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

INTRODUCTION

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.^3–5 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%.^4–9 However, there is still no prospective randomized study comparing both techniques.^7–9

MATERIALS AND METHODS

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.

RESULTS

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.

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.

DISCUSSION

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%.^3–9 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.

CONCLUSION

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.

REFERENCES

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