Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children

Comparative efficacy and safety of different minimal invasive pyeloplasty in treating patients with ureteropelvic junction obstruction: a network meta-analysis

OBJECTIVE

In recent years, the minimally invasive surgical treatment methods of ureteropelvic junctional obstruction (UPJO) have been diverse, but its approach and choice of surgical method are controversial. This network meta-analysis (NMA) aimed to compare the safety and effectiveness of minimally invasive surgeries for UPJO, which included robotic or laparoscopic pyeloplasty, via the retroperitoneal or transperitoneal approach.

METHODS

We searched relevant RCTs in PubMed, Embase, Web of Science, the Cochrane Library, and CNKI. To assess the results of operative time, complications and success rate, pairwise, and NMA were carried out. The models for analyses were performed by Revman 5.3, Addis V1.16.8 and R software.

RESULTS

A total of 6 RCTs were included in this study involving four types of surgeries: transperitoneal laparoscopic pyeloplasty (T-LP), retroperitoneal laparoscopic pyeloplasty (R-LP), robot-assisted transperitoneal pyeloplasty (T-RALP), and robot-assisted retroperitoneal pyeloplasty (R-RALP). This study consisted of 381 patients overall. T-RALP had a quicker operational duration (SMD = 1.67, 95% CI 0.27-3.07, P = 0.02) than T-LP. According to the NMA's consistency model, T-RALP improved the surgical success rate more than T-LP (RR = 6303.19, CI 1.28 to 1.47 × 1011). Ranking probabilities indicated that RALP could be the better option than LP and retroperitoneal approach was comparable to transperitoneal approach. All procedures had high surgical success rates and few complications.

CONCLUSION

Outcomes for four surgical approaches used in the UPJO were comparable, with T-RALP being the most recommended approach. Selection between the transperitoneal and retroperitoneal approaches primarily depended on the surgeon's preference. Higher quality evidence is needed to further enhance the result.

De Novo coupled use of central-vein isolation and tubeless treatment in laparoscopic adrenalectomy

Objective

To explore the combined uses of central vein isolation-based laparoscopic technique and tubeless cardiovascular interventional technique (CVIT) in laparoscopic adrenalectomy.

Methods

31 subject patients with adrenal tumors were recruited and treated from January 2020 to November 2021. Regarding tumor size, the average transverse diameter of the adrenal tumor was (2.2 ± 1.0) cm and the average longitudinal diameter of the tumor was (3.1 ± 1.5) cm, respectively. All subject patients were operated on through the abdominal approach. The "central vein isolation" based laparoscopic technique was adopted to complete the operation. No drainage tube was placed in the patients. For this study, selected performance parameters, including the operation time, intraoperative bleeding, postoperative hospital stays, and postoperative complications were recorded and analyzed.

Results

All the tumors were removed laparoscopically without any conversion to open surgery. All 31 recruited subjects were treated successfully with preservation of adrenocortical function. The mean operation time was 30 min (range from 25 to 63 min); the mean amount of intraoperative bleeding was approximately 3 mL (ranges from 0 to 10 mL); the mean postoperative hospital stay was 3 days (range from 2 to 6 days). Of note, no complications were recorded, such as adjacent organ injury, large vessel injury, infection, and secondary bleeding that occurred during and after the operation.

Conclusion

The combined use of central-vein isolation laparoscopic technique and tubeless treatment ensures a facile, safe, and robust laparoscopic adrenalectomy operation in clinical practice.

Comparative study of different surgical approaches for treatment of UPJ obstruction according to the degree/severity of hydronephrosis factor

OBJECTIVE

To compare the efficacy of two different surgical approaches during and after pyeloplasty according to the degree/severity of hydronephrosis factor.

MATERIALS AND METHODS

Sixty child patients with UPJ obstruction admitted to our hospital from August 2019 to October 2021 were collected. Patients who underwent retroperitoneal laparoscopic pyeloplasty (RPLP) were enrolled into Group A (n = 20), while those who received transperitoneal laparoscopic pyeloplasty (TLP) were selected as Group B (n = 40). Clinical parameters, including gender, age, laterality of UPJ obstruction, degree/severity of hydronephrosis, body weight, operation time, drainage tube indwelling time, complete oral feeding time, and length of hospital stay, were compared between the two groups.

RESULTS

All 60 child patients were operated upon successfully without conversion to open surgery. There were no statistically significant differences in gender, age, laterality of UPJ obstruction, and body weight between the two groups, while the operation time of TLP was shorter than that of RPLP, indicating a statistically significant difference (P < 0.001). The differences in complete oral feeding time, drainage tube indwelling time, and length of hospital stay were statistically significant between the two groups, and RPLP was superior to TLP in terms of postoperative recovery time (P < 0.001). A stratified comparison showed that there were no statistically significant differences in anteroposterior diameter ≤ 20 mm, while there were statistically significant differences in anteroposterior diameter >20 mm. Hydronephrosis is reviewed after 3 months of the operation, degree/severity of hydronephrosis have been reduced.

CONCLUSION

Both RPLP and TLP are safe and feasible in the treatment of UPJ obstruction, and their overall surgical effects are equivalent. For child patients with anteroposterior diameter ≤ 20 mm, RPLP is available, while patients with anteroposterior diameter >20 mm, TLP is recommended.

Recovery of bowel function after transperitoneal or retroperitoneal laparoscopic pyeloplasty. A multi-center study

AIM

To document the recovery of bowel function (BF) in children after transperitoneal (TP) or retroperitoneal (RP) laparoscopic pyeloplasty.

METHODS

Data were obtained retrospectively from four centers between 2008 and 2019 for TP (n = 51) and RP (n = 58). Each surgeon chose which technique to perform.

RESULTS

Subject demographics were not significantly different. Differences in operative times were not significant (RP: 241 min versus TP: 225 min). Mean duration/requirement for postoperative epidural/intravenous analgesia were not significantly different (TP: 1.4 days versus RP: 1.3 days) and (TP: 66.7% versus RP: 67.2%), respectively. Postoperative nasogastric (NG) intubation was more common in RP (TP: 19.6% versus RP: 44.8%; p < .05). NG aspiration (TP: 0.15 mL/kg/hr versus RP: 0.16 mL/kg/hr), nausea (TP: 31.4% versus RP: 17.2%), and vomiting (TP: 19.6% versus RP: 15.5%) were not significantly different. There were no perioperative complications (including ileus). Abdominal distention was problematic in one case per group (TP: 2.0% versus RP: 1.7%). Times for oral liquid (TP: 0.69 day versus RP: 0.83 day), solid food (TP: 0.88 day versus RP 1.07 days), and the first bowel movement (TP: 2.86 days versus RP: 2.79 days), were not significantly different.

CONCLUSIONS

BF recovery would appear to be consistent, independent of technique.

Redo Laparoscopic Pyeloplasty in Infants and Children: Feasible and Effective

Purpose: To determine the feasibility and effectiveness of redo laparoscopic pyeloplasty among patients with failed previous pyeloplasty, specifically examining rates of success and complications. Materials and Methods: We retrospectively reviewed the charts of all patients, who underwent redo laparoscopic pyeloplasty from 2006 to 2017. This included patients who underwent primary pyeloplasty at our institution and those referred for failures. Analysis included demographics, operative time, complications, length of hospital stay, complications, and success. Success was defined as improvement of symptoms and hydronephrosis and/or improvement in drainage demonstrated by diuretic renogram, especially in those with persistent hydronephrosis. Descriptive statistics are presented. Results: We identified 22 patients who underwent redo laparoscopic pyeloplasty. All had Anderson-Hynes technique except two cases in which ureterocalicostomy was performed. Median (IQR) follow-up was 29 (2-120) months, median time between primary pyeloplasty and redo laparoscopic pyeloplasty was 12 (7-49) months. The median operative time was 200 (50-250) min, and median length of hospital stay was 3 (2-10) days. The procedure was feasible in all cases without conversion. During follow-up, all but two patients demonstrated an improvement in the symptoms and the degree of hydronephrosis. Ninety-one percent of patients experienced success and no major complications were noted. Conclusions: Redo laparoscopic pyeloplasty is feasible and effective with a high success rate and low complication rate.

Laparoscopic retroperitoneal approach for retrocaval ureter in children

PURPOSE

Retrocaval ureter (RCU) is a rare congenital anomaly and published data on pediatric laparoscopic management are poor. The aim of this study was to report our experience of retroperitoneal laparoscopic approach for management of RCU in children.

METHODS

A retrospective review of data from patients treated for RCU between 2002 and 2018 in our institution was performed. All patients were positioned in a flank position and underwent a three-port (5-mm optical trocar and two 3-mm trocars) laparoscopic retroperitoneal ureteroureterostomy. Anastomosis was made by 6/0 absorbable sutures. A JJ stent was always inserted.

RESULTS

Five patients with a median age of 94 months (5-152) were operated on and followed up for a median time of 103 months (46-201). Median operating time was 200 min (160-270). No conversion and no transfusion occurred. Median hospital stay was 2 days (1-4). Ureteral stent was removed after 52 days (47-82). Complications included pyelonephretis (N = 1). In all cases, hydronephrosis decreased postoperatively.

CONCLUSIONS

Retroperitoneal laparoscopic approach for RCU is safe and effective in children. Our video demonstrates different patients with specific surgical details to show how to manage these children. The global vision of the upper tract by laparoscopy leads to optimal management of these children even if the anomaly was not detected preoperatively.

Is Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Infants Under 1 Year of Age a Good Option?

Purpose: Laparoscopic pyeloplasty in children younger than 1 year of age is still debatable due to its supposed technical difficulties and failure rate. We present our experience and outcome in infants. Materials and Methods: A retrospective study was conducted in 3 Departments of Pediatric Surgery. We reviewed the records of the children under 1 year of age operated on for ureteropelvic junction obstruction (UPJO), between 2007 and 2017. Anderson-Hynes laparoscopic transabdominal dismembered pyeloplasty was performed. Patients' demographics, results of preoperative and postoperative exams, perioperative details, complications, hospital stay, and long-term follow-up results were analyzed. Results: Sixty cases were operated on during this period (49 boys, 11 girls). Mean age at operation was 4.5 months (1-12 months). Mean operating time was 140 min (80-240 min). There was no conversion in this group. There were four early complications: 1 ileus, 1 hypertension immediately post-operatively requiring medical treatment, 1 omental herniation through a drain orifice, and 1 percutaneous transanastomotic stent migrated intra-abdominally. The two last children had to be reoperated. Mean hospital stay was of 2 days (1-10 days). Late complications: two patients (3.4%) presented a recurrence of UPJO, one had been re-operated 15 months later and for the patient with persistent hypertension, nephropexy was performed for malrotated kidney, 1 year after pyeloplasty. Long term follow-up with a mean of 2.8 years (1-10 years) showed that surgery improved mean pelvic dilatation from 31.8 mm (13-63 mm) preoperatively to 15.3 mm (4-40 mm) postoperatively (P < 0.0001). The renal function slightly improved, from a mean of 35.7% (5-55%) it passed to 40.5% (0-54%), p = 0.137. In three cases the operated kidney became finally non-functional and atrophic. Conclusions: Laparoscopic transperitoneal pyeloplasty is feasible and safe in children younger than 1 year of age. Nevertheless, it requires experience and good intra-abdominal suturing skills. Laparoscopic pyeloplasty has a success rate comparable with open treatment but with less morbidity and better cosmetic results.

Reflective Practice About Retroperitoneal Laparoscopy in Comparison to Open Surgery for Ureteropelvic Junction Obstruction Repair in Children Less Than 1 Year of Age

Introduction: The interest in laparoscopy in the treatment of ureteropelvic junction obstruction (UPJO) in children under 12 months of age remains controversial. The aim of this study is to evaluate feasibility and benefits of retroperitoneal laparoscopy (RL) compared to open surgery in this age group. Materials and Methods: Between January 2012 and May 2017, we performed 222 pyeloplasties: 144 by laparoscopy and 78 by open surgery. From 2012, the choice of operative technique was decided according to the laparoscopic experience of the surgeon; two surgeons operated laparoscopically on all children <12 months of age, while others operated using posterior lumbotomy (PL). The RL is standardized and performed by 3 trocars (5, 3, 3). Pre, per and postoperative parameters were analyzed retrospectively. Statistical tests: Pearson, Fisher, Student and Mann-Whitney. Results: During this 5-year period, 24 RL and 53 PL were included with a median follow-up of 27 months (5-63). In the LR group, postoperative drainage was performed by JJ (13 cases) and external stent (11 cases). No conversion has been listed in this group. In each group there was one failure that needed redo pyeloplasty. Duration of hospitalization and intravenous acetaminophen use were significantly lower in the RL group (2.8 vs. 2.3 days, p = 0.02, respectively) while operating time was significantly longer (163 vs. 85.8 min, p = 0.001). The postoperative complication rate was statistically identical in each group (urinary tract infection, wall hematoma, hematuria…). Conclusion: RL is feasible in children under 1 year of age in the hands of well-experienced surgeons with longer operative time but without added morbidity. Subject to the retrospective nature of our study, the RL seems to offer a benefit regarding duration of hospitalization and analgesics consumption.

Transperitoneal Mini-Laparoscopic Pyeloplasty in Flank Position: A Safe Method for Infants and Young Adults

Introduction and Objectives

Open dismembered pyeloplasty has been the gold standard treatment for ureteropelvic junction obstruction in children. Laparoscopic pyeloplasty (LP) is becoming a standard procedure, but its acceptance is slow. We report our method for minilaparoscopy (MLP) in children using a tansperitoneal approach with the patient in the lateral flank decubitus which we found technically advantageous. 

Materials and Methods

Retrospective review of the records of 52 children and adolescents up to 18 years of age who underwent transperitoneal MLP at our institution during March 2012–October 2017 A 5 mm trocar is placed for the camera at the site of the umblicus by open technique, two 3 mm trocars placed in the upper and lower quadrants of the abdomen. No additional ports were necessary. 20cm long, 3-mm-diameter instruments are used. Few cases needed percutaneous fixation of the pelvis. The anastomosis is performed with 5–0 or 6–0 Polyglecaprone 25 (Monocryl®) with 13 mm half circle needle (TF plus) suture cut to 12–14 cm length and introduced through the 5-mm port. Needles are removed through the 3-mm port under direct vision. 

Results

Fifty-two children (53 renal units) with a mean age of 82 months (range 3.5–204), a mean weight of 24,35 kg (range 7–57), and a mean follow-up of 20,44 months (6–60). Nine children were younger than 12 months, and 14 were ≤10kg. Six patients were >50kg. The mean of preoperative grade of dilatation was III (SFU scale) and postoperatively improved to SFU 0,60 (0–2). In 50 (94,3%) of the cases, there was complete resolution of hydronephrosis. There was no conversions to open surgery. Three patients suffered complications Clavien-Dindo Classification IIIb, 2 omental prolapses through a port site in two children which required general anaesthesia and one percutaneous drainage due to a leakage. No reinterventions related to stent complications or obstruction were found. Mean hospital stay was 4,69 (3–14) days. 

Conclusions

The method of mini LP described here has proven efficient and safe. Weight appeared not to be limitation for both groups ≤10 and >50 kg.

Comparative, Prospective, Case-Control Study of Open versus Laparoscopic Pyeloplasty in Children with Ureteropelvic Junction Obstruction: Long-term Results

INTRODUCTION

We compare open pyeloplasty (OP) versus laparoscopic pyeloplasty (LP) in children in a multicenter, prospective, case-control study.

MATERIALS AND METHODS

From May 2007 to March 2009, a program was established at Hospital Garrahan, the reference center, to perform LP with a mentoring surgeon that would attend the institution once a month. Every new case of ureteropelvic junction obstruction (UPJO) diagnosed in the reference institution was offered to participate in the study. If the patient was enrolled, it was scheduled for LP. The following patient diagnosed with UPJO was operated on with open technique and served as a case-control. In three other facilities, patients were only offered LP and had a matched control open case at the reference institution. The first end point of the study was patient recovery: analgesia requirement and length of hospitalization (LOH). The second end point of the study was resolution of UPJO in long-term follow-up for the two techniques. Demographic data, surgical time, perioperative complications, analgesia requirement, analgesia score during hospitalization, LOH, and outcome were recorded. Both groups received the same postoperative indications for pain control. Parents were asked to assess pain in their children every 4 h postoperatively and to complete a pain scale chart to which the nurses were blinded.

RESULTS

Fifteen OP and 15 LP were compared. Groups were similar with regard to sex, age, weight, and laterality. Mean surgical time was longer in LP than in OP group (mean 188 versus 65 min) (p < 0.01). Hospitalization was shorter for LP group with a mean of 1.9 versus 2.5 days for OP group (p < 0.05). Postoperative analgesia requirement was significantly higher in the OP group with a mean use of morphine of 1.7 versus 0.06 mg/kg in the LP group (p < 0.05). Pain scores were similar in both the groups. At a mean follow-up of 58 months there were no failures.

CONCLUSION

In this prospective comparative cohort, LP was a longer procedure than OP. Both procedures had the same efficacy and complication rates, but patients undergoing LP needed fewer narcotics for pain control and had a shorter hospitalization.

Laparoscopy or retroperitoneoscopy: which is the best approach in pediatric urology?

The emergence of minimally invasive surgery about 20 years ago revolutionized pediatric urology. Advances in pediatric devices allowed the widespread use of minimally invasive techniques in almost the entire range of pediatric urology. In this context, laparoscopy and later retroperitoneoscopy were developed and applied in a wide spectrum of urological diseases. Both approaches have since presented benefits and disadvantages that have been documented in various series. However, few comparative studies have been conducted. The aim of this review is to compare the two approaches and establish which is preferable in each field of pediatric urology.

Pyeloplasty techniques using minimally invasive surgery (MIS) in pediatric patients

Hydronephrosis is the most common presentation of ureteropelvic junction (UPJ) obstruction. We reviewed literature, collecting data from Medline, to evaluate the current status of minimally invasive surgery (MIS) approach to pyeloplasty. Since the first pyeloplasty was described in 1939, several techniques has been applied to correct UPJ obstruction, but Anderson-Hynes dismembered pyeloplasty is established as the gold standard, to date also in MIS technique. According to literature several studies underline the safety and effectiveness of this approach for both trans- and retro-peritoneal routes, with a success rate between 81-100% and an operative time between 90-228 min. These studies have demonstrated the safety and efficacy of this procedure in the management of UPJ obstruction in children. Whether better the transperitoneal, than the retroperitoneal approach is still debated. A long learning curve is needed especially in suturing and knotting.

Pediatric Robot-Assisted Laparoscopic Pyeloplasty

The laparoscopic approach to the pyeloplasty procedure has proven to be safe and effective in the pediatric population. Multiple studies have revealed outcomes comparable to the open approach. However, a major drawback to laparoscopy is the technical challenge of precise suturing in the small working space in children. The advantages of robotic surgery when compared to conventional laparoscopy have been well established and include motion scaling, enhanced magnification, 3-dimensional stereoscopic vision, and improved instrument dexterity. As a result, surgeons with limited laparoscopic experience are able to more readily acquire robotic surgical skills. Limitations of the robotic platform include its high costs for acquisition and maintenance, as well as the need for additional robotic surgical training. In this article, we review the current status of the robot-assisted laparoscopic pyeloplasty, including a brief history, comparative outcomes, cost considerations, and training.

The BULT Method for Pediatric Minilaparoscopic Pyeloplasty in Infants: Technique and Results

We reviewed retrospectively the results of transperitoneal minilaparoscopic pyeloplasty in children younger than 2 years. The surgical technique utilized as well as the retrograde placement of the stent is described in detail. Twenty-four consecutive children with a mean age of 7.9 months (range 1-23), a mean weight of 7.4 kg (range 4-12), and a mean follow-up of 18 months (range 3-59) are included. Preoperative grade of dilatation was 3.8 (SFU scale) and postoperatively improved to 1.5. The AP diameter of the pelvis decreased from a mean of 28-9 mm. In 83% of cases, there was complete resolution of hydronephrosis (grades 0-2) and the rest showed improvement. There was one conversion to open surgery in a child with a horseshoe kidney. There was one omental prolapse though a port site in a child in whom an inappropriate drain was used. There were no stent-related complications and no reinterventions for persistent or recurrent obstruction. Given these outcomes, low complication rate and excellent cosmetic results, we recommend transperitoneal minilaparoscopy with a double J stent and a perirenal drain for infants requiring pyeloplasty.

Differences between intrinsic and extrinsic ureteropelvic junction obstruction related to crossing vessels: histology and functional analyses

PURPOSE

In children, ureteropelvic junction obstruction (UPJO) is mostly caused by intrinsic factors (IUPJO); extrinsic UPJO are rare and often due to crossing vessels (CVs).

METHODS

We retrospectively reviewed all data of children with UPJO that underwent surgery in our institution from 2004 to 2011. Analyses included age at surgery, gender, preoperative and postoperative results of ultrasound and renal scans [differential renal function (DRF); signs of obstruction], and pathology reports. Available histological specimens of cases with CV were compared to a random selection of intrinsic cases in a blinded fashion. After additional Masson's trichrome staining, the specimens were scored for fibrosis, muscular hypertrophy, and chronic inflammation.

RESULTS

Out of 139 patients with UPJO, 39 cases were associated with CV. Median age at surgery was 68 months (range 2-194) in the CV group and 11.5 months (range 0-188) in IUPJO group. Laparoscopic dismembered pyeloplasty (LDMP) was carried out in 134 and open DMP in five patients. Preoperative ultrasound identified 28/39 cases with CV. DRF below 40 % was more frequently seen in CV patients (p = 0.020). Histological analyses revealed no differences between the CV and IUPJO specimens in total. CV patients with higher grades of muscular hypertrophy had lower preoperative DRF, compared to those with higher preoperative DRF (p = 0.026). Functional recovery after (L)DMP was excellent in both groups.

CONCLUSION

We could not find any significant histological differences between CV and IUPJO in children. To obtain excellent functional recovery, surgical procedures with a definite correction of the UPJ should be preferred in paediatric patients with CV.

Transperitoneal versus retroperitoneal laparoscopic pyeloplasty in children: Randomized clinical trial

INTRODUCTION

Laparoscopic pyeloplasty achieves good cosmetic and functional outcomes. Both transperitoneal and retroperitoneal approaches are used. No single study to date has compared the two approaches in a prospective randomized design.

OBJECTIVE

We present a prospective randomized comparison between both approaches in children in a trial to define which technique is better with regard to multiple factors including operative time, hospital stay, recovery of bowel movement, analgesic requirement and complication rate.

STUDY DESIGN

In the period from June 2010 to September 2012, 38 children (25 boys and 13 girls) were operated laparoscopically. Children were randomized into Group I (19 children) operated by the transperitoneal approach, and Group II (19 children) operated by the retroperitoneal approach. Both groups were compared as regards to the operative time, anesthetic changes, and postoperative recovery. A minimum sample size required was calculated to be 19 for each arm based on previous studies of laparoscopic pyeloplasty, using a mean difference in operative time = 40 min, effect size = 0.95, an alpha of 0.05 and power 80% and an online sample size calculator. Statistical analysis was performed using SPSS software using the Fischer exact test, chi square test and Mann-Whitney U test. The operative time was the primary endpoint for comparison between both approaches.

DISCUSSION

Our series is the first in the literature that compares in a prospective randomized design the transperitoneal and retroperitoneal laparoscopic pyeloplasty in children. Shouma et al. is the only prospective randomized study to compare both techniques in adult pyeloplasty. They had a significantly shorter operative time in the transperitoneal group however, the author in the discussion mentioned that he was at the start of the learning curve for retroperitonoscopic pyeloplasty when he conducted his study, which affected the result of the operative time. Hence, as mentioned above, we stressed the importance of a single surgeon with adequate equal experience in both techniques. The recovery of the intestinal motility and start of oral feeding were significantly faster in the retroperitoneal group compared to the transperitoneal group. In our opinion this can be explained by the absence of intraperitoneal manipulations and urine leakage in the peritoneal space. In their series of retroperitoneal pyeloplasty, El Ghoneimi et al. reported feeding after a mean of 1.4 days, however, in our series there was even earlier oral feeding. Shouma et al. reported no significant difference in the start of oral feeding in their adult series. The limitations of our study are: the choice of the 40 min difference created a statistically significant difference in operative time between the groups which might not be considered a truly clinically important difference. In addition, the single author operating for both approaches, which might create a bias, however the author has sufficient experience in both approaches. Moreover, although there were significant differences in hospital stay and intestinal movement between the two groups, it is not clear if these were of clinical significance.

CONCLUSION

Both transperitoneal and retroperitoneal approaches have high success rate. The shorter operative time, shorter hospital stay, rapid recovery of intestinal movement and early resumption of oral feeding are in favor with the retroperitoneal approach.

Preliminary experience with laparoscopic Foley's YV plasty for ureteropelvic junction obstruction in children

INTRODUCTION:

Laparoscopic dismembered pyeloplasty is an acceptable option for ureteropelvic junction (UPJ) obstruction in the paediatric population. We compared our results of laparoscopic dismembered and non-dismembered Foley's YV pyeloplasty.

MATERIALS AND METHODS:

Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. Foley's YV plasty was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres. Children were followed up for urinary infection, and renogram was repeated after 3 months.

RESULTS:

During the study period, 108 children (63 male and 45 female) with a mean age of 4.94 ± 2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children (5 male and 6 female) with a mean age of 4.00 ± 1.776 years underwent laparoscopic Foley's YV plasty. There were no major peri-operative complications noted and conversion to open was not necessary in any child. Renogram done at 3 months post-operatively showed good drainage and improvement of renal function.

CONCLUSIONS:

Laparoscopic Foley's YV pyeloplasty is a safe and effective technique in appropriately selected cases of primary UPJ obstruction in children.

External extension of double-J ureteral stent during pyeloplasty: inexpensive stent and non-cystoscopic removal

PURPOSE

The purpose of the study is to describe our experience with the application of externalized double-J ureteral stent (DJUS) during pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in order to avoid cystoscopy for stent removal.

MATERIALS AND METHODS

Pyeloplasty was performed in 523 infants with UPJO using miniature pyeloplasty technique. After removing the obstructed segment, a 3-Fr. DJUS was placed into the ureter. In order to avoid cystoscopy for the removal of the stent, a feeding tube was passed through the skin and renal pelvis via a separate stab incision, connected to the DJUS and secured to the external body surface (skin), and the pyeloplasty was completed. The feeding tube along with the stent was removed after 3-4 weeks, respectively. Postoperative follow-up visits were performed 1, 3, and 6 months after the procedure.

RESULTS

The mean operative time was 49 min (range 41-79). Patients were discharged after 17 ± 2 h (mean ± SD). No patient experienced bladder spasm or anticholinergic administration. Forty-four patients (8.4 %) experienced minor complications including non-febrile urinary tract infections and mild hematuria. No major complication including urinoma, leakage, and stent migration or displacement was observed during the follow-up period. Stent removal was tolerated by 99.8 % of patients in an outpatient setting with minimal discomfort without performing cystoscopy.

CONCLUSIONS

Using external DJUS along with a pyelocutaneous stent extension during pyeloplasty is a safe, feasible, and beneficial technique. This technique resulted in high success rate with minimal cost and no renal injury. The non-cystoscopic stent removal and elimination of urethral catheterization following pyeloplasty are the other advantages of this technique.

Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis

CONTEXT

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized.

OBJECTIVE

To critically analyze the current status of laparoscopic and robotic repair of UPJO.

EVIDENCE ACQUISITION

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.

EVIDENCE SYNTHESIS

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.

CONCLUSIONS

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.

Laparoscopic transperitoneal pyeloplasty in children from age of 3 years: our clinical outcomes compared with open surgery

OBJECTIVE

To report clinical outcomes for laparoscopic pyeloplasty (LP) in children compared with open pyeloplasty (OP) and literature findings.

PATIENTS AND METHODS

In a prospective study, the outcomes of 57 consecutive transperitoneal LP in children from the age of 3 years were analyzed and compared with a matched historic control group of OP and with series of LP in the literature. Successful result was defined as resolution of symptoms, no conversion or re-operation, improved hydronephrosis, and/or improved renographic drainage.

RESULTS

Mean operative time was 177 (SD 50.5)min in the LP group and 108 (SD 25.6)min in the OP group (p < 0.001). Mean hospital stay was 1.2 (SD 0.46) days in the LP and 6.7 (SD 1.2) days in the OP group. Improvement in renographic drainage was observed more often after LP than after OP (98% vs 83%; p = 0.010). A successful result was reported in 56 (98%) LP and 54 (95%) OP (p = 0.298) patients. Our LP series demonstrates a high success rate compared to literature data.

CONCLUSIONS

Our LP has a similar success rate and more often improved renographic drainage in comparison to OP. Furthermore, our LP demonstrates a shorter hospital stay and favorable outcomes compared to the literature. We thus regard LP as standard treatment for repair of ureteropelvic junction obstruction in children from the age of 3 years.

A minimal invasive surgical approach for children of all ages with ureteropelvic junction obstruction

OBJECTIVE

Open dismembered pyeloplasty is considered the gold standard to treat ureteropelvic junction obstruction (UPJO) in children. Laparoscopic pyeloplasty (LP) and robot-assisted pyeloplasty (RAP) are increasingly popular. Our present protocol consists of using minimally invasive techniques for all children with UPJO. Here, we report our first 40 cases operated under this protocol.

PATIENTS AND METHODS

Retrospective chart review of patients who underwent LP and RAP for UPJO between 2006 and 2010 was performed. Children younger than 4 years of age underwent LP and children aged 4 years and older with robot assistance. Results were assessed comparing pre- and postoperative imaging studies, operating time, hospital course and complications.

RESULTS

Thirty-nine patients underwent 41 dismembered pyeloplasties (20 patients LP, 19 patients RAP). No conversions to open surgery were performed. The difference in operative time was statistically significant. The average hospital stay was 7 days (LP) and 6 days (RAP). All patients showed significant decrease of hydronephrosis and the overall success rate was 100%. The complication rate was 25% in the LP and 28% in the RAP group.

CONCLUSION

Our data show that RAP and LP are effective to correct UPJO with similar outcomes and complication rates. None of the patients in this series required re-intervention to correct obstruction and the results are comparable with open surgery.

Dismembered and non-dismembered retroperitoneoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction in children

PURPOSE

Open dismembered pyeloplasty according to Anderson-Hynes (AHP) is the gold standard treatment for ureteropelvic junction obstruction in children. However, during the last decade, the management has been revolutionized with introduction of laparoscopy and endourology yielding comparable results and less morbid outcomes.

METHODS

Between 1997 and 2010, dismembered and non-dismembered retroperitoneoscopic pyeloplasty was performed in 41 children with a median age of 130 month (range 5-192). 20 children underwent a dismembered pyeloplasty (Anderson-Hynes) and 21 children were operated by a non-dismembered pyeloplasty (Y-V-Plasty).

RESULTS

The mean operation time was 120 min (range 52-257). Intraoperative findings revealed in 29 cases a significant crossing vessel. Based on a furosemide nephrogram and subjective complaints, the success rate was 88 % with a median follow-up of 69 month (range 14-142). The 5 failures (2 Y-V-Plasty, 3 AHP) have been treated by open AHP (n = 2), Laser endopyelotomy (n = 2) and Lap-AHP (n = 1) without further problems.

CONCLUSION

With increasing improvement of the suture techniques, the laparoscopic pyeloplasty represents in experienced hands an alternative method with comparable success rates to the open technique. In our opinion, retroperitoneoscopic pyeloplasty is technically possible and feasible even in infants. We found in our series no statistically significant difference between dismembered and non-dismembered pyeloplasty.

A novel technique of stenting for laparoscopic pyeloplasty in children

PURPOSE

We introduce the novel technique of a percutaneous pyelo-ureterostomy stent for laparoscopic pyeloplasty in children, which overcomes the limitations of previously described stenting techniques.

MATERIALS AND METHODS

A Chiba needle is passed percutaneously across the anterior wall of the renal pelvis after completion of the anterior pyelo-ureteric anastamotic line. A guide wire is inserted through the trocar followed by an angiocatheter over the wire. The stent is passed through the angiocatheter, over the wire and across the wall of the renal pelvis. The wire is withdrawn and the stent distal tip is advanced to the mid-ureter. The posterior anastamotic line is then completed and the renal pelvis closed. The stent is capped on postoperative day 1 and removed in the office on postoperative day 10.

RESULTS

Since 2007 we have used this approach for 14 laparoscopic pyeloplasties (5 right, 9 left) in children with a mean age of 8.8 years (range 5-17). Mean time of insertion was 9:55 min with no difficulties or perioperative complications noted.

CONCLUSION

The antegrade pyelo-ureteral stent is easily and quickly inserted percutaneously as well as removed in the office, thus obviating the need for a second anesthetic.

Laparoscopic pyeloplasty in pediatric patients: the SGPGI experience

Objectives:

To determine the safety, efficacy and long-term outcome of laparoscopic pyeloplasty in pediatric patients.

Materials and Methods:

A prospective analysis of data of pediatric patients under the age of 15 years, who had undergone laparoscopic pyeloplasty from January 2000 to June 2008 was done. The various parameters analyzed were; operative time, blood loss, need for analgesics, intra/postoperative complications, hospital stay and postoperative outcome. Success was defined on the basis of either improvement in the symptoms/or better drainage on postoperative isotope renography.

Results:

A total of 82 patients with a mean age of 7.12 years (four months to 15 years) and male to female ratio of 4.3:1 were included in the study. Dismembered pyeloplasty was done in 70 patients and Foley Y-V plasty in 12 patients via transperitoneal approach using three ports in 79 or four ports in three children. Mean operative time was 151 minutes (78-369); mean blood loss was 88.01 ml (50-250) with a mean hospital stay of 5.05 days (2-11). Conversion to open surgery was required in four (4.87%) patients. Follow-up renograms were available in 74 patients who showed improvement in drainage in 69 patients and obstructed pattern in five; of these two patients had significant deterioration in split function. Two patients among the obstructed group underwent redo pyeloplasty by open technique while the rest three elected for conservative approach. At a mean follow-up of 41.58 months (8-75) the overall success rate was 91.89%.

Conclusion:

Laparoscopic pyeloplasty is effective and safe in children with minimal morbidity and gives excellent long-term results.

Retroperitoneal laparoscopic dismembered pyeloplasty with a novel technique of JJ stenting in children

OBJECTIVE

• To report our experience with retroperitoneal laparoscopic dismembered pyeloplasty for pelvi-ureteric junction (PUJ) obstruction in children.

PATIENTS AND METHODS

• Between March 2007 and December 2009, 38 children with PUJ obstruction (mean age 8.3 years, range 3-14) underwent retroperitoneal laparoscopic dismembered pyeloplasty. • A ureteric catheter was inserted into the mid-ureter cystoscopically. During pyeloplasty, the proximal end of the ureteric catheter was extracorporeally sutured to the distal end of the JJ stent with silk. • The ureteric catheter was then pulled down and the stent was pulled antegrade into the ureter and bladder.

RESULTS

• The approach was retroperitoneal in all patients except one who required open conversion. The overall mean operative time was 162 min (range 145-210 min) and this appeared to decrease with experience. Mean hospital stay was 4 days (range 3-7 days). • Mean follow-up was 20.2 months (range 6-32 months). Satisfactory drainage with decreased hydronephrosis was documented in all patients on ultrasonography and intravenous urography.

CONCLUSION

• Our study shows that retroperitoneal laparoscopic dismembered pyeloplasty is a feasible and effective alternative to open pyeloplasty with a relatively minimal complication rate in children 3 years of age and older, but it should be undertaken by experienced laparoscopic surgeons.

Laparoscopic simultaneous bilateral dismembered pediatric pyeloplasty applying three midline ports

OBJECTIVES

The objective of this study was to describe our experience with laparoscopic simultaneous bilateral dismembered pyeloplasty in two pediatric cases by using three midline ports.

METHODS

A 5-year-old boy and a 5-month-old male infant with bilateral ureteropelvic junction obstruction underwent bilateral laparoscopic transperitoneal dismembered pyeloplasty. A 10-mm trocar was placed through the umbilicus, and two 5-mm trocars were also placed in the midline superior and inferior to the umbilicus. On the left side, dismembered pyeloplasty was performed through a transmesocolic approach. Double-J ureteral stent was inserted through one of the trocars on both sides.

RESULTS

The postoperative period was uneventful. Patients were discharged on postoperative days 4 and 5. Oral feeding was tolerated on the first postoperative day. In a 6-month follow-up period, excretory urography and renal scan showed resolution of obstruction.

CONCLUSIONS

Laparoscopic dismembered pyeloplasty can be performed in a single session for pediatric patients with bilateral ureteropelvic junction obstruction. This can obviate the need for two sessions of anesthesia induction and intubation. However, more studies with large number of patients are needed to confirm this result.

Transmesocolic laparoscopic pyeloplasty in children: a standard approach for the left-side repair

OBJECTIVE

To compare the transmesocolic approach in the left laparoscopic pyeloplasty with the laterocolic right-side repair in children.

PATIENTS AND METHODS

Dismembered pyeloplasty was performed in 77 consecutive children aged 1.2-18.2 years. The transmesocolic approach was used in 49 patients with left hydronephrosis (group I) and the conventional laterocolic approach in 28 patients with right hydronephrosis (group II). Three age groups were defined.

RESULTS

The transmesocolic approach was applicable in 48 of 49 patients (98%); the colic vessels were preserved. The operation time was significantly shorter in the transmesocolic group, also when comparing patients with similar age, incidence of crossing vessels and urinary diversion. A shorter operation time was achieved in children without internal urine diversion. Postoperative complications were encountered in 6.3% of group I and 7.1% of group II without any conversion to open repair or recurrence of obstruction within a 2.5-year follow-up period.

CONCLUSIONS

The transmesocolic approach offers clear anatomy and provides safe access to the dilated left renal pelvis and crossing vessels. The operative time is shorter due to very limited tissue dissection. The medial reflection of the colon is avoided. This approach allows for microsurgical performance of the left-side pyeloplasty in all paediatric age groups.

Laparoscopic management of ureteropelvic junction obstruction in pediatric patients: a new approach to crossing vessels, crossing vein division, and upward transposition of the crossing artery

OBJECTIVE

To demonstrate the role of the laparoscopic approach for management of primary ureteropelvic junction obstruction (UPJO) using two different techniques in the pediatric age group.

MATERIAL AND METHODS

From April 2005 to October 2008, 63 pediatric patients underwent treatment of primary UPJO via a laparoscopic approach. Dismembered pyeloplasty was elected in 56 renal units while nine patients were managed by upward transposition of accessory renal artery after division of accessory renal vein. No JJ stent was required in these nine patients.

RESULTS

Mean age of patients was 61 (2-180) months. Mean operative time was significantly lower in those managed by transposition of aberrant vessels compared with dismembered pyeloplasty. The mean hospital stay was 6.4 (2-14) days for the dismembered technique and 2.1 (1-4) days for the vascular transposition approach. Significant improvement of obstruction was achieved in all of the patients who underwent the modified Hellstrom technique and in 92.81% of the renal units undergoing dismembered pyeloplasty.

CONCLUSION

The technique of laparoscopic transposition of crossing renal artery without violating collecting system may have a role in minimally invasive management of UPJO in selected pediatric patients. Further research with larger samples and a longer follow-up period is required.

Current trends in pediatric minimally invasive urologic surgery

Over the past two decades, laparoscopic and robotic surgery in children has been described as a viable minimally invasive alternative to open surgery for many pediatric urologic conditions. With the goal of reducing the morbidity associated with open surgery, minimally invasive surgery in children is increasingly being performed as laparoscopic and robotic patients appear to be experiencing shorter hospital stays, decreased pain medication requirements, and the potential for improved cosmesis. This article provides an overview of the existing literature in laparoscopic and robotic-assisted laparoscopic urologic surgery in children. Laparoscopic and robotic-assisted laparoscopic surgery appears to be safe and effective in children for a wide range of ablative and reconstructive procedures. Conventional laparoscopic surgery is effective for ablative procedures, while robotic surgery may be ideally suited for reconstructive cases requiring advanced suturing and dissection. Overall, more prospective studies are needed to study the long-term outcomes of minimally invasive surgery in pediatric patients, and the appropriate use of the available technology.

Evolution of laparoscopy in pediatric urology

The use of laparoscopy has evolved over the last 30 years, particularly in the last decade, from merely extirpative or diagnostic procedures to intricate reconstructive procedures on the major genitourinary organs. The development of laparoscopy as a method of treating urological problems has progressed more slowly in children compared with adults; perhaps due to the availability of miniaturized technology, the steep learning curve and the high success of traditional open surgery. This article seeks to provide a comprehensive review of the evolution of laparoscopy from its inception to its present-day applications in the field of pediatric urology, including the current indications and results of various laparoscopic procedures.

Retroperitoneoscopic vs open dismembered pyeloplasty for ureteropelvic junction obstruction in children

PURPOSE

To compare the effectiveness, potential advantages and complications of classical open pyeloplasty with retroperitoneoscopic pyeloplasty in children.

MATERIALS AND METHODS

Two patient cohorts with confirmed ureteropelvic junction obstruction (UPJO) undergoing open or retroperitoneoscopic pyeloplasty over a 7-year period were analysed comparatively.

RESULTS

Operative time was significantly longer in the retroperitoneoscopic group (mean 155 min) compared to the open pyeloplasty group (mean 98 min, P<0.05). Mean hospital stay was shorter in the retroperitoneoscopic group (mean 4.1 days, compared to 5.1 days, open). Complication rates were similar (open, 27% vs retroperitoneoscopic, 29%). These included anastomotic urinary leakage, stenosis and infection. Anastomotic leakage was more common in the retroperitoneoscopic group. There was a 6.6% conversion rate in the retroperitoneoscopic group. Success, defined as improved ultrasonic or renographic parameters, with resolution of symptoms where discernable, was noted in 96% of the open group and 97% of the retroperitoneoscopic group with a mean follow up of 38 and 25 months, respectively.

CONCLUSIONS

Retroperitoneoscopic pyeloplasty is as safe and effective as open pyeloplasty. This technique is now our procedure of choice for children>4 months old. The advantages are more obvious in children over 4 years than in infants. This technique remains difficult to perform and teach.

Experience with laparoscopy-assisted retroperitoneal pyeloplasty in children

PURPOSE

To describe a laparoscopy-assisted retroperitoneal pyeloplasty (LARP) and results of initial experience.

METHODS

Port placement used by Farhat in retroperitoneal-assisted laparoscopic pyeloplasty was modified for better cosmetic results. Surgery was done using 2-cm incision for 5-mm camera port and two 3-mm working ports. Dissection was done anterior to the kidney. The ureteropelvic junction was brought out through the 2-cm trocar site and the pyeloplasty was performed extracorporeally. Between January 2004 and February 2008, a total of 39 kidneys in 38 children with mean age of 4.1 months underwent LARP. The operative time, hospital stay, functional outcome and follow-up renogram studies were reviewed.

RESULTS

The mean operative time was 147 min. 2-cm incision was extended in one patient with malrotated kidney. There was improvement in function in 37 (95%) with no failure. The mean split renal function, preoperative and at follow-up were 35.7 and 44.2%, respectively (P = 0.000). The mean glomerular filtration rate (ml/min), preoperative and at follow-up were 27.4 and 39.1%, respectively (P = 0.000). Mean follow-up period was 24 months.

CONCLUSION

LARP is safe in treating UPJ obstruction in infants. It is recommended especially in small babies where laparoscopic pyeloplasty is difficult.

Retroperitoneoscopic Anderson-Hynes dismembered pyeloplasty in infants and children: a 60-case report

PURPOSE

To present a new technique of retroperitoneoscopic Anderson-Hynes dismembered pyeloplasty (AHDP) in infants and children with ureteropelvic junction obstruction (UPJO) based on our clinical experience.

METHODS

From March 2003 to February 2007, retroperitoneoscopic AHDP was performed in 60 (44 boys and 16 girls) UPJO infants and children with a three-port lateral retroperitoneal approach. The retroperitoneal space was entered via a 1-cm longitudinal incision beneath the 12th rib and further developed by a glove balloon. Video-retroperitoneoscopy was undertaken with a 5-mm laparoscope between the mid axillary line and 1 cm away from the superior border of iliac crest. Dismembered pyeloplasty was carried out with the Anderson-Hynes anastomosis where 5-0 or 6-0 vicryl sutures were over a double-J ureteric stent. Anastomosis was completed with freehand intracorporeal suture techniques. Follow-up studies were conducted by intravenous urography and renal ultrasonography.

RESULTS

Among the 60 patients (62 sides) with retroperitoneoscopic AHDP, only the first two cases were converted to open surgery due to difficulties in developing the retroperitoneal space, and the remaining cases succeeded. The average operative time was 70 +/- 12.6 min (ranging from 55 to 130 min), the average estimated blood loss was 10 +/- 2.2 ml (ranging from 5 to 20 ml), and the average postoperative hospital stay was 7 +/- 1.3 days (ranging from 3 to 15 days). Aberrant artery vessel was intraoperatively observed in seven patients. Postoperative urinary leakage occurred in two patients, but spontaneously disappeared on the 6th and 11th days after the surgery, respectively; and one of them underwent open surgery for recurrent UPJO 8 months later. During an average follow-up period of 24 months, we performed radiographic assessment by intravenous urography and found that all the cases showed good results except the patient who underwent open surgery later.

CONCLUSIONS

Our experience with retroperitoneoscopic AHDP demonstrates that this technique is safe, effective and time saving for treating UPJO in infants and children.

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.

[Experience with laparoscopic pyeloplasty for treating ureteropelvic junction obstruction in children. Technique and results]

INTRODUCTION

Open pyeloplasty has been the gold standard for treating ureteropelvic junction obstruction, with a success rate greater than 90%. However, during the last decade the management has been revolutionized with the introduction of laparoscopy and endourology, yielding comparable results and fewer morbid outcomes.

MATERIALS AND METHODS

Between 1997 and 2007, dismembered and non-dismembered retroperitoneoscopic pyeloplasty was performed in 31 children with a medium age of 123 months (range 36-192 months). Fourteen children underwent dismembered pyeloplasty (Anderson-Hynes) and 16 children underwent non-dismembered pyeloplasty (YV plasty) and in one child we performed an ureterolysis.

RESULTS

The mean operating time was 120 min (range 67-257 min). In 21 cases, intraoperative findings revealed a significant crossing vessel. Based on a furosemide nephrogram and subjective complaints, the success rate was 93%. The two failures (laparoscopic YV plasty and laparoscopic ureterolysis) occurred in the early phase of laparoscopy and have been treated by open Anderson-Hynes plasty.

CONCLUSION

With increasing improvement of the suture techniques, laparoscopic pyeloplasty represents, in experienced hands, an alternative method with success rates comparable to the open technique. In our opinion, retroperitoneoscopic pyeloplasty is technically possible and feasible even in infants.