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

Multimodality imaging spectrum of complications of horseshoe kidney

Horseshoe kidney is the most common congenital renal fusion anomaly with an incidence of 1 in 400–600 individuals. The most common type is fusion at the lower poles seen in greater than 90% of the cases, with the rest depicting fusion at the upper poles, resulting in an inverted horseshoe kidney. Embryologically, there are two theories hypothesizing the genesis of horseshoe kidney – mechanical fusion theory and teratogenic event theory. As an entity, horseshoe kidney is an association of two anatomic anomalies, namely, ectopia and malrotation. It is also associated with other anomalies including vascular, calyceal, and ureteral anomalies. Horseshoe kidney is prone to a number of complications due to its abnormal position as well as due to associated vascular and ureteral anomalies. Complications associated with horseshoe kidney include pelviureteric junction obstruction, renal stones, infection, tumors, and trauma. It can also be associated with abnormalities of cardiovascular, central nervous, musculoskeletal and genitourinary systems, as well as chromosomal abnormalities. Conventional imaging modalities (plain films, intravenous urogram) as well as advanced cross-sectional imaging modalities (ultrasound, computed tomography, and magnetic resonance imaging) play an important role in the evaluation of horseshoe kidney. This article briefly describes the embryology and anatomy of the horseshoe kidney, enumerates appropriate imaging modalities used for its evaluation, and reviews cross-sectional imaging features of associated complications.

Laparoscopic transmesenteric pyeloplasty and isthmusectomy for adult horseshoe kidney with recurrent symptomatic hydronephrosis

INTRODUCTION

There is no consensus for the horseshoe kidneys with recurrent symptomatic hydronephrosis, so we presented our initial experience with a laparoscopic transmesenteric approach.

CASE PRESENTATION

Five patients with symptomatic ureteropelvic junction obstruction were identified by computed tomography urography. The laparoscopic transmesenteric approach was performed in such a way that the mesentery of the small intestine was incised along with the blood vessels longitudinally, and the isthmus was isolated to avoid injury to the mesenteric blood supply; then we cut the isthmus using an endostapler. The ureteropelvic junction obstruction was removed via the Anderson-Hynes technique. The operation time was 135-204 min, and the estimated blood loss was 50-120 mL. Patients had a 5.7-day stay postoperatively, there were no other injuries or complications, and ultrasound scans or computed tomography urography showed good postoperative effects.

CONCLUSION

Laparoscopic transmesenteric surgery is a feasible and safe procedure for selected cases with horseshoe kidney with recurrent symptomatic hydronephrosis.

Robot-assisted laparoscopic pyeloplasty (RALP) in children with horseshoe kidneys: results of a multicentric study

PURPOSE

This multicentric study aimed to report our experience with robot-assisted laparoscopic pyeloplasty (RALP) in children with horseshoe kidney (HSK).

METHODS

The records of 14 patients (11 boys and 3 girls with an average age of 9 years), who underwent RALP for repair of pelvi-ureteric junction obstruction (PUJO) in HSK in five international pediatric urology units over a 5-year period, were retrospectively reviewed. A dismembered pyeloplasty with no division of isthmus was performed in all the cases.

RESULTS

The average operative time including docking was 143.5 min (range 100-205). No conversions to laparoscopy or open surgery or intra-operative complications occurred. Patients were discharged on postoperative day 2 following catheter and drain removal. The JJ stent was removed at mean 33 days postoperatively. Overall success rate was 92.8%. As for postoperative complications, we recorded a urinary tract infection (UTI) and stent-related irritative symptoms, managed with medical therapy, in two patients (II Clavien) and an anastomotic stricture in one patient needing surgical revision with no further recurrence (IIIb Clavien). At follow-up, all the patients (one after redo-surgery) reported complete resolution of symptoms, improvement of hydronephrosis on ultrasound and no residual obstruction on diuretic renogram.

CONCLUSIONS

Our experience suggested that RALP in HSK is safe, feasible and with good medium-term outcomes in expert hands. An accurate pre-operative planning associated with a standardized technique is key points to achieve good surgical and functional outcomes in these challenging cases. The da Vinci robot technology offers the advantages of MIS procedures and overcomes the technical challenges of laparoscopic approach.

Horseshoe kidney and associated anomalies: Single institutional review of 20 cases

BACKGROUND

Horseshoe kidney (HSK) is a common renal fusion anomaly. We undertook this study to discuss various anomalies associated with HSKs. The objective of the study is to study various anomalies associated with HSKs and to assess the need for surgical intervention in patients with these anomalies.

PATIENTS AND METHODS

This is a retrospective cohort study of twenty patients who presented to our institute with the diagnosis of HSKs. The data were analysed with regard to age at presentation, symptoms, associated anomalies, investigations and surgical intervention.

RESULTS

Twenty patients were included in this study. They were referred either with a diagnosis of HSK or were diagnosed during investigations for symptoms and during workup for associated anomalies. Eleven patients were incidentally diagnosed and were asymptomatic, and there were no associated anomalies diagnosed in these patients. Nine patients were symptomatic and were diagnosed with various associated anomalies. Our results concur with recent literature review which suggests that nearly half of the patients with HSKs have associated anomalies. In the present series, all symptomatic patients with associated anomalies required surgical intervention.

CONCLUSION

HSKs being a common fusion anomaly, necessitates a prompt and thorough search of the search for any associated anomalies. Many of these anomalies may require surgical intervention.

Robot-Assisted Laparoscopic Pyeloplasty in a Pediatric Patient with Horseshoe Kidney: Surgical Technique and Review of the Literature

Objective

The aim of this study was to describe the technical aspects of a robotic pyeloplasty in pediatric patients with uretero-pelvic junction obstruction (UPJO) in horseshoe kidney (HSK) through the report of our recent case, and to outline the state of the art of minimally invasive pyeloplasty (MIP) with a systematic review of the literature.

Methods

We describe all the steps of our surgery performed on an 11-year-old patient with left UPJO in HSK in detail. All the anatomic landmarks are clearly showed, with particular attention to trocar placement in a pediatric patient. A systematic review of the literature on the outcomes of MIP in HSK patients has been performed, including 16 articles.

Results

Our surgery was successful following a standardized approach. However, we recorded a rare complication, the herniation of a small portion of omentum through the 8 - mm defect used for the caudal robotic port. The evidence synthesis shows excellent postoperative outcomes for both laparoscopic and robot-assisted laparoscopic pyeloplasties in HSK patients. Probably, MIP should be preferred to the traditional open approach in these patients, when feasible.

Conclusions

Transperitoneal robotic pyeloplasty is an excellent minimally invasive choice for the treatment of UPJO in HSK pediatric patients. The pediatric setting should prompt attention to every detail to avoid unfortunate complications.

Anderson-Hynes pyeloplasty with isthmotomy and lateropexy in horseshoe kidneys with pelviureteric junction obstruction in children

OBJECTIVE

The objective of this study was to evaluate the results of Anderson-Hynes pyeloplasty with isthmotomy and lateropexy in horseshoe kidney with pelviureteric junction obstruction (PUJO).

MATERIALS AND METHODS

Medical records of patients of horseshoe kidney with PUJO operated in our institute between June 1998 and June 2012 were reviewed. Anderson-Hynes pyeloplasty with isthmotomy and lateropexy was performed in all patients. The surgical outcome was evaluated with emphasis on the changes in degree of hydronephrosis by ultrasonography, renal drainage and function assessed by diuretic renal scans.

RESULTS

We studied the records of eight children of horseshoe kidney having unilateral PUJO. Obstruction was caused by a crossing lower-pole vessel in two cases, a high ureteral insertion in three and narrowing of the PUJ in three cases. Post-operative follow-up (median 4.4 years, range 18 months to 10 years) revealed improved renal function and good drainage in all cases. Hydronephrosis disappeared in 3, 4 showed Grade 1 and one showed Grade 2 hydronephrosis. All children are doing well and have no symptoms.

CONCLUSION

Anderson-Hynes pyeloplasty with isthmotomy and lateropexy is a highly effective and safe procedure for treating PUJO in horseshoe kidney in children.

Laparoscopic Anderson-Hynes pyeloplasty without symphysiotomy for hydronephrosis with horseshoe kidney

INTRODUCTION

The objective of this study is to clarify whether symphysiotomy is an essential procedure combined with the laparoscopic pyeloplasty for the surgical treatment of ureteropelvic junction obstruction related to horseshoe kidney.

METHODS

We retrospectively reviewed five horseshoe kidney patients with symptomatic hydronephrosis who underwent laparoscopic transperitoneal Anderson-Hynes pyeloplasty without symphysiotomy between July 2002 and October 2011.

RESULTS

All procedures were completed successfully without open conversion. Mean operative time and estimated blood loss were 209 min and 40 mL, respectively. Anterior crossing vessels were observed in all cases, and four of them were defined as a principle cause of the obstruction. In the remaining case, intrinsic stenosis of the ureteropelvic junction was noted. Crossing vessels were transposed behind the ureter with ureteropelvic anastomosis at the anterior aspect of these structures. Preoperative symptoms were absent postoperatively in all cases. Diuretic renogram showed that renal function of the side with hydronephrosis was unchanged, but diuretic excretion half-time was diminished in all cases.

CONCLUSION

The present data suggest that symphysiotomy can be avoided in many, if not all, cases of hydronephrosis related to horseshoe kidney. Laparoscopic Anderson-Hynes pyeloplasty with transposition of anterior crossing vessels seems effective, especially if aberrant vessels are strongly suspected to be present from the preoperative imaging examination.

Ureteropelvic junction obstruction and calyceal diverticulum in a child with Turner syndrome and horseshoe kidney

Laparoscopic dismembered pyeloplasty for ureteropelvic junction (UPJ) obstruction is considered to be a routine procedure in many pediatric surgical centers. UPJ obstruction is known to be associated with horseshoe kidney and several reports on successful laparoscopic repair in such cases exist. The case of a 9-month-old girl with Turner syndrome is reported. A horseshoe kidney with grade 4 hydronephrosis on the left side was diagnosed by ultrasound during the neonatal period. MAG3 diuretic renography and dynamic magnetic resonance imaging nephrography revealed a differential renal function of 31% and 69% on the left and right side, respectively. No drainage from the left renal pelvis could be demonstrated. Laparoscopy showed a combined UPJ obstruction and a calyceal diverticulum with a narrow infundibulum of the upper pole calices on the left side of the horseshoe kidney. Laparoscopic dismembered pyeloplasty and an additional infundibulopelvic anastomosis was performed. No intraoperative complications occurred. The immediate postoperative course was uneventful. Unobstructed drainage and stable differential renal function on the left side could be demonstrated on MAG3 diuretic renography 6 weeks postoperatively. In conclusion, laparoscopic repair of complex malformations of the upper urinary tract is feasible and leads to good functional outcome in selected cases.

Imaging of horseshoe kidneys and their complications

Horseshoe kidney is the most common renal fusion anomaly and the patients are prone to a variety of complications, such as stone disease, pelviureteric junction (PUJ) obstruction, trauma, infections and tumours. As result of the abnormal anatomy of a horseshoe kidney, imaging and treatment pathways vary substantially from the normal kidney. In this review, we describe the role of modern imaging in depicting horseshoe kidneys and their complications, in tandem with the role the interventional radiologist plays in treating these patients.

Laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction in patients with horseshoe kidneys: technique and 1-year follow-up

OBJECTIVE

To report our experience with laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction (PUJO) in patients with horseshoe kidneys.

PATIENTS AND METHODS

Between January 2002 and May 2003, two men and a woman with horseshoe kidneys (mean age 44.6 years) had laparoscopic dismembered pyeloplasty with robotic assistance for PUJO with no division of the isthmus. Two patients had renal stones which were extracted during surgery. None of the patients had had previous abdominal surgery.

RESULTS

The mean operative duration was 148.3 min, the mean estimated blood loss was <100 mL and the mean hospital stay was 7.6 days. Renal function was preserved in all three patients during the immediate and long-term follow-up as measured by intravenous urography. The three patients had durable clinical and radiographic success during a mean follow-up of 21 months. One patient needed complementary extracorporeal shockwave lithotripsy, and one had an episode of pyelonephritis, which was treated successfully. There were no other significant complications before or after surgery.

CONCLUSION

Laparoscopic robotic-assisted pyeloplasty for horseshoe kidney is safe and feasible, offering the advantages of minimally invasive surgical procedures with enhanced laparoscopic skills related to the use of the robot.