There is still controversy about the best method of ureteric stenting during laparoscopic pyeloplasty (LP). The group with the most published experience prefers the conventional retrograde approach, just before the laparoscopic procedure, including a retrograde pyelogram , but there is the drawback of the additional procedure with more time spent in the operating theatre. There are some reports on antegrade ureteric placement during LP, including the adaptation of a laparoscopic hook , the necessity of an additional puncture , and a disposable dilator/sheath system .
Herein, we report a device originally designed for cholangiography during laparoscopic biliary surgery, applied to totally intracorporeal antegrade stent placement, which permits an easy, safe and logical way of antegrade stenting during LP.
After completing the posterior running suture during LP with no previous procedure, the cholangiogram guide (JaritTM, Hawthorne, NY, USA), a reusable 5-mm, 32-cm instrument built for laparoscopic biliary surgery (Fig. 1), is passed through the uppermost trocar and it is inserted into the ureteric lumen with the help of forceps from the lowermost trocar, to facilitate catheterization and to stabilize the fragile anastomosis (Fig. 2A). The tip of this instrument fits smoothly into the ureteric lumen, assuring safe guidewire (0.9 mm hydrophilic straight-tip) introduction that is advanced down to the bladder, with no manoeuvre to confirm its position in the bladder. The instrument also has a rubber cap on the opposite side that stays outside the patient; this avoids gas leakage during either guidewire or stent advancement, while allowing smooth passage (Fig. 2B,C). The ureteric stent is advanced over the guidewire under laparoscopic guidance, when the stent-pusher is easily seen and the guidewire is removed holding the proximal end of the stent with a grasper (Fig. 2D), so that at the end the stent loop is safely deposited into the renal pelvis; its adequate position is always confirmed with a plain abdominal film after surgery (Fig. 3A).
COMPARISON WITH OTHER METHODS
Mandhani et al. reported on the adaptation of a laparoscopic hook for antegrade stenting during LP, with a method that is very simple, but there is the drawback of using a device built for other purposes (cautery, suction and cutting) and the hook at the tip of the instrument prevents its smooth passage into the ureteric lumen. Tan et al. reported a technique for antegrade stenting with an additional puncture of a 19 F coated needle through the anterior abdominal wall. Although it is effective, an additional puncture is necessary, whereas in the present technique the stent is passed via the established uppermost trocar.
Eichel et al. described a method of antegrade stenting using a 8 F/10 F Amplatz dilator/sheath system that is passed via the uppermost port, and then the 8 F catheter is replaced by a 5 F Kumpe catheter when its tip is placed in the ureter. The only problem with this technique is the use of two more disposable instruments, thereby increasing the costs of the entire procedure; using the cholangiogram guide lowers the costs and just one piece of equipment is necessary to complete the procedure. A useful technique reported by Eichel et al. was to fill the bladder with indigo carmine-stained saline, resulting in blue fluid reflux from the proximal end of the stent; this manoeuvre was also tested in the some of our later procedures, and it worked well.
ADVANTAGES AND DISADVANTAGES
The main advantages with the use of the cholangiogram guide are: it is reusable, it prevents gas leakage, it avoids an additional puncture, it avoids a previous procedure, it permits smooth intra-ureteric catheterization providing tactile feedback of smooth stent passage, exactly as during stent passage through the cystoscope, yet keeping the anastomosis site under visual guidance throughout the procedure. This instrument keeps the guidewire path straight and continuous through the ureteric course, which seems to be why there was no guidewire buckling in our experience. The only disadvantage is the need to buy new equipment.