Idiopathic Retroperitoneal Fibrosis

Idiopathic retroperitoneal fibrosis is a chronic inflammatory process that comes to uro-logic attention when extrinsic compression and encasement of the ureter by surrounding retroperitoneal tissues cause ureteral obstruction. The progressive nature of the inflammatory process can lead to flank pain and renal deterioration. Radiographic findings on intravenous pyelogram or retrograde pyelogram may include medial deviation of the involved ureter and the absence of intraluminal obstruction. Whitaker test as well as nuclear functional studies often demonstrates delayed drainage as a result of extrinsic ureteral compression. Causes of retroperitoneal fibrosis are myriad and include inflammatory bowel disease, vascular aneurysms, radiation, malignancies, retroperitoneal bleeding, and idiopathic, which accounts for the majority of cases.

The laparoscopic approach to the idiopathic retroperitoneal fibrosis ureter remains challenging with only a few cases described in the literature (10-14).

The principles of the laparoscopic approach include biopsy of the retroperitoneal tissues for histologic diagnosis and complete ureterolysis.

First reported by Kavoussi et al. in 1992, laparoscopic dissection and mobilization of the entrapped ureter are feasible but can be technically challenging (10). The extent of retroperitoneal fibrosis often determines the level of technical difficulty, as

The advantage of retroperitoneoscopic approach compared to the transperitoneal method is that bowel mobilization is minimized. In addition, the retroperitoneal approach avoids urinary spillage into the peritoneum, which may reduce the risk of subsequent intraperitoneal adhesion formation. The main disadvantages include limited working space.

Given the small number of cases reported in the literature and bias from case selection and the surgeon's experience, it is difficult to compare the transperitoneal approach to the retroperitoneal approach critically.

The principles of the laparoscopic approach include biopsy of the retroperitoneal tissues for histologic diagnosis and complete ureterolysis.

longer affected ureteral segments (>5 cm) require longer operative time than shorter ones (<2cm) (11).

The laparoscopic surgical approach to idiopathic retroperitoneal fibrosis is similar to that used for the retrocaval ureter (1-4,10,11). After the placement of a ureteral stent, the patient is typically placed in a modified flank position (10,11). The laparoscopic camera port can be placed along the anterior axillary line 2 cm above the umbilicus. Typically three other working ports are needed on the ipsilateral side: one port along the mid-clavicular line at 2 to 3 cm below the costal margin, one at the level of the umbilicus, and one at 2 to 3 cm above the anterior superior iliac spine. In cases where both ureters are affected and require surgical mobilization, additional ports are placed in the corresponding locations on the contralateral abdomen. In more difficult cases, surgical management of the second ureter can be performed in a staged manner (12).

Following mobilization of the colon, a biopsy of the retroperitoneal fibrotic tissue is first taken for diagnostic purposes. Then ureterolysis can be initiated either near the renal hilum or below the iliac vessels, the two locations where the ureter is typically not involved with the fibrotic process. Using blunt and sharp dissection techniques, the ureter is mobilized circumferentially. Use of a vessel loop or Penrose drain around the freed portion of the ureter can provide needed traction and facilitate dissection. Once ureteral mobilization is complete, the ureter is retracted anteri-olaterally into the peritoneal cavity. The parietal peritoneum is reapproximated with sutures or clips to close the retroperitoneal defect, and normal intraperitoneal fatty tissue or the greater omentum can be interposed between the ureter and the retroperitoneal defect. It is important not to kink the ureter excessively in its lateral intraperitoneal placement. The ureteral stent is left in place for two to three weeks, and follow-up nuclear functional studies are recommended at three to six months postoperatively to evaluate urinary drainage.

The laparoscopic approach remains technically challenging with operative times for unilateral ureterolysis that range from 195 to 330 minutes (10,12,14). In certain cases, bilateral ureterolysis at the same setting maybe successful; however, it is not unreasonable to approach each side at a different setting should dissection become too difficult (12). Postoperative hospitalization ranged from 3 to 10 days, and blood loss was negligible in these cases (10,12,14). In the casecontrol report by Elashry et al., laparoscopic unilateral ureterolysis for idiopathic retroperitoneal fibrosis was compared to open surgery (14). In the two laparoscopic cases, mean estimated blood loss was 100 cc compared to 400 cc in the five open cases for idiopathic retroperitoneal fibrosis. Blood transfusions were required in two of the five open cases and not in either of the laparoscopic cases. Parenteral analgesic (morphine) requirement after surgery was dramatically different in the two groups with the laparoscopic group requiring only 2 and 3 mg compared to an average of 143 mg (range, 50-267 mg) in the five open cases. Convalescence was two to three weeks from the laparoscopic group and six to eight weeks for the open group. However, given the small number of cases in this report and possible bias in case selection, the data must be interpreted with caution.

When considering the body of literature on laparoscopic ureterolysis in idiopathic retroperitoneal fibrosis, the advantages include lower operative morbidity, blood loss, postoperative analgesic requirements, and shorter convalescence compared to traditional open approaches. Given the rarity of idiopathic retroperitoneal fibrosis, its uncertain natural history, and the lack of long-term outcome data, close patient follow-up is crucial in the postoperative setting.

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