Gloveport-assisted retroperitoneal pyeloplasty (GARP): a case report

doi:10.21203/rs.3.rs-4869919/v1

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Case Report

Gloveport-assisted retroperitoneal pyeloplasty (GARP): a case report

https://doi.org/10.21203/rs.3.rs-4869919/v1

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Single-port video-assisted techniques, such as one-trocar-assisted pyeloplasty (OTAP) or Round-Traction-Assisted Pyeloplasty (RoTAP), have proven helpful for correcting congenital ureteropelvic junction obstruction (UPJO), especially in infants. We present a case report of a patient diagnosed with UPJO who underwent a minimally invasive pyeloplasty with a RoTAP technical variation based on the gloveport system that allowed bimanual endocavitary dissection and protected the surgical wound during the procedure without increasing the cost or technical difficulty compared to the original technique. This new technique, called gloveport-assisted retroperitoneal pyeloplasty (GARP), could be a valuable alternative for this pathology.

Urology & Nephrology

Pediatrics

Surgery

GARP

gloveport

pyeloplasty

SILS

pediatric

UPJO

In recent decades, multiple minimally invasive techniques have emerged to correct congenital ureteropelvic junction obstruction (UPJO). The advent of laparoscopic techniques has made it possible to approach this procedure through a transperitoneal and retroperitoneal approach [1]. However, the small size of some patients and the technical complexity of the procedure - with a long learning curve that is not always achievable given the limited casuistry- conditions its development. Video-assisted single-port techniques, which combine the advantages of the laparoscopic and open approaches, have proven their use in this pathology, with the one-trochar-assisted pyeloplasty (OTAP) technique being safe, fast, and effective even in infants [2–3]. Recently, another working group developed a variation of this technique known as Round-Traction-Assisted Pyeloplasty (RoTAP) [4], characterized by using an Alexis retractor ®. Lastly, Zouari et al. reported using the gloveport system in this context but through a transperitoneal approach [5].

We present the case of a 23-month-old girl diagnosed with UPJO in whom surgical intervention was indicated. Surgical correction was approached using a technical variation of the RoTAP technique. Under general anesthesia and in lateral decubitus with lumbar hyperextension, the required anatomical landmarks for the procedure were identified and marked (Fig. 1A, B). We made the incision slightly cranial and anterior to the classic lumbotomy approach to gain precise access over the pyeloureteral junction (PUJ). A 12–14 mm transverse incision was made, and access to the retroperitoneum was achieved by blunt dissection (muscle-sparing) until Gerota's fascia was reached. Special care was taken not to be directed anteriorly during dissection to avoid inadvertently opening the parietal peritoneum. Once the retroperitoneum was accessed, a blunt digital dissection of the perirenal space was performed, and an Alexis ® XXS surgical retractor was placed on it. Subsequently, a gloveport with three 5-mm working channels was placed (Fig. 1C). To prepare the gloveport, we used a 5.5-size glove. We made longitudinal incisions at the tip of each finger, on the first, third, and fifth fingers (Fig. 2A). Then, we introduced the trocars up to the central area of the glove (Fig. 2B), and we fixed the trocars with a sterile adhesive strip to prevent C0₂ leakage. (Fig. 2C). The fact that the trocars were introduced up to the glove's central area facilitated the instruments' introduction and sped up the surgery. To create a tight and firm connection between the Alexis ® and the gloveport, the Alexis ® was placed in the surgical field without completing the outer ring´s last 2–3 turns. The gloveport was then placed embracing the Alexis ® outer ring (Fig. 2D), and after that, the last 2–3 outer ring turns were completed. This allowed the gloveport to be partially wrapped around the Alexis (Fig. 2E) and prevented it from accidentally coming off after insufflating C0₂.

C0₂ insufflation was set at 8 mmHg pressure and 1.5 liter per minute flow. These parameters allowed a pneumodissection of the perirenal space and an adequate working cavity (Fig. 3A). The lower renal pole was identified (Fig. 3B), and a blunt dissection was performed until the ureter was identified (Figs. 3B-C). This dissection was performed with Endo-peanuts® (laparoscopic swabs), but any 5 mm laparoscopic instrument could have been used. The gloveport system allowed excellent camera mobility (in our case, we use 5 mm and 30-degree optics). Likewise, two working channels allowed bimanual blunt dissection (Fig. 3C) and intelligent coagulation instruments such as Ligasure ® (Fig. 3D). Ureter dissection progressed until adequate mobilization was verified (Fig. 3E). After that, the ureter was referenced by a vessel loop, which allowed it to be externalized (Fig. 3F-G). The gloveport was disassembled without removing the Alexis ®, and the Alexis ® was retightened with 2–3 turns. Then, lateral references were applied to the ureter and pelvis. These references were applied externally and under direct vision, which was much simpler than if done laparoscopically/retroperitoneoscopically. After that, a standard Anderson-Hynes dismembered pyeloplasty was performed (Fig. 4A-B). We used a double-J stent as a trans anastomotic tutor, making its placement through this surgical access easy (Fig. 4B). After the anastomosis was completed, the surgical cavity was revised (Fig. 3H), a surgical drain was placed, and the wound was closed in a standard fashion (Fig. 1D).

The retroperitoneal approach for pyeloplasty surgery constitutes a complex technique for multiple reasons: 1) The topographical arrangement of the renal anatomy is difficult to interpret from that perspective and requires specific training 2) The retroperitoneal cavity is smaller than the peritoneal one and, therefore, the laparoscopic triangulation and the endocavitary part of the procedure are more complex 3) This surgical field includes vital structures such as the renal vessels and the aorta that pose a vital risk in case of damage. All these challenges are increased when using the present gloveport technique since 1) The triangulation capacity is diminished compared with conventional laparoscopy, and 2) The long trajectory of the gloveport fingers means that the instruments can kink in the glove during their insertion and perforate it. Nevertheless, the present technique (Gloveport-assisted retroperitoneal pyeloplasty or GARP) also has notable advantages: it protects the surgical edges of the wound, allows more precise and faster bimanual endocavitary work, and results in less muscle dissection and less surgical scar, so the functional and esthetic results of this approach could be superior to those of other techniques. However, it is essential to note that this last aspect is not the subject of this study and has not been rigorously evaluated.

Replacing the gloveport with a commercial gelport is an attractive alternative because it solves the potential risk of perforating the glove and facilitates instrument insertion. The trocar path of gelport systems is usually shorter and rigid and does not have a fragile area as in the glove case. On the other hand, the internal ring of the Alexis-type retraction system included in commercial gelports is usually larger. Because of this, it may constitute a greater surgical trauma and distract the surgical wound, increasing its size.

It is pertinent to highlight the role of the assistant in this intervention. On the one hand, given the limited working space and triangulation capacity, camera movements must be minimal and precise, and it is straightforward to accidentally remove the optics from the cavity. On the other hand, the surgeon's intermittent introduction of new instruments through the working channels requires the assistant's intervention since it is easy to pierce the gloveport with the instruments inadvertently in the path between the trocar and the surgical wound (which constitutes the exposed piece of glove). If this occurs, the cavity created with the C0₂ is lost. This can be solved by placing an adhesive in the pierced area or creating a new gloveport. To avoid glove perforation, the assistant guides the instruments through the trocar with its hand from outside the glove and accompanies them to the incision. The assistant should be an experienced surgeon during the initial learning curve of the procedure.

We did not suffer any intraoperative complications during this surgical procedure. Nevertheless, this intervention's main risk or potential complication is damage to adjacent structures (primarily the renal hilum). This complication, common to all minimally invasive surgical techniques for UPJO, makes it potentially necessary to convert quickly to open surgery. This should be considered during the preoperative preparation.

GARP may constitute a safe, fast, economical, and effective alternative to laparoscopic pyeloplasty, especially in infants. We understand these techniques (including OTAP, RoTAP, and GARP) as a surgical alternative that Pediatric Surgeons should know for treating UPJO. We believe that the ideal group of patients for this technique are infants and low-weight patients, in whom the laparoscopic/robotic approach constitutes a significant technical challenge and in whom this technique is fast and effective. Our experience is preliminary, and new reports are needed to develop and optimize the present technique and validate its usefulness in this pathology.

Author contributions:

Javier Arredondo Montero: literature review, surgical technique conception and development, surgical procedure performance, procedure documentation, resources, data extraction, data curation, data interpretation, writing-original draft, writing-review, and editing.

María Rodriguez Ruiz: writing-review and editing.

Original work:

The manuscript authors declare that it is an original contribution, not previously published.

Conflict of interest:

There is no conflict of interest or external funding to declare. The authors don´t have anything to disclose.

Ethics statement:

The Institutional Review Board of our center approved this study under code 24120. Before the submission of this article, verbal and written informed consent was obtained from the patient's legal guardians, whose clinical photographs are included in this publication. This work was carried out following the principles of the Helsinki Declaration (2013 statement).

Ji F, Chen L, Wu C, Li J, Hang Y, Yan B (2021) Meta-Analysis of the Efficacy of Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction via Retroperitoneal and Transperitoneal Approaches. Front Pediatr 9:707266
Cobellis G, Nino F, Pierangeli F, Mariscoli F, Noviello C, Martino A (2017) Retroperitoneoscopic One-Trocar-Assisted Pyeloplasty in Children: An Age-Related Evaluation. J Laparoendosc Adv Surg Tech A 27(6):651–654
Lima M, Tursini S, Ruggeri G, Gargano T, Libri M, Domini M (2007) One trocar assisted pyeloplasty (OTAP): initial experience and codification of a technique. Pediatr Med Chir 29(2):108–111
Domenichelli V, Sabatino M, Straziuso S, Italiano F, Federici S (2015) Round-Traction-Assisted Pyeloplasty (Ro.T.A.P.): A Minimal Approach Using Alexis® Autostatic Retractor. Open J Urol 5(10):192–198
Zouari M, Ben Dhaou M, Ammar S, Jallouli M, Mhiri R (2019) Laparoendoscopic Single-Site (LESS) Surgery in Pediatric Urology: A 4-Year Experience. Curr Urol 12(3):153–157

The authors declare no competing interests.

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Gloveport-assisted retroperitoneal pyeloplasty (GARP): a case report

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