Transperitoneal Dismembered Laparoscopic Pyeloplasty in Infants: Points of Technique

Abstract

Introduction: Definitive reconstruction of pelviureteric junction obstruction has been performed by incisional, endourologic, or laparoscopic approaches.1,2 Among these, laparoscopic approach has been appraised for excellent morbidity profile and durable outcome. Contemplating laparoscopic pyeloplasty in infants poses many challenges. Apart from difficulties in achieving satisfactory anesthesia, the procedure demands considerable technical expertise. The lack of available working space in infants also remains a major hurdle. We demonstrate an operative exercise of transperitoneal laparoscopic dismembered pyeloplasty in a 3-month-old girl and discuss the points of technique. Methods: All patients are evaluated in detail. Imaging included ultrasonography (USG), magnetic resonance urogram (MRU), and diuretic renogram (DR). Patients with gross pelvicaliceal dilatation with compromised renal function were planned for definitive repair. All patients were planned for dismembered pyeloplasty through transperitoneal access. Pneumoperitoneum was maintained at 10 mm of mercury. Usage of thermal energy was restricted during ureteric and pelvic mobilization. After delineation of the pathological segment, dismemberment and exclusion of the pathological segment was undertaken. The ureter was spatulated posterolaterally. Pelvic spatulation was conducted till the most dependent part. Redundant pelvis was excised. Pelviuretric anastomosis was conducted using interrupted sutures of 4-0 polyglactin. Additional pelvic closure was performed in a continuous fashion. A Double-J stent was inserted antegrade after completion of posterior layer of anastomosis. Postprocedure patients were allowed orally once comfortable and discharged after removal of drain and perurethral catheter. Ureteral stents were removed at 6 weeks postprocedure. Patients were followed 3 monthly postprocedure. At 1 year postprocedure, USG, MRU, and DR were evaluated. No intervention during intervening period (ureteral stent, nephrostomy, or redo procedure) and improvement in imaging parameters were considered a successful outcome. Results and Discussion: Twenty-two laparoscopic pyeloplasties were performed in infants between January 2004 and December 2011. Mean age was 6.4 months (range: 3 months to 1 year). Thirteen were males and nine females. Seven patients underwent temporary diversion (percutaneous nephrostomy) before laparoscopic pyeloplasty that was removed at the time of surgery. All procedures were completed by laparoscopy. Mean operation duration was 140.5 minutes. In three patients, antegrade insertion of ureteral stent was not possible. All patients tolerated orals within 12 hours postprocedure. Mean hospital stay was 4.5 days (range: 3–5 days). Nineteen patients (86.36%) completed 1-year follow-up. No patients required any additional intervention in the intervening period. All patients demonstrated improvement in renogram parameters. Among the available options for management of pelviureteric obstruction, a dismembered pyeloplasty has been reported with superior results.1 Although technically demanding, laparoscopic approach can be undertaken in infants. The morbidity profile and appreciable outcome were chief attributes of this approach. The operator should be sufficiently versed with laparoscopic anatomy and intracorporeal suturing exercises. No competing financial interests exist. Runtime of video: 6 mins 13 secs