Surgical outcomes of laparoscopic dismembered pyeloplasty in children with giant hydronephrosis secondary to ureteropelvic junction obstruction

ObjectiveStudies of surgical outcomes after reconstructive surgery for giant hydronephrosis (GH) secondary to ureteropelvic junction (UPJ) obstruction are limited. Over the past two decades, laparoscopic pyeloplasty has gradually replaced open repair in children in several centres. The objective of this study was to assess surgical outcomes of laparoscopic pyeloplasty in children with GH.Materials and MethodsChildren with unilateral primary UPJ obstruction and GH were prospectively included and underwent laparoscopic pyeloplasty. Postoperative ultrasonography was repeated at 3 and 12 months to assess renal parenchymal thickness, and similarly a renogram was repeated to assess improvement in differential renal function.ResultsDuring the study period 2005–2009, 53 children underwent laparoscopic dismembered pyeloplasty for UPJ obstruction. Of these, 8 children had GH caused by UPJ obstruction. The postoperative differential renal function improved in all of them. The postoperative improvement in renal parenchymal thickness at the end of 12 months was comparable to that of the non-GH group.ConclusionsAt 12 months, surgical outcomes after laparoscopic pyeloplasty for GH were satisfactory. Relief of obstruction allows adequate and comparable nephron sparing.     

Laparoscopic pyeloplasty is feasible for lower pole pelvi-ureteric obstruction in duplex systems

Exclusive lower pole pelvi-ureteric junction obstruction (PUJO) in double collecting systems in children is a rare condition requiring reconstructive surgery. We report on the feasibility of laparoscopic transabdominal dismembered pyeloplasty in two cases. Two children with duplicated collecting systems presented with hydronephrosis of lower pole moiety due to exclusive PUJO. Isotope renography revealed impaired drainage of affected lower kidney pole. A four-trocar transabdominal technique was used. No stent was used in one patient with bilateral duplication (male, 6 years) while a 4 Fr. double-J stent was placed laparoscopically in another with unilateral duplication (male, 9 months). Both patients had uneventful laparoscopic transabdominal dismembered pyeloplasty. The operation time was 115 and 155 min, respectively, and was comparable to our previously reported patient series undergoing laparoscopic pyeloplasty for singular collecting systems. After a mean follow-up of 21 months (range 12-42), both patients were asymptomatic and showed improved pelvi-ureteric drainage on isotope renography and improved hydronephrosis on ultrasound scan. Laparoscopic transabdominal dismembered pyeloplasty is safe and effective in children with rare lower pole PUJO in double collecting systems.     

Functional outcome after laparoscopic dismembered pyeloplasty in children

ObjectiveLaparoscopic or retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction in children has become a routine procedure. The aim of this study was to evaluate functional outcome for patients who had undergone a laparoscopic dismembered pyeloplasty.Patients and methodsSeventy children underwent a laparoscopic dismembered pyeloplasty. Median follow up was 24 months (1–48). We reviewed differential renal function (DRF) and tracer clearance with diuretic renography before as well as 3 and 12 months after operation. Ultrasound was used to determine the grade of hydronephrosis pre- and postoperatively.ResultsMedian age at operation was 20 months (1–178). Median operating time was 140 min (95–220). Mean DRF could be preserved with no significant difference (P > 0.05). All patients showed a significant improvement in tracer clearance on diuretic renography postoperatively (P < 0.0001). Ultrasound examinations postoperatively showed a diminished grade of hydronephrosis without significance (P = 0.657).ConclusionIn terms of preservation of DRF the laparoscopic approach is as effective as open surgery. Tracer clearance is significantly improving. Operating times for laparoscopic pyeloplasty are competitive. We conclude that laparoscopic pyeloplasty requires extensive experience in laparoscopic pediatric urology but might replace the open surgical procedure as gold standard in the operative treatment of ureteropelvic junction obstruction.     

Surgery of uretero-pelvic junction obstruction (UPJO)

Uretero-pelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in infants and children. Historically, this condition has been approached surgically through a retroperitoneal approach as described by Anderson and Hynes aiming for an open dismembered pyeloplasty. A true evolution of laparoscopy in pediatric urology took place within the last 30 years. Laparoscopy developed from a merely diagnostic tool for non-palpable testes to “interventional” laparoscopy for extirpative surgery. Finally the era of reconstructive pediatric laparoscopic urology started, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic dismembered pyeloplasty now has become the preferred surgical treatment of UPJO. It offers excellent visualization of the anatomy, accurate anastomotic suturing, thus the precise reconstruction of the UPJ along with good functional outcome. This article aims to provide the current status, indication and operative technique of laparoscopic dismembered pyeloplasty for UPJO in infants and children.     

Bypass pyeloplasty: Description of a procedure and initial results

Introduction and objectiveDismembered pyeloplasty is the surgical technique of choice for open, laparoscopic and/or robot-assisted repair of ureteropelvic junction obstruction (UPJO). We describe a new technique, bypass pyeloplasty, ideally suited for the high inserting ureter, and present initial results.Patients and methodsA wide 1–2-cm side-to-side anastomosis is created between the dilated and elastic portion of the ureter just distal to the UPJO and the lower and dependent portion of the hydronephrotic renal pelvis. The UPJ is not disturbed and the renal pelvis is not surgically reduced. Since 2004, of 27 patients requiring surgery for UPJO, 7 underwent bypass pyeloplasty. The indications for surgery included increasing hydronephrosis or decreasing individual renal function in four, pain in two and pyelonephritis in one. The remaining 20 underwent a classic dismembered pyeloplasty.ResultsDuring a mean follow-up of 26 months, the anteroposterior diameter of the repaired kidney decreased by a mean of 55%. The individual renal function in the repaired kidney improved in two and remained stable in the remainder.ConclusionThese favorable initial results justify further exploration of this simplified technique and its adaptation for laparoscopic and robot-assisted approaches. Bypass pyeloplasty may be a more physiologic procedure in patients with mid to high insertion of the ureter.     

Laparoscopic assisted dismembered pyeloplasty in children: intermediate results

To study the results of an innovative minimally invasive technique of performing dismembered pyeloplasty in children. Using 5 mm camera and 3 mm working ports, the ureteropelvic junction (UPJ) is mobilized by a transperitoneal laparoscopic technique. The UPJ is brought out through a tiny flank incision and a standard dismembered pyeloplasty is performed over a double J stent. Between October 2003 and January 2005, 13 children underwent laparoscopic assisted dismembered pyeloplasty. Indications, operative duration, hospital stay, preoperative and postoperative isotope renogram parameters were analyzed. The children were in the age range of 3 months to 6 years—three were right sided and ten were left sided. Only three were symptomatic while the remaining ten were detected to have UPJ obstruction during evaluation for antenatally detected hydronephrosis. Mean operative duration was 104.2 min (range 80–150 min) with no significant difference in the two patients with crossing vessels. Incision was smaller than 2 cms in all and the average postoperative hospital stay was 3.2 days (range 2–5 days). Follow-up ranging from 28 to 44 months showed reduction in hydronephrosis and improvement in renal function of all the operated units. Isotope renogram in only one patient showed equivocal slopes and prolonged half clearance times though no further surgical intervention was required. This technique has results comparable to that of open pyeloplasty and hence, maybe considered a good option for surgeons making the transition to laparoscopic pyeloplasty.     

Anderson-Hynes pyeloplasty in horseshoe kidney in children: is it effective without symphysiotomy?

Contemporary reports on surgery for horseshoe kidney (HK) still recommend isthmotomy and lateropexy to complete an open pyeloplasty. To evaluate whether simple Anderson-Hynes pyeloplasty without symphysiotomy is effective for relief of ureteropelvic junction obstruction (UPJO) in HK, we studied the records of ten children, two of whom had bilateral UPJO. Only one child presented with calculi; 11 units were operated upon for UPJO, 1 needed a partial nephrectomy. The surgical outcome was evaluated with emphasis on the changes in renal drainage and function assessed by ultrasonography and diuretic renal scans. Associated vesicoureteral reflux was observed more often (25%) than with UPJO in normal kidneys. Obstruction was caused by a crossing lower-pole vessel in three cases, a high ureteral insertion in two and narrowing of the UPJ 7. Postoperative follow-up (mean 5.5 years) revealed improved renal function and good drainage in all cases. Hydronephrosis vanished in 7, whereas grade 2 hydronephrosis remained in two children with former refluxive megaureter and grade 3 in one. All children are doing well and have no symptoms due to the persistent isthmus (Rovsing syndrome). It is concluded that simple Anderson-Hynes pyeloplasty via a flank incision is a highly effective and safe procedure for treating UPJO in HK. Accepted: 13 October 1998     

Evaluation of UPJ obstruction before and after pyeloplasty using MR urography

This article builds on the previous article in this symposium and shows how MR urography contributes to the postoperative evaluation of children with UPJ obstruction. By analyzing the postoperative results, we derived new insights into their preoperative evaluation. With MR urography we combine simultaneous physiological and anatomic evaluation that enables us to identify changes in renal pathophysiology that occur in association with impaired drainage and obstruction. We studied 35 children before and after pyeloplasty. The pyeloplasty was considered successful in 30 and unsuccessful in 5. Both anatomic and functional criteria were used. The anatomic parameters included the degree of hydronephrosis, the appearance of the renal parenchyma, the quality of the nephrogram and the presence of crossing vessels. The functional criteria included the renal transit time, the calyceal transit time, the volumetric differential function, the Patlak differential function, the difference between the volumetric and Patlak differential function and the Patlak number per milliliter of renal tissue. No single parameter was sufficient to fully characterize UPJ obstruction, but by synthesizing all the information we were able to subdivide UPJ obstruction into compensated, decompensated and uropathic kidneys. Decompensated systems had the most significant improvement following successful pyeloplasty. Compensated systems showed little improvement in renal function, and uropathic kidneys were associated with a poor prognosis. It is clear that not all UPJ obstructions are the same, and it seems logical that treatment should be individually tailored rather than using a standard approach for all cases. Because MR urography can identify pathophysiological differences in children with UPJ obstruction that are occult to renal scintigraphy, it has an important potential role in identifying those who will benefit most from pyeloplasty and those who are probably best observed.     

Complications of laparoscopic pyeloplasty in children

Introduction  Laparoscopic pyeloplasty in children has been proven to be safe and effective, with comparable results to open surgery. Due to the extension of laparoscopic indications from ablative to reconstructive procedures requiring endoscopic suturing, most centres have plateaued within their learning curve. Based on our own experience with a little more than 100 cases, we focus on the complications and the definitive learning curve of laparoscopic pyeloplasty in children. Materials and methods  A total of 103 laparoscopic pyeloplasties were performed during the period January 2002 to June 2008. Of these, 102 underwent laparoscopic dismembered pyeloplasty and one underwent laparoscopic vascular hitch for crossing lower pole vessels. Intraoperative incidents/complications were analysed using the Satava classification, and the postoperative complications according to the Clavien classification. Results  Intraoperative incidents occurred in 2.91% of the cases, mostly without consequences for the child including faulty port placement needing placement of an extra port and umbilical port side bleed. Postoperative complications occurred in 11.65% children and included prolonged ileus, prolonged urinary leak, fever, haematuria and recurrent ureteropelvic junction (UPJ) stenosis. Recurrent UPJ stenosis occurred in 4.85% of children needing reoperation. Conclusions  Laparoscopic pyeloplasty in children is not only feasible, but safe and effective. Intraoperative incidents occur in up to 3% of the cases, and complications in 12.9–15.8%. Increased experience, training and knowledge regarding the incidence and management of complications will be able to further reduce these in the future.     

Surgical management of failed pyeloplasty in children: single-center experience

PurposeTo evaluate the outcome of secondary surgical procedures for the management of failed pyeloplasty in children.Materials and methodsBetween 1996 and 2007, 590 cases of primary ureteropelvic junction (UPJ) obstruction underwent open dismembered pyeloplasty at our center. Of these patients, 18 (3%) with recurrent UPJ obstruction (14 males, 4 females; age range: 2–15 years) have undergone management of failed pyeloplasty. Secondary intervention was by open operative procedure in all cases. Clinical and radiological outcomes were assessed. Success was defined as both symptomatic relief and radiographic resolution of obstruction at last follow up.ResultsFollow up ranged from 8 to 41 months (mean 28). The overall salvage rate was 89%. Secondary reoperative surgery was successful in 16 patients: dismembered pyeloplasty in 14 patients (78%) and ureterocalyceal anastomosis in 2 (11%). Nephrectomy was necessitated in 2 patients (11%). No perioperative complications were encountered. All patients showed stability of renal function on radiological follow up without evidence of obstruction and with no further symptoms.ConclusionPersistent UPJ obstruction after pyeloplasty is an uncommon complication. Secondary procedures have a very high success rate with excellent functional results. Nephrectomy is indicated in rare cases of severely deteriorated renal function.     

迷走血管压迫致梗阻性肾积水34例临床分析

目的探讨小儿肾盂输尿管交界部迷走血管压迫致梗阻性肾积水的临床特点及治疗方法。方法回顾性分析1997年1月至2008年6月本院收治的34例迷走血管压迫性肾积水患儿的临床资料。结果34例中,男30例,女4例,左侧28例,右侧6例。平均发病年龄9．5岁。手术方法为离断性肾盂成型术（Anderson—Hynes术式）,术中同时将迷走血管移向肾盂后方。病理检查证实12例合并肾盂输尿管交界部狭窄,术后半年行IVP复查,积水缓解,症状消失。结论小儿肾盂输尿管交界部迷走血管压迫致梗阻性肾积水发病年龄较大,腹痛明显,积水较轻。治疗上在采取离断性肾盂成刮术的同时,应将迷走血管转移到肾盂输尿管交接部的后方。马蹄肾合并肾积水时迷走血管压迫是主要的发病原因。     

胃管作支撑引流管在小儿肾盂成形术中的应用

目的 离断式肾盂成形术是治疗小儿肾盂输尿管连接处梗阻的最常见手术，但在术后尿液引流方式，吻合口是否需要支撑等问题上仍存在争议。我们回顾性总结7年来采用胃管作支撑引流管行离断式肾盂成形术的300余例患儿资料。方法 1994年6月至2001年9月，采用胃管作支撑引流管行离断式肾盂成形术300例。共304侧，均为肾盂输尿管连接处梗阻患儿，其中又侧4例。19例患儿（19侧）另放置了肾造瘘管。术后随访B超，IVU，利尿性肾图，尿常规等，随访期6个月至7年，结果 3例患儿（0.98%)出现肾盂输尿管连接处再狭窄。2例术后出现尿路结石，其余患儿随访显示吻合口通畅，肾功能得到保存或提高，未见尿路感染。结论 胃管作为支撑引流管应用于肾盂成形术是可靠的，具有反应小，引流完全，术后处理简便，可行冲洗，造影，测压检查等诸多优点。     

Pelvi-ureteric junction obstruction with crossing renal vessels: A case report of failed laparoscopic vascular hitch

IntroductionDismembered pyeloplasty has been the traditional technique in the management of pelvi-ureteric junction obstruction (PUJO) secondary to crossing renal vessels in children. Laparoscopic transposition of lower pole vessels for PUJO has been described in children as well as adults.Case reportWe report a child with PUJO secondary to lower pole renal vessels who underwent laparoscopic transposition of vessels. The child had persistent PUJO, which was later treated with laparoscopic dismembered pyeloplasty.ConclusionLaparoscopic transposition of renal vessels is a simple technique, and requires less operating time. It involves no anastomosis or insertion of temporary DJ stent. However, as of now there are no imaging techniques or intraoperative procedures available to confirm that the crossing renal vessels are the sole etiology for PUJO. This option should therefore be used with caution.     

Congenital solitary kidney with obstructive uropathy

Two cases of unilateral renal agenesis presenting as obstructive uropathy in the congenital solitary kidney are reported here. One patient had anuria, hypertension urinary tract infection (UTI) and hydronephrosis due to ureteropelvic junction (UPJ) obstruction on the left side. Ultrasonography was helpful in diagnosing the condition. The second patient had hydronephrosis and hydroureter due to ureterovesical junction (UVJ) obstruction on the right side. Both recovered following corrective surgery in the form of pyeloplasty and ureteroneocystostomy respectively and continued to do well on follow up.     

Excision of the dilated pelvis is not necessary in laparoscopic dismembered pyeloplasty.

PURPOSE: The surgical treatment of choice for significant hydronephrosis is dismembered pyeloplasty. While in open surgery, extensive resection of the dilated pelvis is common practice, laparoscopically usually only a sparing resection is performed. We compared the treatment results of both techniques to investigate whether extensive resection is necessary or not in dismembered pyeloplasty procedures. METHODS: To obtain comparable renal units, matched pairs according to age and relative kidney uptake as shown by (123)J-orthoiodohippurate renography were selected out of a total of 76 patients who underwent dismembered pyeloplasty between 2000 and 2007. Twenty-four patients complied with the criteria for inclusion in the study. Changes in urinary drainage preoperatively and at three months postoperatively were compared between both groups. RESULTS: The mean age in the sparing resection group was 3.8 years (range 0.3 to 14 years); in the extensive resection group it was 3.4 years (range 0.5 to 10 years). Mean urinary drainage improved significantly in both groups from 35.1 +/- 10.7 % to 75.2 +/- 13.2 % (sparing resection) vs. 45.1 +/- 23.7 % to 70.2 +/- 22 % (extensive resection). There were no differences between the groups (p > 0.05). CONCLUSIONS: We conclude that extensive resection of the renal pelvis is not necessary in dismembered pyeloplasty procedures since there were no differences in the renographic outcome of comparable patients treated by the different surgical methods.     

Reconstructive surgery for lower pole ureteropelvic junction obstruction associated with incomplete ureteral duplication

IntroductionThe lower moiety of duplex kidney can be associated with ureteropelvic junction obstruction (UPJO). Surgical correction can be challenging in cases of incomplete duplication where the junction of the lower and upper pole ureters is proximal. We review our experience with this unusual entity with an emphasis on surgical techniques employed in reconstruction.MethodsWe retrospectively reviewed the charts of eight patients with lower pole UPJO who underwent surgery in 2002–2008. The surgical approach, specifically the utilization of the non-obstructed upper pole ureter, used in the reconstruction was noted.ResultsFour of eight patients were symptomatic at presentation with either infection or pain. UPJO was at least in part secondary to lower pole crossing vessels in four patients and was treated with dismembered pyeloplasty. Lower pole to upper pole pyeloureterostomy was necessary in four patients due to short ureteral length between the UPJ and junction of lower and upper pole ureters. No complications or obstruction of either moiety developed during 1 year of follow up.ConclusionsLower pole UPJO in incomplete renal duplication mandates individualized surgical treatment dependent upon anatomy encountered. We have found that pyeloureterostomy is a safe alternative to drainage of the obstructed lower pole.     

Lower pole vessels in children with pelviureteric junction obstruction: Laparoscopic vascular hitch or dismembered pyeloplasty?

ObjectiveTo choose between laparoscopic “vascular hitch” (VH) and dismembered pyeloplasty (DP) in treatment of aberrant lower pole crossing vessels potentially responsible for pelviureteric junction obstruction (PUJO) in older children.Patients and methodsRetrospective study of 19 patients treated laparoscopically for PUJO. Based on videos of the procedures, we studied the anatomical relationship between the renal pelvis, the pelviureteric junction, and the aberrant vessels.ResultsEight patients had laparoscopic VH and 11 had DP. All patients with DP needed drainage. In the VH group, 7/8 patients were asymptomatic and had decreased pelvic dilation. Half of them accepted MAG3 scintigraphy, and in these patients the obstructive syndrome disappeared completely. The last patient in this group was lost to follow-up. We observed three anatomical variations in the location of polar vessels: type 1 (in front of the dilated pelvis), type 2 (in front of the pelviureteric junction), type 3 (under the pelviureteric junction, resulting in ureteral kinking).ConclusionLaparoscopic VH is a simple technique involving no urinary anastomosis or drainage, but we cannot guarantee that the crossing vessels are the sole etiology for PUJO. Following our experience, only patients with type 3 anatomical variations and with a normal pelviureteric junction should be proposed for VH.     

后腹腔镜肾盂成形术治疗小儿肾盂输尿管连接部梗阻的学习曲线

目的 评估不同阶段后腹腔镜肾盂成形术治疗小儿肾盂输尿管连接部梗阻(PUJO)的手术效果,探讨其学习曲线.方法 分析2002年6月至2009年6月期间我院收治的96例接受后腹腔镜肾盂成形术治疗PUJO患儿的资料,根据手术先后次序分为4组(A、B、C和D组),每组24例.比较各组的手术时间、中转开放比例、术后负压引流管留置时间、术后住院天数、术后并发症等.结果 手术时间,A组(255.6±39.8)min明显长于其余三组(P＜0.01),B、C两组间无显著差异;术后住院天数及负压引流时间,在均值上B组的(6.7±3.8)d和(5.3±3.7)d、C组的(6.O±3.4)d和(4.7±2.4)d、D组的(6.8±3.8)d和(6.4±3.9)d较A组(9.3±7.2)d和(7.7±7.8)d缩短;中转开放比例呈逐渐下降(6/24、3/24、2/24、0/24).术后尿路感染发生率各组间差别不明显(5/24、5/24、3/24、4/24).结论 开展24例后,小儿后腹腔镜肾盂成形术的手术时间明显缩短,术后住院天数、负压保留天数缩短,中转开放比例降低,进入一个相对的平台期,其学习曲线在20～30例之间.     

非钳夹式吻合口缝合法在腹腔镜离断式肾盂成形术中的应用

目的 探讨“非钳夹”式吻合口缝合法在腹腔镜肾盂输尿管成形术治疗小儿肾盂输尿管连接部梗阻(UPJO)的手术技巧、疗效及临床应用价值.方法 2015年1月至2015年4月对我院收治的81例肾盂输尿管连接部梗阻小儿肾积水患儿行“非钳夹”式吻合口缝合法经脐单部位腹腔镜肾盂输尿管成形术,其中男68例,女13例,左侧57例,右侧24例,平均年龄3.5岁(11d至15岁),所有患儿术前均行泌尿系B型超声、MRU及MAG3肾核素扫描等检查明确诊断.采用经脐单部位建立手术操作通道,吻合肾盂输尿管前后壁时,离肾盂输尿管吻合口最低点1.0～1.5 cm处于肾盂瓣及输尿管前后壁分别用4-0慕斯线牵引用于缝合吻合口时钳夹与牵拉用,其余方法基本同普通腹腔镜肾盂输尿管成形术.结果 81例患儿手术均获得成功,无中转开放手术,无术中并发症,有2例大龄右侧病变患儿术中在上腹部增加一5 mmTrocar后完成手术.平均手术时间94(80～150)min、术中平均出血量15(10～50)ml、平均引流管拔除时间5(3～10)d、术后平均住院时间7(5～10)d.术后行超声、放射性核素扫描随访3～6个月,术侧肾实质不同程度增厚,肾盂前后径明显减小或消失,62例形态接近正常,患肾分肾功能不同程度恢复.结论 腹腔镜肾盂输尿管成形术治疗小儿肾积水时采用“非钳夹”式吻合口缝合法安全可行,具有损伤小、恢复快、成功率高等优点,值得临床推广应用.     

Ureteropelvic junction obstruction in children: 10 years’ experience in one institution

We reviewed our experience over 10 years with pyeloplasty for ureteropelvic junction obstruction. Preoperative and postoperative isotope renal scans were performed to assess the surgical outcome, with particular emphasis on the postoperative change in renal function (RF). We retrospectively reviewed the medical records of 137 consecutive children with ureteropelvic obstruction operated between January 1994 and December 2003. A total of 109 kidneys in 102 patients were evaluated with renal echo and ^99mTc-diethylenetriaminepentaacetic renography both before and after Anderson–Hynes dismembered pyeloplasty. The improvement of RF >5% was noted in 67 kidneys (61.5%), the function remained stable in 30 kidneys (27.5%), and it deteriorated (>5%) in 12 kidneys (11.0%). Five patients (4.6%) required repeat pyeloplasty for either prolonged urine leakage or reobstruction with deterioration in RF. Dismembered pyeloplasty in children with ureteropelvic junction obstruction is safe. The renal functional improvement can be expected in the majority of kidneys that have impaired function at presentation.