Complications following RC combined with UD surgery are reported to have an incidence ranging from 25–35% [12]. Benign UIAS is a common complication with a reported incidence of 2.7–10%, with a median diagnosis time of 7–18 months after surgery [13]. Patients with benign UIAS may be asymptomatic or exhibit mild symptoms such as obstruction, infection, or stones [3, 14]. Diagnosis is often based on changes in renal function. Anastomotic closure can lead to renal hydronephrosis and irreversible decline in renal function without timely treatment [15]. Wang et al. demonstrated that specific surgical techniques, such as the passage of the left ureter through the sigmoid colon mesentery to obtain sufficient length for anastomosis with the new bladder, may increase the incidence of left UIAS [15]. Therefore, precise surgical techniques, including attention to details such as ureteral disconnection, degree of ureteral tissue separation, interruption time of ureteral blood supply, and tension of ureteral ileal anastomosis suture, are crucial for reducing the occurrence of benign UIAS. The surgeon's experience and the use of robotic assistance play significant roles in achieving successful outcomes. However, a comparison between robotic reimplantation and laparoscopic reimplantation was not conducted due to the sample size limitations.
Minimally invasive surgery [16] and laparoscopic ureteral reimplantation are currently the mainstream treatment methods for benign UIAS worldwide. Minimally invasive surgery options include cystoscope retrograde intubation, antegrade percutaneous nephroureteroscopy combined with retrograde cystoscope dilatation, and endoscopic holmium laser incision. These methods offer fewer complications and a shorter recovery period compared to open surgery [17]. However, some scholars argue that the gold standard for benign UIAS is to incise the narrow segment and reimplant the ureter [18]. Based on our experience, the anatomical structure is often disrupted due to the initial surgery, and resolving tissue and freeing abdominal adhesions constitute a significant portion of the time during secondary surgical treatment. Additionally, locating the anastomosis and narrow segment between the ileal bladder and ureter becomes challenging, resulting in high difficulty and an increased incidence of complications. Therefore, a thorough study and comparison of these two treatment methods are essential.
In this study, there was no significant statistical difference between the two groups in terms of gender, average age (70 ± 11 vs 72 ± 10), BMI (22.7 ± 2.6 vs 22.6 ± 2.5), preoperative creatinine value (107 ± 27 vs 114 ± 37), preoperative urea (8.6 ± 2.8 vs 9.1 ± 4.1), preoperative GFR on the affected side (24.1 ± 2.9 vs 24.7 ± 3.3), and degree of hydronephrosis (P > 0.05). This indicates that the baseline data of the two groups are suitable for subsequent research analysis.
Based on intraoperative data, there were statistical differences (P < 0.05) between group A and group B in terms of surgical time (96 ± 35 vs 184 ± 39), intraoperative bleeding (17 ± 11 vs 84 ± 41), postoperative hospital stay (5.8 ± 1.8 vs 8.4 ± 3.3), and postoperative feeding time (1.7 ± 0.9 vs 2.9 ± 1.3). Compared with laparoscopic reimplantation, endoscopic treatment has a shorter surgical time and less bleeding volume, better safety, and faster postoperative recovery, making it more easily accepted by patients.
According to postoperative data, comparing biochemical test values during postoperative hospitalization may not accurately reflect efficacy. Therefore, we evaluated surgical efficacy through imaging examination, biochemistry, and GFR on the affected side after extubation. The preoperative and postoperative creatinine values, urea values, and GFR values on the affected side of each group were compared. The results showed that there was no significant statistical difference (P > 0.05) for creatinine values (107 ± 27 vs 102 ± 20) and urea values (8.6 ± 2.8 vs 7.9 ± 1.7) in the endoscopic treatment group, while there was statistical significance (P < 0.05) for GFR values on the affected side (24.1 ± 2.9 vs 17.9 ± 3.2). It indicated that patients treated under endoscopy did not show significant improvement in renal function after extubation, and some patients even experienced ureteral restenosis and hydronephrosis, resulting in a continuous decline in renal function.
While the creatinine value (114 ± 37 vs 106 ± 28), urea value (9.1 ± 4.1 vs 8.1 ± 3.2), and GFR value (24.7 ± 3.3 vs 24.7 ± 3.3) of the affected side in the laparoscopic reimplantation group showed no significant statistical significance (P > 0.05). It indicated that creatinine value, urea value, and GFR on the affected side did not show any significant changes in the laparoscopic reimplantation group after extubation, and the reason may be that the renal function on the affected side of most patients didn’t significantly decrease. Besides, the contralateral kidney was still intact and played a compensatory function. In conclusion, laparoscopic reimplantation can improve or delay the deterioration of renal function to a certain extent and alleviate hydronephrosis for a long time. Furthermore, for patients with bilateral stenosis, laparoscopic reimplantation can simultaneously treat both sides of stenosis, but endoscopic treatment usually involves surgery on one side and temporary nephrostomy on the other side, requiring secondary surgery.
The placement of a single-J tube is crucial for maintaining ureteral patency after surgery, and the patency and maintenance of ureteral function after extubation play an important role in judging the efficacy of different treatment modalities. In this study, the time for extubation (6.5 ± 2.2 vs 4.2 ± 3.8), whether hydronephrosis occurred after extubation, and the time to hydronephrosis after extubation (5.4 ± 2.7 vs 11.8 ± 1.9) showed statistically significant differences (P < 0.05) between the two groups. Compared with endoscopic treatment, the extubation time after laparoscopic reimplantation can be earlier, and the reoccurrence rate of restenosis and hydronephrosis after extubation was lower, even the time of occurrence was relatively late. However, endoscopic treatment only showed short-term therapeutic efficacy and cannot permanently solve the problem of ureteral stenosis. Besides, the renal function of the affected side remained decreasing, and the reoccurrence rate of restenosis was higher. While laparoscopic reimplantation can relatively better solve the problem of stenosis, earlier extubation of the single-J tube, keeping the ureter patent for a long time, preserving the residual kidney function, relieving the hydronephrosis, and reducing the reoccurrence of restenosis.
Furthermore, the length of the ureteral stricture is a key factor in deciding the appropriate surgical method. A 1 cm threshold can be considered; ureteral strictures larger than 1 cm are better treated with reimplantation surgery than endoscopic intervention. When the stricture is less than 1 cm, endoscopic treatment is considered more suitable. Daniel et al. demonstrated that the success rate of minimally invasive endoscopic surgery for benign UIAS less than 1 cm can reach 50%, but it only shows a 6% success rate for UIAS greater than 1 cm, while the success rate of reimplantation surgery treatment reached 86% [19]. The length of ureteral stenosis was not deeply explored in this study due to the limitation of sample size, and the generalization of ureteral length will be a focus of our future research.
With the improvement of surgical techniques and methods, the cure rate of minimally invasive endoscopic surgery for benign UIAS has increased but is still lower than that of reimplantation surgery [15]. While the advantages of minimally invasive endoscopic surgery should not be ignored, as it offers certain benefits, it cannot maintain ureteral patency for an extended period. Robot-assisted laparoscopic/general laparoscopic reimplantation seems to be the better choice for patients with benign UIAS.
This study has certain limitations that warrant careful consideration and address in future research. The small sample size underscores the need to enhance statistical power by increasing the number of surgeries and engaging in multi-center collaborative studies to ensure the data's authority and reliability. Moreover, this study only investigated two treatment groups. Future research should explore and evaluate the specific efficacy of four different treatment modalities, including endoscopic balloon dilation, endoscopic holmium laser dissection, robotic-assisted laparoscopic reimplantation, and general laparoscopic reimplantation. Additionally, investigating other treatments for benign UIAS, such as cold knife incision and open surgery, would contribute to a more comprehensive understanding of the subject.