Laparoscopy and Robotics

Prospective Randomized Comparison ofRetroperitoneoscopic vs Open PyeloplastyWith Minimal Incision: Subjective andObjective Assessment in AdultsManish Garg, Vishwajeet Singh, Rahul Janak Sinha, and Satya Narayan Sankhwar

OBJECTIVE To determine the subjective and objective outcomes of retroperitoneoscopic vs open pyeloplasty

Financial Disclosure: The authoFrom the Department of Uro

Shahuji Maharaj Medical UniverReprint requests: Manish Gar

George Medical University, LuckSubmitted: September 30, 201

ª 2014 Elsevier Inc.All Rights Reserved

with minimal incision in a prospective randomized comparison study.

METHODS In this study between August 2011 to July 2013, 30 patients underwent retroperitoneal laparo-

scopic pyeloplasty and 30 open pyeloplasty with minimal incision (incision length <10 cm) afterrandomization. The 2 groups were compared for the visual pain score on the first and secondpostoperative days as the primary end point of the study. Complications were recorded and gradedusing Dindo-modified Clavien classification of surgical complications. Success rates were evalu-ated by improvement in pain score and objectively by diethylene triamine penta-acetic acid renalscan and other parameters. Statistical analysis was performed with SPSS version 16.0 (IBM) withP <.05 considered statistically significant.

RESULTS The difference in the visual pain score (5.6 vs 3.2 on day 1; 3.8 vs 1.5 on day 2) and the

diclofenac requirements (333.3 vs 178.75 mg) were statistically significant and more in the openpyeloplasty. The hospital stay and convalescence were significantly lower in retroperitoneoscopicgroup. Success rate was found to be 96.67% with 1 failure in each group. Two patients in ret-roperitoneoscopic group required conversion. Both groups showed significant improvement inpain score and drainage pattern on diethylene triamine penta-acetic acid scan with decrease inhydronephrosis on ultrasound evaluation.

CONCLUSION Although subjective and objective outcomes are equivalent in both the groups, the retro-

peritoneoscopic approach is associated with significantly less pain, less analgesic requirement,shorter hospital stay and short convalescence in comparison with open pyeloplasty. UROLOGY83: 805e811, 2014. � 2014 Elsevier Inc.

he treatment of ureteropelvic junction obstruc-tion (UPJO) continues to develop with ad-

Tvancements in technology from open technique

to minimally invasive procedures. Traditionally, openpyeloplasty is considered as the reference standard forUPJO with success rates of 90%-100%.1,2 The growingexperience of laparoscopy has emerged as a means tominimize the morbidity of open surgery especially inablative and reconstructive urologic procedures. Althoughprocedures like antegrade and retrograde endopyelotomyare minimally invasive, they tend to have comparativelylower success rates with significant risk of bleeding.3 Thelaparoscopic techniques are increasingly used for urologicdiseases and can be done via transperitoneal or

rs declare that they have no relevant financial interests.logy, King George Medical University (Chhatrapatisity), Lucknow, Indiag, M.B.B.S., M.S., Department of Urology, Kingnow, India. E-mail: dr_manugarg@yahoo.co.in3, accepted (with revisions): November 20, 2013

h

retroperitoneal approaches.4,5 Although preliminary re-ports have demonstrated the feasibility of retroperitoneallaparoscopic approach with results comparable with thosewith open techniques,6,7 randomized comparison has notdone till now to analyze the results of open vs retro-peritoneoscopic pyeloplasty in the prospective design. Thepresent study is executed as the first prospective, random-ized comparison between open pyeloplasty using minimalincision (MIP) and retroperitoneoscopic pyeloplasty andassessed the objective and subjective outcomes.

MATERIALS AND METHODS

A total of 60 consecutive patients with UPJO were enrolled inthis prospective study from January 2011 to July 2013. Theinstitutional ethical approval was obtained, and it was inaccordance with the Declaration of Helsinki. Patients wererandomized according to computer-generated randomizationtable, and MIP and retroperitoneal laparoscopic pyeloplasty(RP) were done in 30 patients each. The patients with differ-ential renal function (DRF) of less than 15%, uncorrected

0090-4295/14/$36.00 805ttp://dx.doi.org/10.1016/j.urology.2013.11.024

coagulopathy, vertebro-spinal deformity, or cardiopulmonary orrespiratory compromised status were excluded from the study.All patients were explained about the minimal incision andlaparoscopic pyeloplasties for the treatment of UPJO and theobjectives of the present study. The patients who refused toundergo randomization or with age <18 years were excludedfrom the study. Apart from the clinical history, physical exam-ination, and blood investigations, imaging studies like ultraso-nography kidney, ureter and bladder (USG KUB), intravenousurography, or contrast-enhanced computerized tomography ofKUB were done. Diuretic technetium-99m-ethylenedicysteine(EC) renal scan was done in all patients to assess the drainagepattern of the kidney, radiotracer washout time (T1/2) andDRF. In patients with infected hydronephrosis presented withpain or fever, percutaneous nephrostomy tube was insertedpreoperatively. Seven patients were found to have associatedrenal pelvic or calyceal calculi at diagnosis. Two patients hadhorseshoe kidney with UPJO and 1 patient has crossed ectopickidney with UPJO in the lower kidney.

The primary objective of the study was to compare the painscores on postoperative days 1 and 2 in retroperitoneoscopic andminimal incision pyeloplasty in the treatment of UPJO. Sec-ondary objectives were to compare each of the operative tech-niques in terms of duration of surgery, complication rates, andpostoperative convalescence and to assess the subjective andobjective outcomes.

Success was defined as when a patient became subjectivelyasymptomatic in the postoperative period, and there was noevidence of obstruction in the drainage pattern of the kidney onthe renal scan in the follow-up period. There were separateretroperitoneoscopic and open surgeon, both expert in theirrespective approaches.

Open TechniqueFor open pyeloplasty, lumber subcostal incision was made withincision length of <10 cm. The abdominal muscles were sepa-rated, and while the peritoneum was pushed back, retroperito-neal space was reached. Anderson-Hynes dismemberedpyeloplasty was done in all patients. Antegrade double-J (DJ)stent was placed in all patients. We found the advantage ofdirect access to ureteropelvic junction with good exposure ofpelvis and renal vessels with this extraperitoneal approachwithout extending the incision.

Retroperitoneoscopic PyeloplastyUnder general anesthesia, retrograde pyelography was done, andureteric catheter was kept in place for easy identification of theureter. The patients were placed in the lateral decubitus (kidneyposition) with a bridge at the flank. Open-port placement forthe camera was done (10 mm) just distal and anterior to the12th rib in midaxillary line. Blunt finger dissection and indig-enous balloon dissection methods were used for creating theretroperitoneal space. Two other ports (12 and 5 mm) wereplaced in the posterior axillary line and the anterior axillary lineabove and in front of the level of iliac crest. Rest of the pro-cedure was same as of open technique following general prin-ciples of pyeloplasty.

Postoperative Course and CareThe patient was kept on intravenous fluid till the recovery ofbowel sounds. Intravenous broad-spectrum antibiotic (ceftriax-one) and injection diclofenac on patient demand were

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administered. Visual analog scale (VAS) for rating pain wasrecorded just before surgery, on the first and second post-operative days and 3 months after surgery. The DJ stent wasremoved after 6 weeks of operation under intravenous sedationand antibiotic cover. Objective parameters were evaluated byEC renal scan, serum creatinine, urine culture, and USG KUBperformed at 3 months of follow-up. Subsequent follow-up ofpatients were done at 6 months and then annually. At eachvisit, apart from the history and clinical examination, serumcreatinine and USG KUB were done.

Statistical AnalysisPower calculation for the study was based on the primary endpoint of VAS at day 2 and blood loss. The sample size calcu-lation was adjusted for the 2 primary comparisons using Bon-ferroni correction and a corresponding z-score for a 2-sidedP value of .025. Preliminary data indicated that enrollment of30 patients was necessary to detect difference in VAS and bloodloss with a power of 95.0% using a 2-sided P value of .025. Thenormalcy of the data was tested by using Kolmogorov test, andthe data was found to be normally distributed; therefore, thepaired t test was used instead of nonparametric test. Statisticalanalysis was performed using unpaired t test, and preoperativeto postoperative changes in variables were compared by pairedt test. SPSS version 16.0 (IBM) was used, and a P value <.05was considered statistically significant.

RESULTSA flow diagram of the study shows the randomizationprocedure in Figure 1, and the baseline demographiccharacteristics of patients are presented in Table 1. A totalof 60 patients were eligible for the study. All patientsunderwent Anderson-Hynes dismembered pyeloplastyusing minimal incision technique or retroperitoneallaparoscopic approach after randomization. Both groupsare comparable with respect to number of patients, age,sex, and other baseline parameters. The mean operatingtime in MIP was 124 � 24.4 minutes vs 135.6 � 27.7minutes in RP group (Table 2). Operating time includesfrom port insertion to port closure in retroperitoneoscopicgroup. The mean blood loss was 64.84� 24.65 mL in MIPand 56.32� 18.43 mL in RP group (Table 2). None of thepatients required blood transfusion. Mean VAS on post-operative day 1 was 5.6 � 1.8 in MIP vs 3.2 � 1.5 in RPgroup and on second postoperative day, mean VAS was3.8 � 1.6 in MIP vs 1.5 � 1.1 in RP group (Table 2).Patients in RP group required significantly less analgesic incomparison with MIP group. Complications were recor-ded and graded using Dindo-modified Clavien classifica-tion of surgical complications (Table 3). The overallcomplications were 10% in MIP vs 13.33% in RP group.No major complications occurred during or after the sur-gery, except 2 patients developed excessive drainage.Excessive urinary leakage in 1 patient in MIP group dis-appeared itself on the sixth postoperative day. Anotherpatient in RP group had persistent high drain output,which on evaluation was because of a blocked DJ stent.The patient was managed by the change of DJ catheter.Two patients in MIP group and 1 patient in RP group

UROLOGY 83 (4), 2014

Table 1. Baseline demographic characteristics of the patients

Variables MIP Group (n ¼ 30) RP Group (n ¼ 30) P Value

Age (y), mean � SD 23.47 � 10.26 27.27 � 9.3 .14*Male/female 17/13 15/15 .60y

Right/left side of involvement 13/17 09/21 .28y

SymptomsLumbar pain 18 23Lump 9 5 .22z

Asymptomatic 3 2Patients with associated stones 3 4 .68Patients with preoperative PCN 2 1 .55Patients with comorbidityDM e 1 .50HT 1 2

Patients with associated anomalies 1.00Horseshoe kidney 1 1Crossed ectopia with UPJO in lower moiety e 1

H/O previous ipsilateral pyeloplasty 1 NA

DM, diabetes mellitus; HT, hypertension; H/O, history of; MIP, open pyeloplasty using minimal incision; NA, not applicable; PCN, pancreaticcystic neoplasms; RP, retroperitoneal laparoscopic pyeloplasty; SD, standard deviation; UPJO, ureteropelvic junction obstruction.* Unpaired t test.y Chi-square test.z Chi-square for trend.

Assessed for eligibility for pyeloplasty (n=71)

Excluded (n=11)

(n=3 )

Analysed (n=30)

Lost to follow-up (n=0)

Underwent MIP (n= 30)

Lost to follow-up (n=0)

Underwent RP (n= 30)

2 conversions to open surgery

Analysed (n=30)

Analysis

Follow-Up

Randomized (n=60)

Figure 1. Flow chart of the study. (Color version available online.)

developed postoperative febrile urinary tract infection,managed by culture-specific antibiotics. In 16 patients(26.67%), anterior crossing vessels were encountered andpreserved during ureteropelvic junction reconstruction.Intraoperatively, 2 patients required conversions fromretroperitoneal laparoscopic to open surgery. One of thesepatients had a history of infection and percutaneousnephrostomy tube insertion 1 year back. Another patientdeveloped CO2 retention and intraoperative bradycardia.

UROLOGY 83 (4), 2014

The mean hospital stay was 6.2� 2.36 days in MIP vs 5.03� 1.7 days in RP group (Table 2). The DJ stent wasremoved 6 weeks postoperatively under local anesthesiaand sedation. In 7 patients, concomitant calyceal stoneswere successfully removed, and no recurrence of renalcalculi was noted till the last follow-up.

The overall success rate was 96.67% with 1 failure ineach group. Two patients, 1 in each group, developedpain after DJ stent removal with development of a renal

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Table 2. Perioperative and postoperative parameters

Variables MIP Group RP Group P Value

Operative time (min), mean � SD 2.05 � 0.57 2.37 � 0.69 .06*Mean � SD VAS on day 1 5.6 � 1.8 3.2 � 1.5 .001*Mean � SD VAS on day 2 3.8 � 1.6 1.5 � 1.1 .001*Mean diclofenac requirement (mg) 333.3 � 85.91 178.75 � 79.81 .001*Patients with crossing vessels 7 9 .55y

Blood loss (mL), mean � SD 64.84 � 24.65 56.32 � 18.43 .13*Mean Hb in postoperative period 9.83 � 0.8 9.79 � 0.89 .84*Days of drain removal, mean � SD 3.9 � 1.15 2.7 � 1.4 .0007*Mean oral intake (d) 2.57 � 0.73 1.8 � 0.66 .0001*Hospital stay (d), mean � SD 6.2 � 2.36 5.03 � 1.7 .028*Median follow-up (mo) 12.7 13.3 .78*Overall complications (%) 10 13.33 .08y

Overall Success rate (%) 96.67 96.67 .18y

Hb, hemoglobin; VAS, visual analog scale; other abbreviations as in Table 1.* Unpaired t test.y Chi-square test.

Table 3. Postoperative complications by Dindo-modifiedClavien classification of surgical complications

ClavienGrading Complication

MIPGroup

RPGroup P Value

Surgical emphysema 1 NAI Prolonged drain output

(conservative)1 NA

II Febrile UTI 2 1 .55II Hypotension e 1 NAIIIa Blocked DJ stent with high

drain output with fever1 NA

IIIb Reintervention 1 e NAEndopyelotomy-redo open e 1

DJ, double J; UTI, urinary tract infection; other abbreviations as inTable 1.

lump. DJ stent was reinserted and again kept for 2months. But the symptoms reappeared after stentremoval. Ultrasonography and EC renal scan confirmedgross hydronephrosis, and renal scan was suggestive of anobstructed drainage pattern. Both the patients underwentopen pyeloplasty and were asymptomatic till the lastfollow-up period.

The median follow-up period in the present study was12.7 months in minimal incision and 13.3 months in RPgroup, respectively (Table 2). All patients weresymptom-free during the follow-up period. Mean VASpreoperatively was 3.43 � 0.97 and 3.2 � 0.89 in MIPand RP group and was 0.97 � 0.96 and 0.83 � 1.0,respectively, at 3 months after surgery showing significantimprovement in pain scores in both groups. Most patientshad grade III or IV hydronephrosis on ultrasound beforesurgical intervention. Postoperative renal ultrasounddemonstrated decrease or complete resolution of hydro-nephrosis in almost all the patients at 6 months. Thefollow-up EC scan was suggestive of significantimprovement in drainage in comparison with previousscans. Preoperatively, the time to reach peak in ECrenogram curve showed rising curve in all patients on thesymptomatic side, whereas, postoperatively, the time toreach peak was decreased to 5.6 � 3.6 minutes (range,

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2.12-7.0 minutes) in MIP and 3.84 � 1.6 minutes (range,2.36-16.11 minutes) in RP group, respectively (Table 4).Forty-three patients presented with T1/2 of 20 minutes orhigher in preoperative diuretic renal scan. In the rest ofthe patients, T1/2 could not be commented due to poorfunction and drainage. Although preoperative meanT1/2 was 23.31 � 5.3 minutes in MIP group and 19.35 �5.1 in RP group, postoperative mean halftime decreasedto 10.31 � 4.0 minutes and 8.6 � 2.5 minutes, respec-tively, at 3 months. Mean preoperative DRF on EC scanwas 31.83 � 7.74% in MIP and 35.34 � 13.4% in RPgroup, and it was improved to 33.28 � 7.9% and 38 �14.16% in MIP and RP groups, respectively, in thefollow-up renal scan (Table 4).

COMMENTTechnological advances have significantly improved boththe diagnostic and therapeutic alternatives available in thecontemporary management of upper urinary tract obstruc-tion. Open pyeloplasty, originally described by Foley in1937 and modified by Anderson and Hynes, remains thereference standard, with which all other treatment modal-ities are compared.8 A significant postoperative pain and along recovery time with incision site scar are the majordisadvantages of the open pyeloplasty. Many minimallyinvasive approaches come into limelight to minimize thedrawbacks of open pyeloplasty, which include endopyelot-omies by antegrade or retrograde route, Acucise endopye-lotomy (Applied Medical), balloon dilation techniques,laparoscopic pyeloplasty, or more recently robotic pyelo-plasties.9 However, with the exception of laparoscopic androbotic pyeloplasties, these must be measured against thelower success rates (61%-89%) with significant risk ofbleeding compared with open pyeloplasty.10-12

Laparoscopic pyeloplasty as a treatment option for theUPJO combines the advantage of an open reconstructionunder direct magnified vision with the low morbidity ofan endoscopic approach.1,13,14 Schuessler et al15

described the first transperitoneal access in 1993, andthe initial retroperitoneoscopic approach to pyeloplasty

UROLOGY 83 (4), 2014

Table 4. Comparison of preoperative and postoperative parameters

Subjective Outcome Preoperative Mean Pain Score Postoperative Mean Pain Score at 3 mo P Value

MIP group 3.43 � 0.97 0.97 � 0.96 .0001*RP group 3.2 � 0.89 0.83 � 1.0 .0001*Objective outcome Preoperative mean T1/2 (min) Postoperative mean T1/2 (min) P ValueMIP group 23.31 � 5.3 10.31 � 4.0 .0001*RP group 19.35 � 5.1 8.6 � 2.5 .0001*

Objective Outcome Preoperative %DRF Postoperative %DRF P Value

MIP group 31.83 � 7.74 33.28 � 7.9 .0285*RP group 35.34 � 13.4 38 � 14.16 .0112*

Preoperative serum creatinine Postoperative serum creatinine P ValueMIP group 0.78 � 0.26 0.78 � 0.31 .99*RP group 0.714 � 0.23 0.80 � 0.23 .21*

HDN Gradeon USG

Minimal IncisionPreoperatively (n ¼ 30)

At 3 mo(n ¼ 30)

At 6 mo(n ¼ 30)

RetroperitoneoscopicPreoperatively (n ¼ 30)

At 3 mo(n ¼ 30)

At 6 mo(n ¼ 30)

IV 18 7 4 19 9 3III 12 11 7 11 8 7II 9 6 10 5I 3 4 2 9No HDN 9 1 6

DRF, differential renal function; HDN, hydronephrosis; USG, ultrasonography; other abbreviations as in Table 1.* Paired t test.

was first reported by Janetschek et al16 in 1996. Laparo-scopic pyeloplasty is reported in several series, but trans-peritoneal route was more commonly used approach inthese studies.17 In open pyeloplasty, the standard of careconsists of lumbar posterior approach rather than thetransperitoneal, because it is a more anatomical directapproach, and the exposure of the renal pelvis is better.16

To our mind, the use of laparoscopic techniques shouldnot involve a change in the surgical approach. Liapiset al18 concluded that retroperitoneoscopic route may bepreferable for most upper urinary tract surgeries afteranalyzing the complications of retroperitoneoscopic pro-cedures in more than 600 patients.

However, laparoscopic surgery in the retroperitonealzone requires more precise orientation, more delicatemaneuvering, and a longer learning curve in comparisonwith transperitoneal approach.19,20 These limitations ofthe laparoscopic pyeloplasty can be overcome by the daVinci Surgical Robotic System (Intuitive Surgical). Theresults of robotic pyeloplasty appear equivalent to that ofopen and laparoscopic repairs. According to a meta-analysis study, although cost and availability are the re-straint factors at present, robotic pyeloplasty is a mini-mally invasive standard of care equivalent to laparoscopicpyeloplasty because of its precise suturing and shorterlearning curve.21 Robotic-assisted dismembered pyelo-plasty can also be performed efficiently by the retroperi-toneal laparoscopic technique.9

Nevertheless, there are few studies that have comparedthe open and laparoscopic pyeloplasty techniques, butmost of these studies were not randomized or actuallycomparative.6,22-24 Bonnard et al24 also had the viewthat the comparison results of retroperitoneal laparo-scopic vs open pyeloplasty should be confirmed by aprospective, randomized studies. Rather most of these

UROLOGY 83 (4), 2014

studies used transperitoneal than retroperitonealapproach for comparison.25,26 Also, none of these studieshad assessed both subjective and objective outcomes onuniform format, nor did they use Clavien classificationsfor grading complications. We solely used retroperitonealroute for ureteropelvic junction reconstruction in thisseries.

In the present study, the retroperitoneoscopic laparo-scopic dismembered Anderson-Hynes pyeloplasty wasdone in 30 patients, and results were compared betweenopen pyeloplasty and minimal incision afterrandomization.

Open pyeloplasty is traditionally done by long muscle-cutting incision, which resulted in longer operating timesand increased morbidity. We used relatively shortermuscle-splitting incision, thus, avoiding injury to sub-costal neurovascular bundle, which lies between internaloblique and transversus abdominis muscles to reduce thewound-related pain and other complications. Becausemost patients included in the present study were adults, amean length of 7.6 cm incision was used. While Klingleret al2 and Zhang et al6 used 23.8 � 9.1 and 21 cm in-cisions, respectively, in their comparison study of open vslaparoscopic pyeloplasty with consequent abdominal wallherniations and thromboembolism due to long incisionand subsequent prolonged stay. No such complicationsoccurred in the present study.

The mean operating time in RP and MIP groups was135.6� 27.7 and 124� 24.4 minutes, respectively, and nosignificant difference in the duration of surgery was foundbetween 2 groups (P ¼ .06). Soulie et al9 also found themean operating time similar in both groups (165 vs 145minutes). Zhang et al6 in their comparative study even hadless operating time in retroperitoneoscopic group ascompared with open group (80 vs 120 minutes).

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The mean blood loss in this study was 64.84 mL in MIPand 56.32 mL in RP group, which is comparable withother studies.9,21-26 The conversion rate in the presentseries (6.7%) is comparable with other published series(0%-9%).9,21-26 There was significant difference in painscores between the 2 groups in postoperative period withsignificantly fewer requirements of analgesics. The lowerpain score and the decreased consumption of post-operative analgesics allow early ambulation and resump-tion of oral intake in the RP group. Calvert et al27

concluded that the efficacy of laparoscopic pyeloplastyis equivalent to that of open pyeloplasty with less woundpain at 6 months.

In the present study, complications were recorded andgraded according to Dindo-modified Clavien classifica-tion of surgical complications. Overall complication ratewas 10% in MIP and 13.33% in RP group, which iscomparable with those reported in literature.9,21-26 Therewas no major complication occurred in our series, andmost of them were managed conservatively. In our study,the success rate in RP approached to that of MIP with 1failure in each group. Both of these patients underwentredo surgery and were asymptomatic till the last follow-up. Scarring in the lumber region due to previoussurgery or prior nephrostomy insertion may result indifficulty in creating the retroperitoneal space and diffi-cult dissection due to local adhesions. Thus, retro-peritoneoscopic pyeloplasty might not be feasible in thesecases, and open approach seems better in such conditions.

Historically, success rates of retroperitoneoscopic pye-loplasty ranges from 67%-98%.28 Further studies showedthat with increase in experience, overall success rate isabove 95%.29 High success rates are the sheer advantageof retroperitoneoscopic pyeloplasty over other minimallyinvasive endoscopic techniques.

We observed that retroperitoneoscopic pyeloplastywas also feasible in the anomalous kidneys. In the pre-sent study, 3 of the 60 patients had associated congen-ital anomalies. Retroperitoneoscopic approach was usedin 2 of these patients. One patient had a horseshoekidney with UPJO, and another had fused crossedectopic kidney with UPJO in the lower moiety. Thirdpatient with horseshoe kidney underwent minimalincision pyeloplasty. All these surgeries were uneventful.Patients in both groups were asymptomatic in thefollow-up period with significant relief of pain. MeanVAS has significantly decreased at 3 months of follow-up period (P ¼ .0001).

There was significant improvement in drainage patternon follow-up EC renal scan. Although renal scan at 6months of follow-up in 4 and 3 patients in MIP and RPgroups, respectively, showed sluggish but nonobstructeddrainage, they were completely asymptomatic. MeanT1/2 was more than 20 minutes in most patients, pre-operatively. Significant decrease in halftime was observedpostoperatively at 3 months renal scan and reached atnonobstructed level in both groups (P ¼ .0001). MeanDRF on follow-up EC scan showed improvement in

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differential function in comparison with the previousscan.

The present study was limited by relatively smallnumber of patients when considering each group, andfurther studies are required to comment on long-termsuccess. In this series, the retroperitoneoscopic pyelo-plasty was done by the expert surgeon. Definitely, trans-peritoneal laparoscopic approach has less learning curvecompared with retroperitoneoscopic pyeloplasty, andmany centers still need to use the retroperitoneoscopicapproach.

CONCLUSIONExcellent subjective and objective outcomes can beachieved through both minimal incision and retro-peritoneoscopic pyeloplasty in experienced hands with anacceptable operating time. Retroperitoneoscopicapproach is associated with lower pain scores, bettercosmesis, and early convalescence in comparison withopen technique but relatively a difficult procedure withsteep learning curve.

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