| Abstract|| |
Laparoscopic pyeloplasty is an accepted way of dealing with pelviureteric junction obstruction in children with extrarenal pelvis. However, intrarenal pelvis has been considered a relative contraindication for laparoscopic pyeloplasty. Here, we describe the technique of laparoscopic dismembered pyeloplasty in a child with intrarenal pelvis. The key when one embraces laparoscopic dismembered pyeloplasty is to ensure that outcomes are not compromised. A successful outcome requires a widely patent, well-vascularised anastomosis performed free of tension.
Keywords: Intrarenal pelvis, laparoscopic pyeloplasty
|How to cite this article:|
Lintula H, Kokki H. Laparoscopic dismembered pyeloplasty in a child with a relatively inaccessible intrarenal pelvis. Afr J Paediatr Surg 2011;8:225-8
|How to cite this URL:|
Lintula H, Kokki H. Laparoscopic dismembered pyeloplasty in a child with a relatively inaccessible intrarenal pelvis. Afr J Paediatr Surg [serial online] 2011 [cited 2019 May 26];8:225-8. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/2/225/86069
| Introduction|| |
Pelviureteral junction obstruction (PUJO) is the most common cause of paediatric hydronephrosis.  Expectant management can be recommended in children with asymptomatic hydronephrosis. Because PUJO can lead to progressive deterioration in renal function, surgery is indicated in patients with decreased renal function, large anterior-posterior pelvic diameter, recurrent urinary tract infections and/or pain.  Dismembered pyeloplasty has been considered the "treatment of choice" for the management of PUJO with success rate exceeding 90%.  Dismembered pyeloplasty with resection of the pelviureteral junction has been shown to be superior to nondismembering techniques due to accurate elimination of intrinsic factors for obstruction. 
Laparoscopic dismembered pyeloplasty has become an accepted technique of dealing with PUJO in children with extrarenal pelvis.  The large extrarenal pelvis can be easily exposed laparoscopically with medial mobilisation of the colon. Furthermore, the extrarenal pelvis can be further mobilised using a retracting hitch stitch. In addition, the portion of the pelvis to be removed can be used to manipulate the renal pelvis and the pelviureteral junction.  In contrast, a completely intrarenal pelvis requires extensive mobilisation of the proximal ureter and the lower pole of the kidney to gain access to the pelviureteral junction. Therefore, intrarenal pelvis has been considered a relative contraindication for laparoscopic dismembered pyeloplasty.  Here, we report our initial experience with laparoscopic dismembered pyeloplasty in a child with a relatively inaccessible intrarenal pelvis.
| Case Report|| |
A 12-year-old (height 141 cm; weight 34 kg) girl presented at our emergency department with vomiting, fever, and a right-sided flank pain of 2 days duration. During the previous 6 months, she had recurrent urinary tract infections and intermittent abdominal pain. On examination, the right flank was tender with percussion test. Her body temperature was elevated (38.9°C). Laboratory findings showed slight leukocytosis (17,700 cells/mm 3 ) and an elevated C-reactive protein value (202 mg/l). Urinalysis revealed pyuria, bacteriuria, and positive nitrite test; the urine culture showed Escherichia More Details coli. Renal ultrasonography revealed a right-sided hydronephrosis with antero-posterior pelvic diameter of 34 mm. Intravenous antibiotic therapy with cefuroxime (750 mg, 8 hourly for 14 days) was initiated for acute pyelonephritis and the patient was taken to the paediatric surgical ward for further observation. Despite analgesic treatment, the patient experienced unremitting flank pain, and a temporary percutaneous nephrostomy was placed to drain pyonephrosis. The placement of the nephrostomy was complicated with intra- and perirenal haemorrhage. However, the child became asymptomatic after the insertion of the nephrostomy. The nephrostomy was removed after 14 days. Prior to removal of the nephrostomy tube, we performed antegrade pyelography that showed a slight relief of PUJO.
To avoid recurrent pyelonephritis, we decided to perform laparoscopic dismembered pyeloplasty at 14 days after the removal of the nephrostomy. Preoperative renal ultrasound demonstrated a persistent right-sided hydronephrosis. Imaging with Tc-99m-mercaptoacetyltriglycerine (MAG 3) showed that the right kidney contributed 45% of renal function with evidence of PUJO (T1/2 > 15 minutes).
The procedure was performed under an endotracheal general anaesthesia. On induction of anaesthesia, the patient received 750 mg of cefuroxime for antibiotic prophylaxis. The patient was catheterised before surgery and the Foley catheter was left in place for gravity drainage. A nasogastric tube was inserted. The patient was placed in a 45° lateral position with the right side elevated and secured to the operating table. The surgeon and the assistant were located on the left side of the operating table, opposite to the affected pelviureteral junction. The monitor was placed at the right side of the operating table allowing both the surgeon and the assistant to view the procedure at all times. The procedure was performed with reusable instruments using three 5-mm working ports (one lower mid abdominal, one upper mid abdominal and one right subcostal) and one 10-mm sheath for camera. The camera port was inserted infraumbilically using an open technique, and pneumoperitoneum was established with the pressure maintained below 12 mmHg. The affected right kidney was exposed retrocolically, and Gerota's fascia was opened longitudinally. Dense scarring and inflammation was seen around the kidney. The inflamed perirenal tissue was detached from the renal capsule. The dilated renal pelvis was not found but the upper ureter was identified between the lower pole of the kidney and the inferior vena cava. The ureter was traced upwards and laterally. The patient did not have an aberrant crossing artery. To gain access to the pelviureteral junction, a complete mobilisation of the lower pole of the right kidney was required. By lifting the lower pole of the kidney and locking the jaws of the grasper to the lateral abdominal wall, a self-retaining retractor was established. The kidney was lifted into a vertical position [Figure 1]. The poorly vascularised and fibrotic pelviureteral junction was exposed. The renal pelvis was found to be completely intrarenal [Figure 2]. Therefore, the stay sutures could not be used. The proximal ureter was dismembered with a relatively small cuff of renal pelvis, leaving a 1.5 cm pyelotomy to reanastomose to the ureter. The pelviureteral junction and a 2-cm segment of proximal ureter were excised. The lateral wall of the normal ureter was opened longitudinally and spatulated for 2 cm along its lateral margin. The ureter was further mobilised 8 cm distally to allow a tension-free ureteropelvic anastomosis. The anastomosis was performed with 4-0 polyglactin suture on reverse cutting needle. The first suture was placed at the apex of the spatulated ureter from outside in, and then taken through the most distal part of the pyelotomy. The posterior anastomosis was completed running up the length of the spatulated ureter and pelvis. A double-J stent (4.8 F, 18 cm) was mounted on the guide wire and passed through the proximal ureter into the bladder. The upper coil of the double-J stent was left within the renal pelvis. The anterior anastomosis was completed as a continuous layer. The peritoneum was not closed. A perinephric drain was inserted. We performed cystoscopy to confirm the correct position of the double-J stent. The double-J stent was drawn 2 cm caudally to place the lower coil completely in the bladder. Laparoscopic pyeloplasty was completed in 320 minutes.
|Figure 1: The kidney was lifted into a vertical position to gain access to the pelviureteral junction|
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On postoperative day 1, the patient developed urinoma. Computed tomography revealed an anastomosis leakage associated with a caudal migration of the double-J stent. At cystoscopy, the malpositioned double-J stent was removed and a 6-cm longer double-J stent (6 F, 24 cm) was inserted in a retrograde fashion. After the second stenting, output from the perirenal urinoma diminished and the drain was removed on day 7. The patient was discharged on postoperative day 8. Prophylactic antibiotic therapy with trimetoprime (100 mg once a day) was continued for 3 months. Removal of the ureteral stent was undertaken 4 weeks postoperatively at cystoscopy under general anaesthesia. The child was evaluated by MAG renography and ultrasound at 3 and 12 months after the operation. The patient was asymptomatic at both follow-up visits, and imaging with Tc-99m-mercaptoacetyltriglycine (MAG 3) showed that the right kidney contributed 46% of renal function with no evidence of obstruction [Figure 3]. The postoperative antero-posterior pelvic diameter was 27 mm, compared with 34 mm preoperatively.
|Figure 3: MAG 3 imaging at 12 months after right-sided laparoscopic dismembered pyeloplasty. In diuretic renography, a T1/2 value (time until a 50% decrease in activity in the kidneys was observed after injection of furosemide) was 7 minutes for the right kidney (yellow line) and 3 minutes for the left kidney (blue line). The right kidney contributed 46% and the left kidney 54% of total renal function|
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| Discussion|| |
Transperitoneal dismembered laparoscopic pyeloplasty has proved to be an effective minimally invasive treatment for PUJO. , Although operative times have been reported to be increased relative to open pyeloplasty, laparoscopic pyeloplasty has shown advantages of quick recovery, shorter hospital stay, less postoperative pain and opioid analgesic use, and an earlier return of normal daily functions.  Several authors have shown that laparoscopic pyeloplasty can be performed in children with short-term outcomes (resolution of hydronephrosis, improvement of drainage or relief of symptoms) similar to those undergoing open pyeloplasty. ,,,, In the transperitoneal approach, the dilated extrarenal pelvis and the pelviureteral junction can be easily exposed with medial mobilisation of the colon.  In contrast, an access to the pelviureteral junction is more difficult in children with intrarenal pelvis.
In our patient in whom the renal pelvis was relatively inaccessible, because of an intrarenal location and intense perirenal scarring, extensive mobilisation of the lower pole of the kidney and the proximal ureter was required. To gain access to the pelviureteral junction, we had to lift the kidney into an upright position. Manipulation of the inflammated tissue appeared to be difficult with the laparoscopic instrumentation. There is no sensation at the tip of the forceps, and the importance of avoiding visceral injury made the dissection slow. The renal pelvis and the pelviureteral junction were identified by following the cephalad course of the ureter. We had difficulties to bring up the remaining ureter up to the level of the renal pelvis for tension-free anastomosis, and further ureteral mobilisation was required. Moreover, we could not use a hitch-stitch suture, which could have stabilised the renal pelvis and facilitated suturing during laparoscopic pyeloplasty. Therefore, the ureteropelvic reanastomosis was time-consuming to perform.
Few studies have addressed the issue of comparing the outcomes of patients with PUJO achieved by two different laparoscopic techniques: dismembered and non-dismembered pyeloplasty. ,,,, Three of the five studies evaluating the effects of the dismembered pyeloplasty and the nondismembered Y-V procedure reported similar therapeutic results. ,, Szydelko and co-workers  found that the patients who underwent non-dismembered Y-V plasty had significantly less operative times while maintaining similar postoperative outcomes. The shortened operative time in the Y-V plasty group was explained by the fact that fewer anastomotic sutures were needed in this procedure, which made it technically easier and more feasible. In contrast, Klingler and co-workers  have reported poor success for laparoscopic nondismembered Y-V plasty. According to the authors, their results were in agreement with experience in open surgery, where excision of the strictured pelviureteric junction and reduction of the enlarged renal pelvis gives the best and the most durable results in treatment of PUJO. Moreover, Casale and co-workers  have reported the success rate of 94% for dismembered pyeloplasty and 43% for nondismembered pyeloplasty in children with PUJO. The difference in outcomes between the two laparoscopic techniques was attributed to the dysplastic tissue found in pelviureteric junction obstructions, which is only rearranged in nondismembered procedures but resected in Hynes-Anderson dismembered pyeloplasty. Further research in the form of prospective studies comparing the outcomes of the two laparoscopic techniques is required.
A double-J stenting is a standard of care to drain pyeloplasty in many centres. ,,,, The double-J stent may have an advantage of a lessened nursing care and reduced morbidity after pyeloplasty.  Egan and co-workers  have shown that double-J stenting may result in more rapid resolution of hydronephrosis after pyeloplasty. The double-J ureteral stent is often placed antegrade after ureteral spatulation and before beginning the anterior wall of the anastomosis to minimise the risk of undue traction or compromise to the reanastomosis. ,, However, complications related to stent malpositioning have been reported with blind antegrade stenting. Malpositioning of the lower end of the double-J stent is usually associated with difficulties to negotiate the ureterovesical junction.  In our patient, the initially inserted stent was too short (18 cm) resulting in malpositioning of the upper coil of the double-J stent. According to the formula (stent length = patient's age in years + 10) developed by Palmer and Palmer,  the proper double-J stent length would have been 23 cm. We prefer now longer stent length, which permits the upper coil to rest in the upper pelvis away from the anastomosis. Furthermore, we still place the double-J stent antegrade but we confirm now proper positioning of the lower coil of the stent in the bladder by instillation of methylene blue through the Foley catheter.
In conclusion, the successful outcome in this case supports the consideration of laparoscopic dismembered pyeloplasty for treatment of PUJO in children with intrarenal pelvis. The key when one embraces laparoscopic dismembered pyeloplasty is to ensure that outcomes are not compromised. A successful outcome requires a widely patent, well-vascularised anastomosis performed free of tension.
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Department of Paediatric Surgery, Turku University Hospital, PO Box 52, FI-20521, Turku
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]