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: 1.71). 09/2009; 23(8):1307-11.
Source: PubMed


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.

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    • "No 28.9 100 US plus RS 0 Lopez et al. [15] 32 7.7 152 9.3 10.3 No 22 100 US plus RS 0 Chacko et al. [16] 52 4.3 248 0 13.4 Yes 20 98 RS 1.9 Maheshwari et al. [17] 82 y 7.1 151 4.8 17.9 No 41.5 91.9 RS 2.4 Szavay et al. [18] 20 1.68 1408 1.4 4.2 No 248 100 RS 0 Metzelder et al. [19] 46 5.5 175 4.3 6.8 "
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    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.
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