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Laparoscopic Treatment of Retroperitoneal Fibrosis: Report of Two Cases and Review of the Literature

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Laparoscopic Treatment of Retroperitoneal Fibrosis: Report of Two Cases and Review of the Literature MARCH-APRIL REV. HOSP. CLÍN. FAC. MED. S. PAULO 55(2):69-76, 2000 LAPAROSCOPIC TREATMENT OF RETROPERITONEAL FIBROSIS: REPORT OF TWO CASES AND REVIEW OF THE LITERATURE Lísias Nogueira Castilho, Anuar Ibrahim Mitre, Flávio Haruyo Iizuka, Oscar Eduardo Hidetoshi Fugita, José Roberto Colombo Jr. and Sami Arap RHCFAP/3006 CASTILHO L N et al. - Laparoscopic treatment of retroperitoneal fibrosis: report of two cases and review of the literature. Rev. Hosp. Clín. Fac. Med. S. Paulo 55(2):69-76, 2000. SUMMARY: Objectives: We present the results of treatment by laparoscopy of two patients with retroperitoneal fibrosis and review the literature since 1992, when the first case of this disease that was treated using laparoscopy was published. We also discuss the contemporary alternatives of clinical treatment with corticosteroids and tamoxifen. Case report: Two female patients, one with idiopathic retroperitoneal fibrosis, and other with retroperitoneal fibrosis associated with Riedel’s thyroiditis, were treated using laparoscopic surgery. Both cases had bilateral pelvic ureteral obstruction and were treated using the same technique: transperitoneal laparoscopy, medial mobilization of both colons, liberation of both ureters from the fibrosis, and intraperitonealisation of the ureters. Double-J catheters were inserted before the operations and removed 3 weeks after the procedures. The first patient underwent intraperitonealisation of both ureters in a single procedure. The other had 2 different surgical procedures because of technical difficulties during the first operation. Both patients were followed for more than 1 year and recovered completely from the renal insufficiency. One of them still has occasional vague lumbar pain. There were no abnormalities in the intravenous pyelography in either case. Conclusions: Surgical correction of retroperitoneal fibrosis, when indicated, should be attempted using laparoscopy. If possible, bilateral ureterolysis and intraperitonealisation of both ureters should be performed in the same operation. DESCRIPTORS: Retroperitoneal fibrosis. Ureteral intraperitonealisation. Ureterolysis. Retroperitoneal fibrosis was first brosis into 2 groups: idiopathic and IRF afflicts all races equally, being described by French urologist Albarran secondary1. Idiopathic retroperitoneal predominant in the male sex in the pro- at the beginning of the century and has fibrosis (IRF), which comprises to two- portion of 2:1 to 3:1, with its peak of received countless other names through thirds of the total cases, is retroperito- incidence being between 40 and 60 time: Ormond’s disease, fibrotic peri- neal fibrosis in which no etiology can years of age4. There is evidence that the ureteritis, plastic periureteritis, chronic be defined and that does not associate onset of IRF depends on hereditary periureteritis, sclerosing retroperitoneal itself to any other etiopathogenic con- predisposition, and may have an etio- granuloma, fibrotic retroperitonitis, dition (Table 1). Secondary retroperi- logic relation with the arteriosclerotic perianeurismatic retroperitoneal fibro- toneal fibrosis (SRF) is associated with process of the terminal aorta and the sis, subclinical chronic periaortitis, and cancer, drugs, chemical products, in- iliac arteries1,5,6. IRF has an initially in- chronic periaortitis1,2. Until recently, fections, inflammatory diseases, retro- sidious and vague clinical presentation different etiopathogenic conditions peritoneal bleeding, or radiotherapy1. with symptoms being malaise, lumbar were grouped under the name of ret- pain, anorexia, low fever, and asthenia. roperitoneal fibrosis which generated From the Division of Urology, Hospital das Of these, the most frequent, which confusion in medical literature. Current Clínicas, Faculty of Medicine, University of must therefore be emphasized, is lum- practice is to classify retroperitoneal fi- São Paulo. bar pain, which is present in 80% to 69 REV. HOSP. CLÍN. FAC. MED. S. PAULO 55(2):69-76, 2000 MARCH-APRIL Table 1 - Retroperitoneal fibrosis: tic bifurcation, sparing the posterior plications, or to facilitate the ureteral etiology in 491 patients* region of the great vessels. The medial identification and dissection, a Double- deviation of the ureters in their middle J catheter is introduced in each of the Etiology Percent portion is typical, however non-pathog- ureters, days or weeks before surgery, Idiopathic 67.8 nomonic, as is the approximation of remaining there for 2 to 3 weeks after Methysergide 12.4 the aorta and the vena cava, in opposi- surgery9. Malignancies 7.9 tion to what occurs in malignant meta- Open surgery has been traditionally Mediastinal fibrosis 3.3 static diseases, in which augmented performed through a median trans- Periaortic inflammation 2.4 interaortocaval lymph nodes promote peritoneal incision. Some prefer open- 8 Mesenteric fibrosis 2.0 distancing of the great vessels . ing the retroperitoneum through a me- Sclerosing cholangitis 1.6 The treatment of IRF is controver- dian incision in the posterior perito- sial, not only because the natural his- neum, beginning superiorly between Aortic abdominal aneurism 1.6 tory of the disease is not well known the duodenum and the inferior mesen- Crohn’s disease 1.2 due to its low incidence, estimated by teric vein, others opt to incise the line Thrombophlebitis 1.0 some to be 1/200 000 inhabitants9, but of Toldt, mobilizing the colons medi- Riedel’s thyroiditis 0.8 also because there are reports of spon- ally1,2. Both retroperitoneal approaches Other 5.3 taneous regression10 and favorable re- allow ureterolysis, the envelopment of * Modified from Koep & Zuidema 3 sponses to several different pharmaceu- the ureters with fatty tissue followed by tical treatments with corticosteroids, intraperitonealisation. The open sur- tamoxifen, azatioprin, methotrexate, gery has approximately 9% mortality 90% of the cases; however, this symp- cyclophosfamide, and penicillamine, and 60% morbidity, either because the tom is not diagnostic. With the evolu- used alone or in combination, with or patients frequently present chronic re- tion of the disease, manifestations in- without concomitant use of Double-J nal insufficiency and poor clinical con- dicative of renal insufficiency due to ureteral catheters1,11. Unfortunately, all ditions, or because of the extent of the bilateral ureteral compression, such as reports of clinical treatment involve surgery9. hypertension, edema and anemia, or small numbers of patients and are not When possible, the underlying dis- even signs caused by the compression controlled studies; for this reason, ease of SRF is treated. When this is not of retroperitoneal veins, such as edema many urologists, claiming good results possible, the clinical or surgical treat- of the lower limbs, varicocele, and hy- in the long run, have opted for imme- ment for IRF can be performed, with drocele1,4 may appear. Diagnosis of diate surgical treatment, once the diag- similar results2,9,12. IRF in its initial phase is very difficult nosis is established1,2,5,12. Surgical treat- Since 1992, several cases of because the physical examination of ment consists basically in unilateral or laparoscopic ureterolysis and the patient is usually normal and the bilateral ureterolysis. Some defend bi- intraperitonealisation have been de- clinical laboratory findings are nonspe- lateral treatment in all cases, even if scribed, with low morbidity rates and cific, the most constant being the eleva- there are no radiological evidences of no deaths reported9,13-18. Elashry, et al tion of ESR (erythrocyte sedimentation involvement of both ureters.1 The ure- compared the results of 6 laparoscopic rate) present in over 80% of the cases.2 terolysis is the liberation of all the in- surgeries with 7 open surgeries, all uni- The clinical diagnosis depends funda- carcerated portion of the ureter, which lateral ureterolysis cases, and con- mentally on the demonstration, by is usually involved by a circular con- cluded that the laparoscopic approach computerized tomography (CT) or, centric fibrosis, from its proximal is superior in all considered aspects, preferably, magnetic nuclear resonance healthy portion to the distal portion, with the only exception being mean (MRI) 7, of a unilateral, or, far more generally free of fibrosis, below the surgical time: 255 minutes for the frequently, bilateral thickening of the iliac vessels. The ureteral liberation, as laparoscopy versus 232 minutes for the retroperitoneum, which may extend an isolated procedure, can lead to re- open surgery9. Because of these reports vertically from the renal hilum to the lapse, hence the preference of the ma- and our previous experience with pelvic brim, and laterally from one jority of surgeons for wrapping the ure- laparoscopic technique, we decided to psoas muscle to the other. In the ma- ters with retroperitoneal fat or greater evaluate the results of laparoscopic jority of cases, the fibrotic retroperito- omentum, or, alternatively, intra- intraperitonealisation in retroperitoneal neal thickening is located between the peritonealisation them1,2,9. Whenever fibrosis cases and also review the last lumbar vertebrae and the first sac- possible, whether to alleviate renal in- medical information related to the ral vertebrae, in the region of the aor- sufficiency, reducing the risk of com- treatment of retroperitoneal fibrosis. 70 MARCH-APRIL REV. HOSP. CLÍN. FAC. MED. S. PAULO 55(2):69-76, 2000 CASE REPORTS Surgical technique The patient undergoing single-stage
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