Article

Pediatric laparoscopic pyeloplasty: lessons learned from the first 52 cases.

Department of Surgery, Division of Urology, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.
Journal of endourology / Endourological Society (Impact Factor: 2.1). 09/2009; 23(8):1307-11.
Source: PubMed

ABSTRACT The use of laparoscopy for pediatric pyeloplasty is increasing. We review our experience with our first 50 cases and describe the main technical points learned during this experience.
We retrospectively reviewed the charts of all patients who underwent laparoscopic pyeloplasties (LP) over a 4-year period (January 2004 to January 2008) at our institution. Patient demographics, operative details, hospital stay, outcomes, and complications were examined.
Fifty-two patients underwent LP from for primary repair of ureteropelvic junction obstruction (UPJO). Thirty-six male and 16 female were operated on at an average age and weight (range) of 51.8 months (3 weeks to 216 months) and 20 kg (3.9-74.2 kg), respectively. Intraoperatively, 47/52 (90%) underwent retrograde ureteropyelography (RUPG), and 51/52 (98%) had a ureteral stent placed during surgery. Nine crossing vessels (17%) were identified at the time of surgery. The anastomoses were performed with a running absorbable suture. Operative time was 248 min (range 120-693 min). The average hospital stay was 3 days (range 1-7). A bladder catheter usually remained indwelling for 2 days and a perirenal drain for 3 days; they were removed before hospital discharge. The stent remained in place on average 39 days (range 11-127 d) and was removed with the patient under a brief general anesthetic. Anastomotic patency was seen in 51/52 (98%) patients determined by improvement on postoperative renal ultrasonography and/or resolution of symptoms. Mean follow-up was 20 months (range 3-50 mos). Complications included recurrence of UPJO necessitating redo LP (1), dislodgement of a nephrostomy (1), stent replacement (1), ileus (2), and vascular injuries treated laparoscopically (2). No patients needed conversion to open surgery.
LP has supplanted open pyeloplasty at our institution. We have noted improved success by performing RUPG to define the anatomy and stent placement at the beginning of the case, using purple 5-0 or 6-0 poliglecaprone suture for the anastomosis and a 5-mm wide-angle lens for visualization. We found no disadvantages for the transperitoneal approach, although we find it necessary to leave a drain. With the increased use of LP in pediatric urology, we hope these observations from our experience will help improve the learning curve for others making this transition.

0 Followers
 · 
77 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introductie: Om de laparoscopische pyelumplastiek (LP) in onze kliniek te accepteren als nieuwe behandeling voor UPJ-stenose bij kinderen, moeten de resultaten ervan minstens gelijkwaardig zijn aan die van de conventionele open pyelumplastiek (OP), met een duidelijk korte opname. Het doel van deze studie is het vergelijken van onze resultaten van de LP bij kinderen vanaf 3 jaar met die van de OP en de resultaten van de LP zoals beschreven in de literatuur. Materiaal en methoden: In de periode van april 2006 t/m september 2010 werden in totaal 51 keer een LP transperitoneaal verricht bij kinderen vanaf de leeftijd van 3 jaar. De historische controlegroep bestond uit de patiënten vanaf de leeftijd van 3 jaar die van 1998 t/m 2005 een OP (n = 80) ondergingen. Een succesvolle pyelumplastiek is gedefinieerd als: symptoomvrij, geen conversie of re-operatie/-interventie, een echografisch verbeterde dilatatie en/of een renografisch verbeterde afvloed. Resultaten: De gemiddelde operatieduur in de LP-groep was significant langer dan in de OP-groep (176 vs 113 minuten; p< 0,001). In de LP-groep was geen conversie. De gemiddelde opname in de LP-groep duurde significant korter dan in de OP-groep (1,2 vs 6,7 dagen; p< 0,001). In de LP-groep bleek de renografische afvloed vaker verbeterd dan in de OPgroep (98% vs 86%; p= 0,019). Een succesvol resultaat werd gezien bij 50 patiënten in de LP-groep en bij 77 patiënten in de OP-groep (98% vs 96%; p= 0,55). Onze LP toonde duidelijk een korte opname en een zeer hoge succeskans in vergelijking met de in de literatuur beschreven resultaten. Conclusie: In vergelijking met de OP heeft de LP een langere operatieduur, vaker een verbeterde renografische afvloed, en is de behandeling minstens even succesvol. Daarnaast gaat onze LP gepaard met een duidelijk korte opname en zeer gunstige uitkomsten in vergelijking met de literatuur. Gezien deze gunstige resultaten beschouwen wij de LP als onze standaardbehandeling van UPJ-stenose bij kinderen vanaf 3 jaar.
    06/2011; 1(4). DOI:10.1007/s13629-011-0048-z
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized. To critically analyze the current status of laparoscopic and robotic repair of UPJO. A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population. Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.
    European Urology 07/2013; 65(2). DOI:10.1016/j.eururo.2013.06.053 · 12.48 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Laparoscopic pyeloplasty in children remains controversial and is not included in most pediatric urology centers because of technical difficulties and lack of long-term results. OBJECTIVE: To critically analyze our 10-yr experience with the retroperitoneal approach (RA), with a particular interest on the impact of the learning curve in a teaching center. DESIGN, SETTING, AND PARTICIPANTS: Patients who underwent pyeloplasty between 1999 and 2010 at our institution were reviewed (n=390). The diagnosis of ureteropelvic junction obstruction was confirmed by ultrasound and technetium Tc 99m mercaptoacetyltriglycine-3 renal scan or magnetic resonance imaging; the same criteria were used to evaluate the outcome. The lateral RA was selected in children >1 yr of age without abnormal migration or fusion of the kidney (n=104). SURGICAL PROCEDURE: Dismembered pyeloplasty and anastomosis were performed using running monofilament 5-0 or 6-0 absorbable suture. All were drained by double-J stent except 20 cases drained by external transanastomotic stent. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed intra- and postoperative morbidity and analyzed the teaching of technique and learning curve. Data are expressed as medians and interquartile range (25th, 75th percentiles) for quantitative variables. RESULTS AND LIMITATIONS: Median age was 6.2 yr (2.2-10.3). Thirty-three patients had crossing vessels. Median operative time was 185min (160-235). Median hospital stay was 2 d (1-2). Redo pyeloplasty was needed in only two children (2%). Median follow-up was 2.1 yr (1.4-4.1). Operative time was <3h after 35 cases. After 30 cases performed by the same surgeon, standardization of the technique was feasible, which helped in the teaching process because 50% of the final 30 cases were done by trainees. CONCLUSIONS: Retroperitoneal dismembered laparoscopic pyeloplasty is a safe, reliable, and efficient procedure with an excellent outcome in selected children according to their indications and age, and the experience of the surgical team. Even if the transmission to trainees is successful, it is still a long learning process and remains a challenging task for a teaching center.
    European Urology 08/2012; 63(3). DOI:10.1016/j.eururo.2012.07.051 · 12.48 Impact Factor