Laparoscopic Transperitoneal Dismembered Pyeloplasty in Horseshoe Kidney: Our Experience

Abstract

Introduction: Laparoscopic pyeloplasty in horseshoe kidneys has been scarcely reported till date.1 We narrate our experience in this procedure. The video spans 7 minutes and 52 seconds and demonstrates an operative exercise of laparoscopic pyeloplasty in a horseshoe kidney. Materials and Methods: Patients undergoing laparoscopic pyeloplasty for significant pelviureteric obstruction along with a horseshoe fusion anomaly were included in this analysis. Patients were evaluated in detail (clinical, blood profile, and imaging). Retrograde pyelogram was performed immediately before the laparoscopic procedure. Transperitoneal approach was employed involving four ports: 1–10-mm camera port and 3–5-mm working ports. Dismembered pyeloplasty was performed in all. Ureter was mobilized and shifted cranially. Ureteral stenting was achieved in antegrade fashion. Pelviureteric anastomosis was done with interrupted sutures. Stent was removed at 6 weeks postprocedure. All patients were evaluated 3 monthly. At 1 year postprocedure follow-up, imaging was ordered (intravenous urogram or computed tomography urogram, diethylenetriamenepentacetic acid renogram). Results and Conclusions: Six laparoscopic pyeloplasties were performed between March 2005 and June 2009. Patient mean age was 31.2 years (range 19–42 years). Four patients were men and two women. Presenting complaints were flank pain and recurrent urinary infection. The left side was affected in all. Mean operative duration was 175 min (range 165–200 min). Mean blood loss was 150 mL (range 100–200 mL). No significant intraoperative or postoperative events or conversions to open approach were experienced. Mean time for drain removal was 38 h (range 30–50 h). Mean analgesic requirement was 2.2 g (range 1.5–3 g) of paracetamol. Mean duration of hospital stay was 3.67 days (range 3–5 days). At 1 year follow-up imaging all units demonstrated satisfactory pelviureteric drainage. Pelviureteric obstruction in horseshoe kidneys may be addressed by endopyelotomy or preferentially pyeloplasty.2 Laparoscopic pyeloplasty in these scenarios is technically challenging because of aberrant renal anatomy. Both Y-V plasty and dismembered pyeloplasty have been described. Reported success rates for pyeloplasty in horseshoe renal anomalies ranges between 55% and 80% in open approach and 91% for laparoscopic approach.1 Superior success rates were perceived in our series than reported in literature. This may be attributed to the differences in our operative technique. In all cases, dismembered pyeloplasty was performed. Preprocedure ureteral stenting hinders proper estimation of the extent of pathological segment and compromises spatulation achieved, and was avoided. All pelviureteric handling was performed with restricted usage of thermal energy; wide spatulation of ureter was performed up to mucosal pouting. To ensure tension-free anastomosis, wide mobilization of the ureter with cranial shift of the same was undertaken. Interrupted sutures incorporating optimum mucosa are also of utmost importance. In our opinion, laparoscopic pyeloplasty in horseshoe kidney renders durable results and excellent morbidity profile. No competing financial interests exist. Runtime of video: 7 mins 52 secs