Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

"Journal of clinical and diagnostic research is a welcome change in publishing practices. It aims to reach out to the grass-root level researchers who do not lack in experience, clinical material and ideas, but lack in their knowledge in English language and statistics. The journal achieves it's aim by supporting in these exact domains.
It also gives due credit to all research designs like descriptive and qualitative studies while many journals ignore these important study designs. The rigorous review process does not allow any compromise in quality
It is indexed in many indexing agencies and the articles are available under creative commons licence free of cost
The frequency of publication supports many aspiring authors from India and other countries.
It's wide scope welcomes articles across various specialities in medicine. In an era when there is an unscientific insistence on speciality specific research by regulatory bodies in medical education, JCDR supports collaborative research across specialities. I wish the publisher all the best in his future endeavors."



Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2011 | Month : December | Volume : 5 | Issue : 8 | Page : 1601 - 1605

A Prospective Randomized Controlled Trial Complains Open Pyeloplasty and Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction (UPJO): Subjective Outcome

Srinivas K.K., Uppin I.V., Nerle R.B.

1. MS. Surgery, Assistant Professor, Department of General Surgery, SDMCMSH, Dharwad. 2. MS Surgery, MCH Urology, HOD and Professor, Department of Urology JNMC, Belgaum. 3. MS Surgery, Retd HOD and Professor, JNMC, Belgaum PLACE OF STUDY Department of Urology KLES Hospital and MRC, Belgaum

Correspondence Address :
Srinivas K.K.
Phone: 9482235235
E-mail: drsrinivaskalabhavi@yahoo.co.in

Abstract

Background: A study was conducted at the KLES hospital and MRC, Belgaum, for a period of 1 year from April 2004 to March 2005.

Objectives: To compare the efficacy of open pyeloplasty and laparoscopic pyeloplasty in the treatment of primary ureteropelvic junction obstruction with regards to the subjective outcome.

Materials and Methods: A total of 30 patients of congenital UPJO was evaluated and operated. All the 30 patients were randomized into two groups of 15 each. One group formed the open pyeloplasty group and the other formed the laparoscopic pyeloplasty group. All the patients were assessed for the subjective outcome post-operatively and all the patients were followed up for a minimum of 3 months. The results were analyzed by using the Student’s paired and unpaired tests.

Results: The mean age group, the laterality of involvement of the kidney and the sex ratio were almost similar between the two groups. The pre-operative pain and the activity levels were almost similar and comparable between the 2 groups. But, there was a significant post-operative improvement in the pain and the activity level in each group. In our study, we found that the improvement in the pain and the activity level post-operatively was much better in the laparoscopic pyeloplasty group patients as compared to those in the open pyeloplasty group patients. The time period when oral feeds were started and the drain was removed, was slightly more in the laparoscopic group, owing to the transperitoneal approach. There was no conversion to open procedure done in any of laparoscopic cases. The postoperative cosmesis was better inthe laparoscopic pyeloplasty patients as compared to the open pyeloplasty patients.

Conclusion: Our study was done on a small number of patients and the post-operative follow up was only for 3 months. It is difficult to draw conclusions from such a study. Hence, a large randomised controlled trial with a long period of follow up studies are needed to establish the role of laparoscopic pyeloplasty in the treatment of UPJ obstruction. The potential advantages of laparoscopic pyeloplasty over open pyeloplasty are decreased post-operative pain, a shorter period of hospitalisation, a short convalescence and improved cosmesis. Laparoscopic pyeloplasty is a technically challenging procedure and it is still in its infancy. It is being practised at only few medical centres around the world. With the recent technological advances, laparoscopic pyeloplasty has become a valid alternative to endoscopic pyelotomy and open pyeloplasty.

Keywords

Urology, Urosurgery, PUJ

How to cite this article :

Srinivas K.K., Uppin I.V., Nerle R.B.. A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL COMPLAINS OPEN PYELOPLASTY AND LAPAROSCOPIC PYELOPLASTY FOR URETEROPELVIC JUNCTION OBSTRUCTION (UPJO): SUBJECTIVE OUTCOME. Journal of Clinical and Diagnostic Research [serial online] 2011 December [cited: 2019 Sep 17 ]; 5:1601-1605. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=December&volume=5&issue=8&page=1601-1605&id=1791

INTRODUCTION
Many treatment options exist for the management of UPJ obstruction. Open pyeloplasty has a high success rate and it has been considered as the gold standard. But significant post-operative pain and a long recovery time period are related to the open pyeloplasty surgeries. In an attempt to minimize the post-operative morbidity of open surgical UPJ correction, many minimally invasive options have been developed. These include balloon dilatation, antegrade endopyelotomy, retrograde endopyelotomy, acucise endopyelotomy and laparoscopic pyeloplasty (1). Laparoscopic pyeloplasty was first reported in 1993, both by Schuessler and co workers and by Kavoussi and Peters, who utilized the dismembered pyeloplasty technique (2). During the last decade, advances in the endourological techniques have resulted in significant progress in the development of minimally invasive surgical procedures for treating UPJ obstruction (3). The combination of less post-operative morbidity, improved cosmesis, shorter convalescence and comparableoperative success rates has lured many patients away from the gold standard of open pyeloplasty. Only few retrospective studies have been conducted to compare laparoscopic and open pyeloplasty. The success rates are comparable for laparoscopic pyeloplasty and open pyeloplasty (3).

OBJECTIVES
To compare the efficacy of laparoscopic pyeloplasty v/s open pyeloplasty in the treatment of primary UPJ obstruction with respect to the SUBJECTIVE OUTCOME (Post-operative pain, activity level and time when oral feeds were started.)

Material and Methods

The present study was a prospective randomized control trial which compared laparoscopic pyeloplasty and open pyeloplasty in the treatment of primary ureteropelvic junction (UPJ) obstruction, which was conducted in the Department of Urology, KLES hospitaland MRC, Belgaum, during the period of 1 year from April 1004 to March 2005. A total of 30 patients were evaluated and operated for primary UPJ obstruction. They formed the clinical material for our study. Clearance from the ethical committee of the institution was obtained before the start of the study.

Source of Data
All the cases of primary UPJO of any age group which reported to the Department of Urology, KLES Hospital Belgaum.

Method of Collection
• Sample size – 30 patients. • Sampling procedure: A total of 30 patients was selected and randomized into 2 groups of 15 each. 15 patients underwent open pyeloplasty and 15 patients underwent laparoscopic pyeloplasty.

Follow-up
All the patients were followed-up for a period of minimum 3 months to assess the subjective outcome. Routinely, in the uncomplicated cases, ureteric stent removal was done at 6 weeks. The total study period was 15 months.

Selection criteria
a. I nclusion criteria All the patients of primary UPJO of any age group who were diagnosed clinically and/or radiologically (including both symptomatic and asymptomatic patients).

b. E xclusion criteria:
i. Patients with secondary UPJO. ii. Patients with long segments of UPJ obstruction in which a normal caliber proximal ureter could not be brought to the renal pelvis without causing a lesion. iii. Patients with urinary tract infection and a huge capacity pelvic. iv. General contraindications for laparoscopic surgery (e.g. morbid obesity, major bleeding disorders, unacceptable anaesthesia risks and patients who do not tolerate the pneumoperitorium). v. Patients who were unfit for surgery due to co morbid medical conditions. vi. Redo surgeries or failed pyeloplasty.

All the patients were evaluated in detail by randomization. The diagnosis of primary UPJO was firmly established in all the patients, based on their history, physical examination, renal sonography and scintiography. The risks of the operation were fully explained to the patients and their parents and these included post-operative infection, bleeding, failed pyeloplasty, the need to convert to open surgery in case of laparoscopic pyeloplasty, damage to other viscera and adhesion formation.

The following investigations were done in all the patients.

1. Blood – complete haemogram, BT, CT 2. Urine – Routine Microscopy 3. Minirenals – RBS, B-Urea, S-Creatinine, S-Electrolytes 4. Serology –HIV, HBSAg 5. X-ray KUB 6. Renal USG 7. IVP

8. 99 mTc- DTPA scan. 9. CT scan / MR-Urogram (selected patients) of KUB. 10. Chest X-ray and ECG.

A prior fitness certificate was taken from a physician/paediatrician. The consent for the surgery was taken from the patients or the patients parents. An enema was administered on the night before the surgery to ensure that the colon was empty.

Anaesthesia
All the patients were operated under general anaesthesia. A retrograde pyelogram was done in all the patients before the surgery to delineate UPJO and to rule out other associated anomalies such as VUR (vesico-ureteral reflux). The patients were catheterized and the catheter was left on free drainage during the operation. Intra operation antibiotics were administered to minimize the risk of infections.

Position
The patients were put in the lateral position and were secured by placing a sand bag to support their backs. They were further stabilized by strapping their iliac crests to the operating table with adhesive bandages . They were placed as close as possible to the edge of the operating table.

Surgical technique
1. Anderson Hynes dismembered open pyeloplasty. 2. Laparoscopic Anderson – Hynes pyeloplasty.

Post-operative care
1. The drain was removed in less than 5 CC/ 24 hrs 2. The catheter was removed the next day 3. Oral fluids and feeding were started at the appearance of peristaltic bowel sounds.

Follow-up
1. In uncomplicated cases, the actual stent was removed after 6 weeks. 2. All the patients were followed up for urinary tract infection and renal scintigraphy was repeated at 3 months.

Assessment of the subjective outcome: The subjective outcome of these 2 groups was assessed, based on the response to the pain analog and the activity questionnaire of Nadler et al4. This questionnaire assessed the perceived pre-operative and postoperative pain on a scale of 0 (no pain) to 100 (worst pain) and also the activity levels on a scale of 0 (bed rest) to 100 (full/ unrestricted). In children who were less than 6 yrs of age, a pictoral pain analog scale was used and the questionnaire was given to their parents to mark. All the patients received the same questionnaire. The patients were asked to comment on the pain and the activity level at the time of surgery and at the time of follow-up for the ureteral stent removal, usually after 6 weeks of surgery. The pre-operative assessment of the pain was based on memory and the post-operative assessment was based on the current status. The mean differences between the pre-operative and the postoperative pain and the activity scores were compared by using paired‘t’ tests.

The analog pain and the activity questionnaire which assessed the pre-operative and the post-operative pain and the activity:

1. Please mark on the following scale the level of discomfort you experienced before your procedure0____________________________________________ 100 (no pain) (worst pain) 2. Please mark on the following scale the level of discomfort you are experiencing now, (6 weeks after the procedure) 0 ____________________________________________100 (no pain) (worst pain) 3. If before your procedure, your discomfort level was 100%, what is your current level of discomfort? ____________________________________________(0-100%) 4. Please mark on the following scale your level of activity before your procedure 0 ____________________________________________100 (bed rest) (full activity) 5. Please mark on the following scale your level of activity after the procedure (6 weeks). 0 ____________________________________________100 (bed rest) (full activity

Results

A total of 30 patients with primary UPJO who attended the Department of Urology, KLES and MRC, Belgaum, during a period of 1 year from April 2004 to March 2005 were selected for the study. All the 30 patients were randomized into 2 groups of 15 each. 15 patients underwent open pyeloplasty and this formed the open pyeloplasty group and the remaining 15 patients underwent laparoscopic pyeloplasty, who formed the laparoscopic pyeloplasty group. All the cases were followed up for a minimum of 3 months.

Sex incidence
Out of 15 patients in the open pyeloplasty group, 11 patients were males and 4 were females and out of 15 patients in the laparoscopic group, 11 were males and 4 were females (Table/Fig 1).

Laterality
Out of 15 patients in the open pyeloplasty group, 4 had primary UPJO in the right kidney, 9 had it in the kidney and 2 had B/L UPJO. Out of 15 patients in the laparoscopic pyeloplasty group, 6 had primary UPJO in the right kidney, 07 had it in the left kidney and 2 had B/L UPJO (Table/Fig 2).

Age
The average age of the patients who underwent open pyeloplasty was 22.83 yrs (range-5mts-48yrs) and that of those who underwent laparoscopic pyeloplasty was 20.42 yrs (range-8 mts to 65 yrs) (Table/Fig 3).

Symptoms
Most of the patients presented with pain in the loin region or an asymptomatic mass per abdomen or both (Table/Fig 4).

Associated anomalies
Out of 15 patients in the open pyeloplasty group, one patient had a right solitary kidney (an absent left kidney). Out of 15 patients in the laparoscopic pyeloplasty group, one patient had a horse shoe kidney with a contracted kidney on the contralateral side and hypertension (Table/Fig 5).

Post-operative subjective outcome
The subjective outcome of the 2 groups was assessed, based on the response to the pain analog and the activity questionnaire of Nadler et al (Table/Fig 6).

Discussion

The gold standard for the repair of UPJ obstruction is open pyeloplasty and the best clinical results have been reported with the complete dismembering techniques like the Anderson-Hypes procedure. The success rates of this technique are reported to be 90-100% (5),(6). Open surgical techniques result in significant per- and post-operative morbidity, post-operative pain and scarformation. In the hope of decreasing the surgical morbidity which is associated with the open approach, several minimally invasive procedures have been introduced during the past two decades, specifically antegrade and retrograde endopyelotomy (7),(8),(9). The cumulative experiences with these procedures have shown a fairly good success rate (61-89%) and a significant risk of bleeding. The minimal invasive endoscopic procedures were reported to have a good initial success rate. However, long-term results, even in the highly selected cases, are poor.

Endopyelotomy became popular in the 1980s and 1990s as a minimally invasive technique with low complication rates, relatively short operating times and a short convalescence period.

More recently, the laparoscopic procedures which are used to treat UPJO have combined the advantages of minimally invasive procedures. A high degree of safety and high success rates have been obtained with open surgical procedures. Since the end of the last decade, laparoscopic pyeloplasty has become increasingly popular. The success rates have been quoted to be about 87- 100% (10),(11),(12). This procedure allows the identification of the crossing vessels, excision of the diseased UPJ plus or minus a reduction pyeloplasty and a watertight anastomosis. In addition, the analgesic requirement, the hospital stay and the recovery period are considerably reduced as compared to the open pyeloplasty. Schuessler et al. first introduced laparoscopic pyeloplasty in 1993 and a variety of authors have reported on their clinical experiences with respect to this promising new technique. The techniques which have been described, differed mainly in the way of performing the pyeloplasty by utilizing either a complete dismembering or a non-dismembering technique. Laparoscopic pyeloplasty can be performed via a retroperitoneal or a transperitoneal approach. Equivalent success rates have been quoted in the literature for both these methods. In our study, we used a transperitoneal approach for all the patients in the laparoscopic pyeloplasty group, as this approach offered ease in identifying, dissecting and mobilizing the intra-abdominal structures, while the potential disadvantages included a prolonged ileus, adhesion formation, and injury to the adjacent viscera.

The major advantage of the retroperitoneoscopic approach was that it provided a direct route to the UPJ and thus allowed access without interference from the intra-abdominal structures. However, the working space was limited, and the absence of anatomic landmarks made the dissection more cumbersome. The greatest drawback which was associated with these treatments was the risk of vascular injury. Sampaio has shown that in 72.2% of the cases, the crossing vessels could be found either anterior or posterior to the UPJ. These vessels could be injured during the UPJ incision without a prompt intra-operative recognition, leading to significant bleeding. Faerber et al. reported two bleeding complications in their series of 32 patients (6.2%). Merety K et al. reported bleeding that required transfusion in 95 patients and in 16% of their patients in their series of antegrade and retroantegrade endopyelotomies respectively.

The results of laparoscopic pyeloplasty from several institutions which reported on the adult series, suggested that this procedure was a viable alternative to both open and endoscopic procedures. With the increased training and experience, the success rate has clearly exceeded that of endoscopic approaches and it is similar to that of open pyeloplasty. The potential advantages of laparoscopic pyeloplasty over open pyeloplasty are decreased post-operative pain, shorter hospitalization, short convalescence and improvedcosmesis. An important caveat, as was concluded by Bauer et al13, is that neither open nor laparoscopic pyeloplasty can universally guarantee complete pain relief. Laparoscopic pyeloplasty in children is even more technically challenging than that in adults because of the smaller operative space and the need for finer suture material. However, laparoscopic pyeloplasty has been demonstrated to be feasible and to have satisfactory early results. After a decade, laparoscopic pyeloplasty has emerged as a durable elective technique for the management of UPJ obstruction.

Laparoscopic pyeloplasty is continuing to progress and it offers promise for some of the most challenging circumstances. As the technology advances and as the clinical experience increases, this technique may universally replace open pyeloplasty as the gold standard.

In our present study, the total 15 patients who underwent open pyeloplasty, were in the age group of 5 months to 54 yrs (mean age = 22.82yrs) and the male to female ratio was 2.75:1. The laterality, that is the involvement of the right and left kidney was in the ratio of 1:2.25 and 2 cases had bilateral involvement, (13.33%). Both had undergone open pyeloplasty earlier in our institute. The associated anomalies were found in 2 of the 15 patients, (13.33%). One of those had a double moiety ureter on the left side with lower moiety meter UPJO and the other patient had a right solitary kidney.

The other 15 patients who underwent laparoscopic pyeloplasty by the transperitoneal approach, were in the age group of 9mts – 65 yrs (mean age = 20.42yrs) and the male to female ration was 2.75:1. The laterality, that is the involvement of the right and the left kidney was in the ratio of 1:2.25 and 2 cases had bilateral involvement (13.33%). Both had undergone open pyeloplasty, one at our institute and the other had undergone it elsewhere. The associated anomalies were found in one patient in the laparoscopic pyeloplasty group (6.66%), who had a horseshoe kidney. In the literature, it is mentioned that UPJO occurs more commonly in males than in females, that the ratio exceeds 2:13 and that left sided lesions pre-dominate (approximately 67%). Bilateral UPJO is present in 10-40% of the cases and our patient demographics were in concordance with the reports in the literature.

The pain and the activity level were assessed both pre-operatively and by using a pain analogy scale and the activity questionnaire of Nadler et al. in both the groups. The pain and the activity level were assessed pre-operatively just one day prior to the surgery and post-operatively, the pain and the activity level were assessed after 6 wks at the time of the ureteral stent removal. The statistical analysis was done by using the Students unpaired and paired‘t’ tests.

The mean pre-operative pain level in the open pyeloplasty group was 62.66% and the mean post-operative pain level at 6 weeks was 18%. The mean pre-operative activity level was 54.66 and the mean post-operative activity level at 6 weeks was 90.66. The mean pre-operative pain level in the laparoscopic group was 59.0 and the mean post-operative pain level at 6 weeks was 5.33. The mean pre-operative activity level was 48.66 and the mean postoperative activity level at 6 weeks was 96.33. From the results, we could assess that the difference between the mean pre-operative pain levels of the open and the laparoscopic pyeloplasty groups was not significant and that the difference between the mean pre-operative activity levels of both the groups and the difference between the post-operative activity levels of both the groups were not significant. The difference in the pain level between theopen and the laproscopic pyeloplasty groups was significant and the difference between the activity levels of both the groups was significant. The results concluded that the laparoscopic pyeloplasty group patients had significant improvement in the pain and the activity level post-operatively than those patients who had undergone open pyeloplasty.

In the laparoscopic pyeloplasty group, the conversion to open pyeloplasty was not done in any patient. No anastomotic stricture was observed in any patients. The success rate was 100% in both the groups. The mean time when oral feeds were started in the open pyeloplasty group was 1.4 days and it was 2.33 days in the laparoscopic pyeloplasty group.

In the literature, only few studies have compared the objective and subjective out comes between open versus laproscopic pyeloplasty. A study which was conducted by John J Bauer and Louis R Kovoussi (13) compared laparoscopic vs. open pyeloplasty with respect to the objective and subjective outcomes. The results showed that out of 42 laparoscopic group patients, 90% were pain free and that 62% showed significant improvement in the flank pain 2 patients had minor improvement and 2 had no improvement in the pain. Surgery failed in only 1 patient with complete obstruction. A patient UPJ was demonstrated in 98% of the laparoscopic group patients. In the most recent radiographic study, the mean follow-up was found to be 15 months for the 35 open surgery group patients. 91% were found to be pain free, 31% patients significantly improved after the surgery, one patient had only minor improvement and 2 became worse.

Conclusion

The results of laparoscopic pyeloplasty from several institutions which reported on the adult series suggested that this procedure was a viable alternative to both the open and endoscopic procedures. With the increased training and experience, its success rate has clearly exceeded that of endoscopic procedures and it is similar to that of open pyeloplasty. After a decade, laparoscopic pyeloplastyhas emerged as a durable elective technique for the management of UPJ obstruction. Laparoscopic pyeloplasty is continuing to progress and it offers promise for some of the most challenging circumstances. As the technology advances and as the clinical experience increases, this technique may universally replace open pyeloplasty as the gold standard.

References

1] D Duane Baldwin, Jennifer A Dunbar, Nancy Wells, Elspeth M, Mc Dougall. Single centre comparison of laparoscopic pyeloplasty, acucise endopyelotomy and open pyeloplasty. Journal of Endourology Apr 2003; 17.

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Steven B Streem, Jenny J Franke, Joseph A, Smith JR. Campbell’s Urology. Second edition. Vol 1 38-40, Vol 3 478-89.
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Hartley G, Cileton JR, George W Kalpan. Ureteropelvic-junction obstruction. King’s Infant Children Urology. 3rd edition: 19-29.
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Nadler, Pearle, Nakada, Clayman RV. Access endopyelotomy. Assessment of the long-term durability. Journal of Urology 156: 1094-96.
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Jarrett TW, Chan DY, Charambura TC, et al. Laparoscopic pyeloplasty: the first 100 cases. Journal of Urology 2002; 167: 1253-56.
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Bauer JJ, Bishoff JT, Moore RG, Chen RN, Iverson, et al. Laparoscopic versus open pyeloplasty: Assessment of objective and subjective outcome. Journal of Urology 1999; 162 (3-1): 692-95.

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