Improved instrumentation to facilitate laparoscopic ureteroureterostomy

Summary

Various technical advances have been investigated in an attempt to simplify reconstructive laparoscopic surgery. We report the initial use of a non-perforating, titanium vascular closure staple (VCS) (US Surgical Corp., Norwalk, CT) in combination with a tissue approximator device for performing laparoscopic ureteroureterostomy (UU). 12 female, Yucatan mini-pigs were prospectively randomised to undergo laparoscopic ureteral transection at the level of the lower pole of the kidney. An end-to-end UU was performed using only the VCS clips in six animals and using VCS clips and a newly-designed tissue approximator (TA) in six animals. The ureteral stent was removed 10–12 days after UU. Retrograde pyelography and differential creatinine clearances (CrCI) were performed at 6 and 12 weeks following UU. At 12 weeks, the animals were euthanised and the site of the UU was examined grossly and histopathologically. A histological healing score [0 (excellent) to 15 (poor)] was determined for each UU. An average of 12 clips was used for the laparoscopic UU. Group A, stapled UU, had an operating time of 22.0 ± 14.7 min compared with Group B, stapled UU with TA, which had a time of 4.83 ± 4.78 min (p = 0.04). The change in ureteral diameter (mm) for Group A and Group B were found to be 0.06 ± 2.35 and 0.864 ± 3.18 respectively (p = 0.84). Healing scores for Group A and Group B were similar: 5.83 ± 2.64 and 5.83 ± 4.11, respectively (p = 0.94); change in CrCI were also similar 4.40 ± 8.88 and 1.30 ± 13.36 respectively (p = 0.55). At 12 weeks, no intraluminal clips or calcifications were found fluoroscopically or grossly. Healing scores were satisfactory, with minimal fibrosis or inflammation found at the site of the UU. However, in one animal, focal bone metaplasia was found at the staple site. The non-perforating VCS clip allows for the efficient performance of a laparoscopic UU; the tissue approximator further reduces the operative time and improves the accuracy of clip placement. The resulting anastomosis appears to heal well. A clinical trial using this instrumentation is currently in progress.

Key Words:

• laparoscopy
• ureteroureterostomy
• vascular clips