PrednisoneUSLeft LUWI WOIRF2018:Ç
ESR: 90RS: OUTamoxifenNo symptoms
TM (−)Cr 0.9
MAD (−)RS, no OU
No CTh

A/S, age and sex of the patients; CR, clinical record; BT, blood test; DI, diagnostic image; *, age; ♂, male; ♀, woman; RN, radical nephrectomy; AH, arterial hypertension; Ç, year; Cr, creatinine (mg/dL); ESR, erythrosedimentation rate (mm/hour); TM, tumor markers; MAD, markers of autoimmune disease; CT, computed tomography; MRI, magnetic resonance imaging; RS, renal scintigraphy; PET, positron emission tomography; OU, obstructive uropathy; RK, right kidney; LK, left kidney; RF, retroperitoneal fibrosis; IRF, idiopathic retroperitoneal fibrosis; LUWI, laparoscopic ureterolysis with intraperitonealization; LUWI WO, laparoscopic ureterolysis with intraperitonealization without omentoplasty; OUWI, open ureterolysis with intraperitonealization; US, ureteral stent; CTh, corticosteroids therapy; PBS, procedure before surgery; RE, renal ectasia; TTO, treatment; PA, pathological anatomy; RP, renal parenchyma

In an average follow-up period of 31.2 months (25–63), all patients are asymptomatic, with an average creatinine of 1.52 (0.9–2.1) with a renal scintigraphy without an obstructive pattern. No patients required neither corticosteroid therapy nor dialysis after surgery.


Obstructive uropathy related to IRF is an uncommon but severe disease that may cause renal loss with dialysis requirement. Prompt diagnosis and appropriate treatment may prevent terminal kidney disease.1,2 However, there is no standardized treatment.3,4

In patients with OU associated with IRF, as discussed in our cases, there are two treatment options: medical treatment (corticosteroids or methotrexate or tamoxifen or the combination of these drugs) with or without urinary stent or urinary stenting followed by a SUWI with or without corticosteroid therapy.4,10,11

Medical treatment with urinary stenting demonstrated a success rate between 53% and 75%. Fry et al.10 reported a success rate of 75% in 24 patients treated with prednisone associated with a urinary stent for 13.7 months. But, after a follow-up of 60.9 months, Ilie et al.11 reported that only 54% of the patients were either free of corticosteroids therapy or urinary stent. These data indicate that patients treated medically require a urinary stent for long periods of time, which is associated with huge morbidity.

Open ureterolysis with intraperitonealization or LUWI has shown success rates between 83% and 100%.39 O’Brien and Fernando4 performed a prospective analysis of 50 patients who underwent OUWI and showed a 94% success of urinary stent free without corticosteroid therapy a year after surgery. Duchene et al.5 evaluated 73 patients who performed LUWI in a multicenter study and showed an 83% success rate 17.7 months after surgery with or without adjuvant corticosteroid therapy. Simone et al.6 with a few patients who underwent LUWI showed a success rate of 100% at 37.7 months after surgery without adjuvant corticosteroid therapy.

When LUWI and OUWI were compared, Elashry et al.7 showed that patients treated with LUWI had less morbidity, less blood loss, and less hospitalization with similar functional results than OUWI. Srinivasan et al.,8 in a series of 70 patients, showed that there were no differences between the two techniques in the resolution of OU, but patients who underwent LUWI had less blood loss and less hospitalization. However, Styn et al.,9 in his comparative study did not see differences between the two groups in terms of complications or transfusion requirements, but the success rate was 87.5% after OUWI, and 93.8% after LUWI.

Even though this report is a retrospective study and the number of cases is low, it shows that LUWI without omentoplasty is feasible with good results in the medium-term follow-up.


Laparoscopic ureterolysis with intraperitonealization without omentoplasty is a safe and feasible surgical option and provides good results in medium-term, follow-up in patients, with IRF as we described in our case series.


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