Outcome based comparison of surgical approaches for pediatric pyeloplasty: dorsal lumbar versus flank incision

Laparoscopic versus open pyeloplasty in paediatric pelvi-ureteric junction obstruction

AIM

Compared to open pyeloplasty (OP), we hypothesised that laparoscopic pyeloplasty (LP) is associated with early recovery, a shorter length of stay (LOS) and less analgesia requirement.

METHODS

Between 2011 and 2016, 146 dismembered pyeloplasty cases were reviewed, of which 113 were in the OP group and 33 were in the LP group. We evaluated both groups regarding operative time, LOS, success rate, complications rate and analgesia requirement. Subgroup analysis was done for patients above the age of 5 years, and within the OP group (dorsal lumbotomy (DL) vs. loin incision (LI)).

RESULTS

The success rate was 96% in the open group and 97% in the laparoscopic group. The median operative time was significantly shorter in the open group for the entire cohort (127 vs. 200 min; P < 0.05), and in children older than 5 years (n = 41, 134 vs. 225 min; P < 0.05). Other parameters were similar in both groups. The median LOS was significantly shorter (2 vs. 4 days; P < 0.05), and the median analgesia requirement was less (0.44 vs. 0.64 mg/kg morphine; P < 0.05) in the DL (n = 60) compared to LI (n = 53).

CONCLUSION

Both OP and LP dismembered approaches are equally effective in treating pelvi-ureteric junction obstruction. Overall, the LOS, complications rate and analgesia requirement were not significantly different; however, the operative time was significantly longer in LP.

Retroperitoneal laparoscopic non-dismembered pyeloplasty for uretero-pelvic junction obstruction due to crossing vessels: A matched-paired analysis and review of literature

OBJECTIVE

To compare laparoscopic Anderson-Hynes pyeloplasty (LAHP) and retroperitoneal laparoscopic YV-pyeloplasty (LRYVP) in ureteropelvic junction obstruction (UPJ) in presence of a crossing vessels (CV).

METHODS

Our database showed 380 UPJO-cases,who underwent laparoscopic retroperitoneal surgery during the last 2 decades including 206 non-dismembered LRYVP, 157 dismembered pyeloplasties LAHP, and 17 cases of laparoscopic ureterolysis. Among them 198 cases were suitable for a matched-pair (2:1) analysis comparing laparoscopic retroperitoneal non-dismembered LRYVP (Group 1, n = 131) and dismembered LAHP (Group 2, n = 67) in presence of a crossing vessel. Patients were matched according to age, gender, kidney functions, and obstruction grade. Complications were graded according to modified Clavien-classification.

RESULTS

Comparative data were similar between both groups (LRYVP vs. LAHP) including mean operating time (112 min vs. 114 min), complication rates (4.2% vs. 7.3%) mainly Grade 1-2 according to Clavien classification, and success rates (90% vs. 89%). These results reflected in the reviewed literature indicate that LRYVP provides the advantage of minimal dissection in case of CV with similar outcome. However, redundant pelvis and anteriorly crossing vessels still require a dismembered pyeloplasty LAHP.

CONCLUSION

LRYVP has achieved similar results compared with the previous golden standard of open surgery, especially in case of crossing vessels apart from presence of a redundant pelvis or anteriorly crossing vessel. This can be further improved when using the small access retroperitoneoscopic technique respectively mini-laparoscopy.

Postoperative outcome following pyeloplasty in children using miniflank incision and transanastomotic stent: a prospective observational study

PURPOSE

To assess the postoperative outcome in children undergoing pyeloplasty, using a single transanastomotic indigenized stent.

METHODS

329 pyeloplasties were performed by small miniflank incision (3-5 cm) with lateral position for unilateral cases and prone position for bilateral cases during 1993-2009. The procedure involved decompression of the hydronephrotic sac, single layer anastomosis at the PUJ using 5/6-0 suture (reduction of the pelvis if required). An indigenized # 6, Teflon transanastomotic stent (TAS) with multiple holes (modified recently to a self-retaining loop in pelvis) was placed and taken out through the renal pelvis and the main skin incision. The stent served both as a nephrostomy and a stent. The kidney was not mobilized during the procedure. Postoperative results were assessed for early complications.

RESULTS

The mean age of the patients was 3.4 years (1 month-14 years). Bilateral simultaneous pyeloplasties were done in 16 cases with a mean age of 5.6 months (2-12). The stent was removed after 4-5 days in most cases after confirming distal flow on clamping. The post-operative complications included slippage of stent (11), blockage/nondrainage (7), difficult retrieval (4), urine leak (4), urinoma (3) and post-operative infection (1). DTPA scan at 3 months follow-up depicted improved drainage in 271 units, preserved renal function in 58 units and improved renal function more than 5% in 246 units.

CONCLUSION

Pyeloplasty using a single Teflon TAS is helpful not only in achieving effective drainage in children undergoing pyeloplasty, but also avoids the complications usually encountered with the use of nephrostomies, or double J stents.

Role of laparoscopy in reconstructive surgery

PURPOSE OF REVIEW

Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery.

RECENT FINDINGS

We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited.

SUMMARY

Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

Is one-day hospitalization after open pyeloplasty possible and safe?

OBJECTIVES

A critical pathway was developed to determine whether open pyeloplasty could be performed in preadolescent and adolescent children with ureteropelvic junction (UPJ) obstruction with patients safely discharged after a 1-day hospitalization.

METHODS

Twenty-six consecutive children who underwent open dismembered pyeloplasty for the treatment of UPJ obstruction and followed a critical pathway for preoperative education, operative management, and postoperative care were evaluated. The patients received a caudal anesthetic for preventive analgesia unless not technically possible and postoperative ketorolac (Toradol) unless contraindicated. A child was required to fulfill five strict criteria to be discharged from the hospital.

RESULTS

The 26 patients with UPJ obstruction consisted of 18 boys and 8 girls (age range 2.4 months to 16.7 years). Of the 26 patients, 24 (92%) were discharged on the first postoperative day, with a mean length of hospitalization of 1.1 days (range 1 to 3). All patients younger than 6 years of age (19 patients) were discharged on the first postoperative day. Of the 25 patients who received a caudal block, 24 (96%) were discharged on the first postoperative day. All patients tolerated the procedure well without major complications.

CONCLUSIONS

This is the first study, to our knowledge, to describe a detailed critical pathway for open pyeloplasty to treat UPJ obstruction. This enabled all children younger than 6 years of age and more than 90% of all patients to be discharged uniformly on the first postoperative day.

EXTRAVESICAL URETERAL REIMPLANTATIONS FOR THE CORRECTION OF PRIMARY REFLUX CAN BE DONE AS OUTPATIENT PROCEDURES

PURPOSE

Extravesical ureteral reimplantations are thought to be less morbid compared with traditional intravesical techniques. We believe a shorter length of stay can be achieved in children undergoing extravesical reimplantation for the correction of primary reflux without experiencing a reduction in quality of care.

MATERIALS AND METHODS

During a 16-month period 2 boys and 42 girls underwent extravesical ureteral reimplantation and received similar postoperative care by a single pediatric urologist (D. P. S.). These children were 1 to 14 years old (mean age 4.7) and underwent reimplantation for correction of primary vesicoureteral reflux due to breakthrough urinary tract infections, moderate/high grade reflux and parental desire. Unilateral and bilateral reimplantations were done in 21 and 23 children, respectively, and 9 underwent reimplantation of duplex systems. Each child received 0.25 to 0.5% marcaine locally instead of caudal at termination of the surgical procedure. Criteria for patient discharge home included sufficient urine output, toleration of a liquid diet, adequate pain control with oral analgesics and "parental readiness." Renal and bladder ultrasound was obtained no earlier than 1 month following surgery. Postoperative cystograms were obtained in any child with a febrile urinary tract infection or at parental request. Charts were reviewed for demographics, operative procedures, postoperative intravenous analgesic doses, catheter requirements and length of stay, defined as hours from surgery to discharge home. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative cystograms.

RESULTS

The length of stay for all children ranged from 5 to 30 hours (average plus or minus standard deviation 13.3 +/- 6.8). Of the children 31 (70.5%) were discharged home the same day while the remaining 13 (29.5%) went home the next day. When comparing the outpatient surgical group to those hospitalized for 1 night, there were no significant differences in age, operative times and technique (unilateral versus bilateral). Children discharged home the same day required significantly fewer doses of intravenous analgesics (1.7 +/- 0.23 versus 2.7 +/- 0.36, p = 0.025). Intravenous narcotics were primarily used in the recovery room and ketorolac tromethamine was administered on the surgical ward. Seven children were discharged home with urethral catheters due to urinary tract infection in 1, transient urinary retention in 4 and surgeon preference in 2. Those patients discharged home with an indwelling catheter had a significantly longer length of stay (hours) compared to those without catheters (20.3 +/- 8.3 versus 12.0 +/- 5.6, p = 0.026). The child discharged home with a catheter due to urinary tract infection was rehospitalized 2 days later and received 48 hours of intravenous antibiotics. Postoperative cystograms revealed resolution of reflux in 12 of 13 children (92.3%). One child with preoperative bilateral high grade reflux had unilateral reflux on postoperative cystogram. Followup of 41 children at 3 to 19 months (mean 9.1) revealed no other significant complications.

CONCLUSIONS

In our experience extravesical ureteral reimplantation for the correction of primary reflux can be done on an outpatient basis in the majority of children without an increase in morbidity. Pain management and catheter placement significantly influence length of stay in children undergoing extravesical ureteral reimplantation.

Extravesical ureteral reimplantations for the correction of primary reflux can be done as outpatient procedures

PURPOSE

Extravesical ureteral reimplantations are thought to be less morbid compared with traditional intravesical techniques. We believe a shorter length of stay can be achieved in children undergoing extravesical reimplantation for the correction of primary reflux without experiencing a reduction in quality of care.

MATERIALS AND METHODS

During a 16-month period 2 boys and 42 girls underwent extravesical ureteral reimplantation and received similar postoperative care by a single pediatric urologist (D. P. S.). These children were 1 to 14 years old (mean age 4.7) and underwent reimplantation for correction of primary vesicoureteral reflux due to breakthrough urinary tract infections, moderate/high grade reflux and parental desire. Unilateral and bilateral reimplantations were done in 21 and 23 children, respectively, and 9 underwent reimplantation of duplex systems. Each child received 0.25 to 0.5% marcaine locally instead of caudal at termination of the surgical procedure. Criteria for patient discharge home included sufficient urine output, toleration of a liquid diet, adequate pain control with oral analgesics and "parental readiness." Renal and bladder ultrasound was obtained no earlier than 1 month following surgery. Postoperative cystograms were obtained in any child with a febrile urinary tract infection or at parental request. Charts were reviewed for demographics, operative procedures, postoperative intravenous analgesic doses, catheter requirements and length of stay, defined as hours from surgery to discharge home. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative cystograms.

RESULTS

The length of stay for all children ranged from 5 to 30 hours (average plus or minus standard deviation 13.3 +/- 6.8). Of the children 31 (70.5%) were discharged home the same day while the remaining 13 (29.5%) went home the next day. When comparing the outpatient surgical group to those hospitalized for 1 night, there were no significant differences in age, operative times and technique (unilateral versus bilateral). Children discharged home the same day required significantly fewer doses of intravenous analgesics (1.7 +/- 0.23 versus 2.7 +/- 0.36, p = 0.025). Intravenous narcotics were primarily used in the recovery room and ketorolac tromethamine was administered on the surgical ward. Seven children were discharged home with urethral catheters due to urinary tract infection in 1, transient urinary retention in 4 and surgeon preference in 2. Those patients discharged home with an indwelling catheter had a significantly longer length of stay (hours) compared to those without catheters (20.3 +/- 8.3 versus 12.0 +/- 5.6, p = 0.026). The child discharged home with a catheter due to urinary tract infection was rehospitalized 2 days later and received 48 hours of intravenous antibiotics. Postoperative cystograms revealed resolution of reflux in 12 of 13 children (92.3%). One child with preoperative bilateral high grade reflux had unilateral reflux on postoperative cystogram. Followup of 41 children at 3 to 19 months (mean 9.1) revealed no other significant complications.

CONCLUSIONS

In our experience extravesical ureteral reimplantation for the correction of primary reflux can be done on an outpatient basis in the majority of children without an increase in morbidity. Pain management and catheter placement significantly influence length of stay in children undergoing extravesical ureteral reimplantation.

Nephrostomy tube drainage with pyeloplasty: is it necessarily a bad choice?

PURPOSE

Despite continued controversy regarding the optimal method of urinary diversion after dismembered pyeloplasty in children, we have treated the majority of our patients with postoperative nephrostomy tubes and no stents. We report our experience.

MATERIALS AND METHODS

The records of all patients who underwent surgery for ureteropelvic junction obstruction from August 1985 to October 1998 and were treated only with a nephrostomy tube after pyeloplasty were reviewed for hospital course, complications and postoperative followup. All patients had a perinephric Penrose drain as well as a Foley catheter placed for bladder drainage.

RESULTS

A total of 137 pyeloplasties were performed in 132 patients, including 5 with bilateral ureteropelvic junction obstruction, using only nephrostomy tube drainage with an average followup of 2.1 years. Initial nephrostograms demonstrated good drainage across the repair with no extravasation in 91% of patients. Subsequent nephrostograms revealed a widely patent anastomosis in the remaining cases. No patient had postoperative obstruction, or required secondary pyeloplasty or nephrectomy. Urinary tract infection developed in 2 patients (1.5%). Mean hospitalization was 4.4 days. There was a significant difference in length of stay in the last 5 years compared to that in previous years (3.4 versus 5.8 days, p <0.05) and hospital stay continues to decrease.

CONCLUSIONS

Use of only a nephrostomy tube after pyeloplasty resulted in few complications and an open anastomosis in 100% of cases. Nephrostomy drainage not only serves as a protective mechanism, but also allows easy access for radiographic studies before removal of the tube. In addition, nephrostomy tube drainage does not prolong hospitalization and the tube may be easily removed on an outpatient basis without further anesthesia.

Antegrade pyelography before pyeloplasty via dorsal lumbar incision

PURPOSE

The need for contrast imaging of the ureter before routine pediatric pyeloplasty is controversial. We evaluated the use of antegrade pyelography for upper tract imaging before pyeloplasty via dorsal lumbar incision.

MATERIALS AND METHODS

The records of all patients who underwent pyeloplasty from April 1994 through April 1998 at our institution were reviewed. The findings and outcome of patients with presumed ureteropelvic junction obstruction in whom antegrade pyelography was performed under the same anesthetic were assessed, and those in whom this procedure changed the planned operative approach were identified.

RESULTS

Antegrade pyelography was performed without complication in 72 patients before planned pyeloplasty and 2 attempts were unsuccessful. In 10 cases (14%) plans for dorsal lumbar incision were abandoned based on findings of renal malrotation in 3, ureteral stricture in 2, ureterovesical junction obstruction in 2, unusually low or high position of the ureteropelvic junction in 1 each, and concurrent ureteropelvic and ureterovesical junction obstruction in 1. The study was misinterpreted in 1 case of renal malrotation and 1 case of horseshoe kidney, and the dorsal approach was used. In 1 of these cases conversion to an anterior approach was required. A nonobstructing ureterovesical junction was seen in 2 other patients who had ureteropelvic junction obstruction with mild ureteral dilatation on ultrasound.

CONCLUSIONS

The dorsal lumbar incision may provide inadequate exposure in certain patients with upper tract obstruction. Antegrade pyelography is a simple, safe and useful technique to visualize the collecting system before planned pyeloplasty via dorsal lumbar incision, allowing the surgeon to choose a more suitable operative approach or procedure when warranted.