Synergy : BJU International 87 (1), 126-126

Open dismembered pyeloplasty has been the traditional treatment for PUJ obstruction in children [1]. Despite good long-term success rates, open pyeloplasty in children beyond infancy has several drawbacks, including postoperative pain, prolonged convalescence and a prominent skin incision. In an effort to overcome these drawbacks, percutaneous antegrade and endoscopic retrograde pyelotomy were developed. However, antegrade endopyelotomy in children has lower success rates (62–82%) than open pyeloplasty and has the disadvantage of prolonged periods (4–6 weeks) of indwelling stents [2,3]. The Acucise™ method is difficult in children because the ureter is smaller than the catheter and there is a significant risk of haemorrhage after incision [4,5].

Laparoscopic pyeloplasty was developed in adults [6–8] and recently in children [9,10] to offer a minimally invasive alternative to open surgery, while maintaining the previous success rates. However, the intracorporeal suture technique, which is extremely difficult and time-consuming, has been an obstacle to many surgeons attempting laparoscopic pyeloplasty. The reported operative duration of laparoscopic pyeloplasty, at 2–8 h [6–9], is much longer than that for open pyeloplasty and other minimally invasive techniques. To simplify the procedure, we devised a method to extract the PUJ from the abdominal cavity through the 10-mm port tract and complete the anastomosis externally.

Methods

Indications

From October 1997 to January 1998, laparoscopic pyeloplasties were performed on three children (aged 2, 9 and 10 years) with symptomatic PUJ obstruction. One patient presented with a palpable mass, one with flank pain and the other with pain associated with pyelonephritis. Two patients had disease on the left side and one on the right. One patient had a ureteric polyp associated with the PUJ obstruction. None had a previous history of intra-abdominal or renal surgery. All children were evaluated before surgery using ultrasonography, IVP and a DTPA scan. A diagnosis of PUJ obstruction was assumed if IVP revealed hydronephrosis in the absence of a visualized ureter, or if there was narrowing of the PUJ and delayed excretion of the contrast medium from the renal pelvis. A DTPA scan to was used to confirm the relative function of the kidney and the isotope renography half-time; the PUJ obstruction was confirmed if the diuretic response was abnormal (T1/2 > 20 min).

Surgical technique

The patients were placed in a 45° lateral decubitus position and as close to the edge of the operating table as possible. After inducing general anaesthesia, urethral and nasogastric catheters were placed. If the renal pelvis was not seen on IVP a retrograde pyelogram was taken to delineate the shape and location of the PUJ. An umbilical 10-mm blunt-tip trocar with internal balloon seal (Origin Medsystems, Inc., Menlo Park, CA, USA) was inserted transperitoneally using the open technique and a pneumoperitoneum created to a pressure of 12 mmHg. A 5-mm trocar was inserted in the ipsilateral upper quadrant and a 10-mm trocar in the ipsilateral lower quadrant, the exact site determined by the position of the PUJ. The colon was mobilized sufficiently to expose the dilated renal pelvis and proximal 3–4 cm of ureter.

An 18 G needle was introduced percutaneously, and the renal pelvis punctured and aspirated. The proximal ureter and renal pelvis were dissected free from surrounding adventitia. The PUJ was grasped with forceps and extracted from the abdominal cavity with the trocar through the 10 mm ipsilateral lower quadrant tract in two patients and the umbilical port site in one. In one patient who had severe hydronephrosis, the PUJ was taken out through the umbilical port tract, as it was near the umbilicus, crossing the midline, and two 5 mm instrument channels were used. Senn retractors were introduced through the 10 mm port tract and the collapsed abdominal wall pushed downwards to expose the PUJ. The exteriorized PUJ was dismembered and anastomosed using 5/0 or 6/0 polyglactin. In one patient who had a recurrent pyelonephritis, the anastomosis was made over a JJ stent. The renal pelvis was then allowed to return into its bed, the 10 mm trocar reinserted and haemostasis confirmed. A Penrose drain was passed through the 5 mm cannula and placed in the perinephric space. The retroperitoneum was not re-approximated. The ports were withdrawn under vision and the 10 mm port tracts closed in layers with 3/0 polyglactin (Fig. 1).

Laparoscopically assisted pyeloplasty was successful in all patients; the PUJs of the patients were extracted from the abdomen and anastomosed after resection of the PUJ with no undue tension. The mean operative duration was 115–125 min. All patients were able to eat on the first day after surgery. Analgesics were administered for 1 day in two patients (15 mg ketorolac tromethamine and 25 mg pethidine HCl, respectively). The Foley indwelling urinary catheter was removed on the first day, and the Penrose 3 days after surgery in two patients and after 6 days in one. One patient who had a JJ stent required general anaesthesia to remove the stent at 6 weeks. All patients were discharged 7 days after surgery, when they resumed normal activities.

IVP and ultrasonography 6 months later showed significant improvements in all patients (prompt function, decreased caliectasis and decreased size of the renal pelvis; Fig. 2). The preoperative symptoms subsided completely after surgery in all patients. There were no serious complications during or after surgery, e.g. bleeding, urinary extravasation or UTI.

Comparison with other methods

Indications

In adult patients, laparoscopic pyeloplasty for PUJ obstruction is as successful as open pyeloplasty, but with less morbidity [6–8]. The technical difficulty of intracorporeal suturing has prevented its frequent use in children [9,10]. Recently, there have been some improvements in laparoscopic suturing instruments, e.g. the automatic laparoscopic suturing device, but these are not delicate enough for intracorporeal suturing with fine sutures in children [7] and intracorporeal suturing remains a major obstacle to laparoscopic pyeloplasty in children. Tan and Roberts [10] used a ‘hitch-stitch’, which stabilized the pelvis and facilitated suturing during dismembered pyeloplasty, reducing the operative duration. They inserted a JJ catheter, which may be advisable in the presence of active inflammation, after a difficult repair or with a solitary kidney, but has the added morbidity of requiring general anaesthesia to remove the stent in children. In a meticulously sutured watertight pelvic-ureteric anastomosis with a ‘no-touch’ technique, as in open surgery, stents or nephrostomy tubes are probably unnecessary.

Exteriorization of the anastomosis as described here combines the benefits of minimally invasive surgery with the ease of open surgery. This technique needs no intracorporeal suturing and makes a meticulous anastomosis possible with no unnecessary trauma to the anastomotic site, and therefore with no need for stenting. Stents were avoided in two of the present patients. The operative duration reported in contemporary laparoscopic pyeloplasty series is 2.25–8.5 h [7,11], being longer for inexperienced surgeons (those with fewer than five procedures) [7]; in the present three patients the duration (2 h) was considerably less. The exteriorization of the anastomosis is already used in laparoscopically assisted bowel surgery [12,13]. The PUJ of children, with a dilated extrarenal pelvis, can be exteriorized easily even though it is less mobile than bowel, because the abdominal wall of children is thin and flexible. This technique could even be used in small children, i.e. most of those with PUJ obstruction. However, the experience with laparoscopic pyeloplasty is currently too limited to judge the efficacy with confidence. Anecdotally, the results are as good as those expected for an open repair. There is apparently less morbidity in older children. To our knowledge, laparoscopic pyeloplasty has not been used in infants, as it confers no significant advantages in recovery over open pyeloplasty. However, laparoscopic pyeloplasty has potential advantages of better cosmetic results and less postoperative pain, which is difficult to evaluate objectively in young children.

Advantages and disadvantages

Indications

The transperitoneal approach has been used in paediatric laparoscopic pyeloplasty because the space between the 12th rib and the iliac crest is too narrow to angle the instruments adequately for intracorporeal suturing [9,10]. The present technique will make it possible to use a retroperitoneal approach, which has the theoretical advantage of reducing the risk of intraperitoneal adhesion. In the present method, IVP was used routinely, with operative retrograde pyelography if necessary; these investigations are important to exclude the existence of unsuitable PUJ anatomy for laparoscopically assisted pyeloplasty (narrowing of the long segment of proximal ureter, insertional anomaly with the ureter inserted high, or intrarenal pelvis) and to decide the best site for the skin incision for the 10 mm port. Because of cultural factors and that all the patients were medically insured, patients usually requested to stay in hospital until their sutures were removed; an increased hospital stay in the present patients did not reflect increased morbidity.

The most important part of the present technique is the avoidance of excessive tension on the PUJ during exteriorization; this can be prevented by pushing the collapsed abdominal wall downward with retractors, rather than pulling on the PUJ. However, the technique cannot be applied where the intrarenal pelvis is small or patients have a thick abdominal wall.

Acknowledgements

Indications

I thank Elizabeth Penington for her proof reading.

References

Indications