Minimally invasive ureterolysis in retroperitoneal fibrosis (Ormond´s disease) – video

Overview

Introduction: In idiopathic retroperitoneal fibrosis, ureteral involvement of the retroperitoneal fibrotic mass (especially in the middle part of the ureters) dominates, leading to the development of (dolicho-)megauterets with subsequent progressive renal insufficiency. The left side tends to be affected earlier. The solution is to influence the etiopathogenesis of the disease (especially corticosteroid treatment) and diversion of the upper urinary tract. Either permanent stenting of both ureters with all its disadvantages or ureterolysis. Historically open via midline laparotomy, more recently minimally invasive. In this paper we evaluate the results of minimally invasive (laparoscopic or robotic assisted) ureterolysis.

Abstract: Between 2001 and 2024, nine patients were indicated for bilateral ureterolysis. Three men (33%) and six women. Mean age 58.5±6.9 (48.8–69.6) years. Body mass index (BMI) 28.9±5.8 (19.5–38.1). First four laparoscopically, subsequently five robotic assisted. In two (22.2%) patients ureters could not be released from severe fibrotic changes (one laparoscopy left with stents, the other robotically assisted open nephrectomy in a kidney with 8.6% function and open secondary ureterolysis – via midline laparotomy). The bilateral operation time (without open surgery) was 154.0±33.5 (100–201) min.

Video: Shows the robotic-assisted bilateral ureterolysis. The 4-arm daVinci Xi system is used, 70° lateral position. Starting with the more affected left side. With Veres needle, capnopneumoperitoneum pressure of 12 mmHg created, 11 mm assisted port inserted through umbilicus, four robotic 8mm introduced under visual control. Camera 30°, ProGrasp™, bipolar grasper Maryland™, monopolar scissors. Paracolic peritoneum opened, ureter found and liberated from the lower pole of the kidney to below the iliac vessels. Medial peritoneum inserted under the ureter and fixed to the lateral margin with Hem-o-lok® L Clips. The port in the umbilicus was left, the position was changed and the procedure was performed identically on the right side. Abdominal cavity was not drained. Ureteral stents removed in 3–6 weeks.

Results: In the eight patients where the ureters could be liberated (15 ureters, 1 open), long term follow-up is known for all 15 ureters. No further stenting is required, the upper urinary tract is sonographically free of dilatation and no renal insufficiency has been seen. Mean follow-up time is 63.9±64.3 (1–158) months. In eight cases, combined corticosteroid therapy always resulted in significant regression of fibrotic masses.

Conclusion: Ureterolysis in idiopathic Ormond’s disease is feasibly miniinvasively (laparoscopically or robotically assisted) in 77.8% with surprisingly good long-term results protecting the upper urinary tract and avoiding long-term stenting in 100%. The robotic option is now clearly preferred.

Keywords:

retroperitoneal fibrosis – megaureter – robot – laparoscopy – ureterolysis