Laparoscopic Pyeloplasty In Infants Research Articles

Laparoscopic pyeloplasty in neonates and infants is safe and efficient.

Dismembered laparoscopic pyeloplasty (LP) is a well-accepted treatment modality for ureteropelvic junction obstruction (UPJO) in children. However, its efficacy and safety in infants, particularly neonates, remain uncertain. To address this significant knowledge gap, we aimed to compare outcomes between a cohort of neonates and infants undergoing LP vs. open pyeloplasty (OP) at less than 6 months and 6 weeks of age. We conducted a retrospective analysis of data from patients who underwent primary pyeloplasty at our institution between 2000 and 2022. Only patients aged 6 months or less at the time of surgery were included, excluding redo-procedures or conversions. Ethical approval was obtained, and data were assessed for redo-pyeloplasty and postoperative complications, classified according to the Clavien-Madadi classification. A standard postoperative assessment was performed 6 weeks postoperatively. This included an isotope scan and a routine ultrasound up to the year 2020. A total of 91 eligible patients were identified, of which 49 underwent LP and 42 underwent OP. Patients receiving LP had a median age of 11.4 (1-25.4) weeks, compared to 13.8 (0.5-25.9) weeks for those receiving OP (p > 0.31). Both groups in our main cohort had an age range of 0-6 months at the time of surgery. Nineteen patients were younger than 6 weeks at the time of surgery. The mean operating time was longer for LP (161 ± 43 min) than that for OP (109 ± 32 min, p < 0.001). However, the mean operating time was not longer in the patient group receiving LP at ≤6 weeks (145 ± 21.6) compared to that in our main cohort receiving LP. There was no significant difference in the length of stay between the groups. Four patients after LP required emergency nephrostomy compared to one patient after OP. The rate of revision pyeloplasty in our main cohort aged 0-6 months at surgery was 8% in the patient group receiving LP and 14% in the patient group receiving OP (not significant). Three revisions after LP were due to persistent UPJO, and one was due to stent migration. Only one patient requiring revision pyeloplasty was less than 6 weeks old. To our knowledge, this is one of the largest collectives of laparoscopic pyeloplasty performed in infants, and it is the youngest cohort published to date. Based on our experience, LP in neonates and infants under 6 months appears to be as effective as open surgery.

Outcome analysis of immediate and delayed laparoscopic pyeloplasty in infants with severe ureteropelvic junction obstruction.

The treatment timing of ureteropelvic junction obstruction (UPJO) in infants remains controversial. This study aimed to compare the recovery effect of renal morphology of immediate and delayed laparoscopic pyeloplasty in infants with severe UPJO. The infants with severe UPJO-induced hydronephrosis who underwent laparoscopic pyeloplasty according to their age at the time of surgery [the immediate treatment (IT) group: ≤1 month of birth, the delayed treatment (LT) group: 3-6 months of birth] in our center between 2010 and 2019 were enrolled in this study. Ultrasonography was used to assess renal morphology, including anteroposterior diameter (APD) of a pelvic, parenchymal thickness (PT), polar length (PL), and Society of Fetal Urology (SFU) grade. Preoperative and postoperative renal morphological outcomes at 6, 12, and 24 months were measured and compared. During this period, a total of 135 patients were assigned to receive either IT (n = 73) or LT (n = 62) and were included for analysis. There were no significant differences in renal morphology indices at baseline between groups of IT and LT. The APD, PT, and PL in both groups all recovered to certain degrees compared with those at baseline, however, the IT group recovered more significantly than the LT group. Despite there being no significant difference in SFU grade between the two groups before and after surgery, the reduction of SFU grade in the IT group was more significant than that in the LT group during the 6-, 12- and 24-month follow-up periods. The PL, SFU, and APD were greater in the IT group than in the LT group at 6, 12, and 24 months of follow-up. At 6 months PL was not significantly higher between the two groups, while the outcome was significantly different at 12 months and 24 months. Immediate laparoscopic pyeloplasty for the infant with severe ureteropelvic junction obstruction is effective, and it can accelerate the recovery of renal morphological indices in infants with severe UPJO-induced hydronephrosis.

Comparing Robot-Assisted Laparoscopic Pyeloplasty vs. Laparoscopic Pyeloplasty in Infants Aged 12 Months or Less.

Objective: To investigate the outcomes of minimally invasive approach to infants with ureteropelvic junction (UPJ) obstruction by comparing the two surgical modalities of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP).Methods: We conducted a retrospective review of all consecutive infants aged ≤12 months who underwent either LP or RALP in a single institution over the period of 2008–Jul 2020. We included primary pyeloplasty cases that were performed by or under the supervision of the same surgeon.Results: Forty-six infants (LP = 22; RALP = 24) were included with medians of age and body weight at 6 months (2–12months) and 8.0 kg (5.4–10 kg), respectively. There was no difference between the two groups in the patients' demographics and pre-operative characteristics. All infants underwent LP or RALP successfully without conversion to open surgery. None had intraoperative complications. Operative time (OT) was 242 min (SD = 59) in LP, compared with 225 min (SD = 39) of RALP (p = 0.25). Linear regression analysis showed a significant trend of decrease in OT with increasing case experience of RALP(p = 0.005). No difference was noted in the post-operative analgesic requirement. RALP was associated with a shorter hospital length of stay than LP (3 vs. 3.8 days; p = 0.009). 4/22(18%) LP and 3/24(13%) RALP developed post-operative complications (p = 0.59), mostly minor and stent-related. The success rates were 20/22 (91%) in LP and 23/24 (96%) in RALP (p = 0.49).Conclusions: Pyeloplasty by minimally invasive approach is safe and effective in the infant population. RALP may have superiority over LP in infants with its faster recovery and a more manageable learning curve to acquire the skills.

Optimising working space for laparoscopic pyeloplasty in infants: Preliminary observations with the SGPGI Protocol.

Aims:This study aimed to test the efficacy of SGPGI protocol to minimise bowel distension and optimise working space for laparoscopic pyeloplasty in infants.Methodology:All infants who underwent laparoscopic pyeloplasty for unilateral pelvi-ureteric junction obstruction (PUJO) between January 2017 and March 2020 were included in the study. The patient cohort was divided into two groups: Group A and B. Group A included patients who underwent routine pre-operative preparation. Group B included patients wherein the SGPGI protocol was used. The key features of the protocol were fasting for 8 h, enemas, inserting a nasogastric tube in the pre-operative period and decompressing the colon on the operation table. Demographic features, pre-operative, intraoperative and post-operative parameters were compared between the two groups.Results:A total of 26 infants with unilateral PUJO underwent laparoscopic pyeloplasty during the study period. Group A included 12 patients and Group B included 14 patients. Both the groups were similar in age, weight and sex distribution. The median surgeon's rating score for suturing conditions was 2 for Group A and 5 for Group B patients (P > 0.05). The operating time was significantly longer in Group A (196 ± 21 min) as compared to Group B (114 ± 18 min) (P < 0.05). In Group A, intra-abdominal pressure (IAP) varied between 9 and 14 mmHg (median 12 mmHg), while in Group B, IAP varied between 6 and 9 mmHg (median 8 mmHg) (P < 0.05). In Group A, in 2/12 cases (16.7%), conversion to an open procedure was necessary because of inadequate working space owing to gross intestinal distension. Two patients in Group A also had intraoperative injuries to adjacent structures due to poor working space.Conclusions:Optimal working space is critical to the performance of advanced laparoscopic surgery like pyeloplasty in infants. SGPGI protocol significantly improves working space, which permits a faster and safer surgery with a lower intra-abdominal working pressure. This protocol is simple, safe and easy to replicate at most centres in our country.

A systematic review and meta-analysis of conventional laparoscopic versus robot-assisted laparoscopic pyeloplasty in infants

While there are several reports confirming the safety and efficacy of laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children there have been none comparing LP and RALP specifically in infants. In this meta-analysis, we have compared the outcomes of LP and RALP in infants. Pubmed (Medline), Publon, Index Medicus and Embase were searched using the search terms: pyeloplasty (laparoscopic OR robot-assisted) AND (infant), to identify all papers pertaining to LP and RALP. Systematic review was performed to identify information regarding number of patients/renal units, age, body weight, operating time, hospital stay, success and complications. Meta-analysis of heterogeneity was reported with I2statistics. Once heterogeneity was found low, the pooled outcomes were compared with student's t test and Fishers exact test, wherever appropriate. After screening a total of 267 articles, 18 articles were included (10 articles on LP, 7 on RALP, 1 reporting both), comprising 323 renal units for LP and 173 renal units for RALP. With low heterogeneity (I2: 0%) both groups were considered to have been conducted under similar conditions for fixed effect model. There was no significant difference between the success rates of LP or RALP (97.5% vs 94.8%; p=0.21). The mean age at operation was significantly lower for LP (5.6±1.8 months) than RALP (7.2±1.2 months, P=0.0001). The duration of surgery was 137±45min for LP while significantly higher at 179±49min for RALP (p=0.0001). The mean (s.d) time to discharge was 2.0 (1.9) days for LP while 1.3 (0.4) days for RALP. The overall complication rate was significantly higher (summary table) for RALP than LP (p=0.03), mainly due to more port-site hernias in RALP. In the present study, we found that the success of LP and RALP in infants was similar. RALP in infants had longer duration of surgery, similar hospital stay and higher Clavien-3 complications than LP. While several studies have reported favorable outcomes for RALP over LP in children, this was not the case in infants. The smaller workspace, in an infant, can significantly limit the mobility of robotic instruments and increase the chance of port-site conflicts or trocar collisions. The use of larger robotic ports and instruments in the small space of infant abdomen might have been responsible for higher complications in RALP, including significantly larger number of port-site hernias. This meta-analysis represents the early experience of most RALP in infants, and it is possible that with experience RALP outcomes in infants also will catch up with LP. Miniaturization of robotic instruments might render RALP the future standard of care for pyeloplasty in infants.

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.

MORPHOFUNCTIONAL OUTCOMES OF LAPAROSCOPIC PYELOPLASTY IN INFANTS OF THE FIRST THREE MONTHS OF LIFE

Introduction. This study describes authors’ experience in performing laparoscopic pyeloplasty in infants whose age does not exceed 3 months of life, and compares pre- and postoperative results of these surgeries in order to answer the question - does the laparoscopic technology for the treatment of hydronephrosis in newborns and infants provide acceptable results based on improving kidney morphology and function? Material and methods. 105 children, aged 3 months, were enrolled into this retrospective study who for 8 years, since 2012, have been laparoscopically operated on for congenital hydronephrosis. Because of bilateral renal damage, a total of 110 surgeries were performed, including simultaneous pyeloplasty in 5 patients. All patients had dismembered pyeloplasty with the Anderson-Hynes technique via transparietal laparoscopic access. Indications for surgery were: decreased renal function with obstruction signs of urine outflow from the pelvis confirmed by radioisotope renography; a combination of reduction of parenchyma thickness and increase of pelvis diameter at serial ultrasound studies; or a combination of these pathologies with urinary tract infection. During the trial, the following parameters were recorded: demographic data, findings of perioperative diagnostic examinations, surgical details, recovery process after surgery and long-term consequences. Results. The average age of patients was 50.24 days. Of 105 patients, 60 (57.14%) were less than 1 month old, and the remaining 45 (42.86%) were 1-3 months old. Gender distribution in groups was as follows: m / f = 73:32. Unilateral operations on the left kidney were in 61.82% patients, on the right kidney - in 33.64% patients. 4.54% patients had bilateral pyeloplasty. Average duration of surgery was 73.07 minutes (40-120 minutes). The average length of hospital stay was 4.19 days (2-9 days). At the early postoperative period, 4 (3.6%) patients developed postoperative complications - urinoma formation. A comparison of pre- and postoperative renal morphometry findings by ultrasound and Doppler ultrasound examination showed a significant decrease of renal pelvis dimensions and improved renal blood flow. The pelvis size decreased in average from 23.5 to 5.5 mm (p = 0.001), and RI from 0.72 to 0.64 (p = 0.001). Functioning of the operated kidney, as showed by the radioisotope renography, improved from 34 to 45.27 (p = 0.001). Long-term follow-up observation revealed one relapse of the disease (0.9%) - stenosis of pyeloureteral anastomosis which required a repeated laparoscopic pyeloplasty. One patient (0.9%)/ who was under follow-up observation for 36 months, had deterioration and loss of kidney function without signs of renal obstruction at the level of pyeloureteral segment which required laparoscopic nephrectomy. Thus, taking into account one relapse and loss of kidney function in one patient, we can state that the effectiveness of laparoscopic pyeloplasty in our study was 98.2%. Conclusion. Summarizing results of the applied laparoscopic pyeloplasty in the youngest group of patients whose age does not exceed 3 months of life, it can be stated that the minimally invasive approach contributes to normalizing morphological and functional parameters of kidney.

Laparoscopic Pediatric Pyeloplasty: Trends in Regions of the Russian Federation

Introduction. The use of minimally invasive surgery of urteropelvic junction obstruction was started in the in the mid-90s of the last century. Replacement rates of open surgery and methods of the minimally invasive surgery are different in various countries. We analyzed the spread of minimally invasive technologies in some regions of the Russian Federation.Purpose of the study. To study the dynamics of replacement of open pyeloplasty with laparoscopic pyeloplasty in certain regions of the Russian FederationMaterial and methods. Available data included the annual number of laparoscopic and open pyeloplasties, patient age, complications, and medium-term results. Our analysis screened 1581 pyeloplasties, which were performed during 2004‒2018 in eight regions of the Russian Federation. The patients were separated into two groups according to age. There were 566 infants and 1015 older children. A total 908 (57.4%) laparoscopic pyeloplasty (LP) and 673 (42,6%) open pyeloplasty (OP) were performed. Of those patients who underwent laparoscopic pyeloplasty, 274 (48.4%) were infants, while 624 (61.5%) were older children. The rates of LP and OP use were then assessed according to year of surgery. A binary logistic regression model was used to evaluate the statistical significance of the rate of LP use over time, to predict postoperative complications and to compare the effectiveness of LP in comparison with OP.Results. The use of LP increased remarkably during the study period. In regions with 5 years of LP experience, LP utilization rate was significantly higher. The rate of LP in infants has been associated with increasing experience in the LP. A total, 70% of older children and 59% of infants were operated with LP in 8 regions in 2018.Conclusion. In some regions of the Russian Federation, the rate of LP is markedly increased and almost replaces open surgery. In regions where LP has been introduced over the past 5 years, the replacement rate is higher than in regions where LP was introduced before.

Comparison of Robotic Pyeloplasty and Standard Laparoscopic Pyeloplasty in Infants: A Bi-Institutional Study.

To compare outcomes between robotic pyeloplasty (RP) and standard laparoscopic pyeloplasty (LP) in the infant population for the treatment of ureteropelvic junction (UPJ) obstruction. We performed a retrospective cohort study of all children under 1 year of age who underwent RP or LP at two different medical centers between October 2009 and February 2016. Patient demographics, perioperative data, complications, and results were reviewed. Thirteen patients underwent standard LP, and 21 patients underwent RP during the study period. Median age and median weight at time of operation for the whole cohort were 6.1 months and 7.9 kg. Surgery success rates were similar with 95% and 92% in RP and LP, respectively. There was no statistically significant difference in operating time between the 2 groups, with a median time of 156 minutes in RP (range 125-249) and 192 minutes (range 98-229) in standard LP (P = .35). Median length of hospital stay was significantly shorter in the robotic group with a median stay of 1 day (range 1-3) and 7 days (range 7-12) in the standard LP group.(P < .0001) Drains or nephrostomy tubes were used more often in the laparoscopic group (100%, 13/13) as opposed to RP (9.5%, 2/21, P < .0001) There was a comparable complication rate between the 2 groups, 30.8% for LP and 23.8% for RP (P = .65). The minimally invasive dismembered pyeloplasty is safe and effective in the infant population and produces high success rates. The results, complication rates, and operative time were comparable between the two surgical methods while the standard LP demonstrated longer hospital stay. Both the robotic approach and the LP can be successfully utilized for the benefit of infants with UPJ obstruction.

A Modified Antegrade Stenting Technique for Laparoscopic Pyeloplasty in Infants and Children

Objective: There are 2 critical steps of stent placement during laparoscopic pyeloplasty (LP) in children. Introduction to the ureteropelvic junction and passing through the ureterovesical junction. We aimed at overcoming those 2 steps by creating a modified technique. Methods: Consecutive 27 children undergoing transperitoneal laparoscopic dismembered pyeloplasty by a single surgeon were prospectively enrolled into this study. The modifications of our technique are using an Amplatz dilator and a closed tip stent. Results: The mean age of the children was 6.7 (range 4 months-17 years). The mean time of stent insertion was 2.7 ± 2.0 (2-6) min and the operative time was 128.3 ± 17.6 (90-180) min. The mean number of days of hospital stay was 2.0 ± 0.4 (1-3). After a mean follow-up period of 20.3 ± 4.2 (14-30) months, no operative failure was detected. Conclusion: Our modified technique is a completion of the current armamentarium for stent placement during LP in infants and children.

Laparoscopic pyeloplasty in infants: Single-surgeon experience

Although laparoscopic pyeloplasty (LP) is popular in children, its role in infants is less well defined. It is presumed that infant LP is technically challenging, with a higher failure rate. To consider the hypothesis that LP can be safely and successfully performed in infants. The records of 111 infants that underwent LP from March 2009 to December 2013 with at least 1 year of follow-up, were retrospectively reviewed. The results of pre- and postoperative imaging studies (ultrasound (US) and diuretic renogram (DR)), operative details and complications were noted. Pre- and postoperative parameters were compared using statistical software. The details are given in the Table. Laparoscopic pyleoplasty was successfully completed using three ports in all children without any open conversions. There were complications in 14 children (12%); 13 did not require a second intervention and the final outcome was not affected. One child (1%) had a re-obstruction with worsening hydronephrosis (HDN) 2 months after stent removal; she underwent successful redo LP. Median follow-up was 2 years; LP was successful in relieving the obstruction in 115 kidneys (99%); all had follow-up US, while 76 children had follow-up DR. The tests showed significant reduction in HDN (mean pre-operative anteroposterior diameter (APD) of renal pelvis, 34.4 mm (SD 13.4) versus mean post-operative APD 10.6 mm (SD 5.7), p < 0.001) and improved drainage in all kidneys. In unilateral cases, there was significant improvement in mean split renal function (SRF) of the operated kidneys (pre-operative 22.1% (SD 8.6) versus post-operative 35.6% (SD 11.4), p < 0.001). Over the past 6 years, all pyeloplasties at our unit have been performed by laparoscopy, irrespective of the age or weight of the child. In this large retrospective series, it is demonstrated that infant LP is a safe and successful operation; pyeloplasty in this age group not only resulted in significant reduction of hydronephrosis, but also in significant functional improvement. The results are comparable to published series comparing open pyeloplasty to laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70 to 96%, and complication rates ranging from 0 to 24% for open pyeloplasty.

Double J or Transrenal Transanastomotic Stent in Laparoscopic Pyeloplasty in Infants and Children: A Comparative Study and Our Technique

We compared our experience with intra- and extracorporeal stenting in laparoscopic transabdominal pyeloplasty in children and adolescents. As the placement of transanastomotic stents during laparoscopy can be difficult, we developed a technique for laparoscopic transrenal stent placement. Eighty-six consecutive patients who underwent laparoscopic transabdominal pyeloplasty in our institution from December 2003 to November 2012 were retrospectively analyzed. Initially we antegradely placed the double J catheter (n=48), whereas in later patients transrenal/transcutaneous stents were inserted (n=38), either via a cannula from the flank (n=33) or from the inside-out by transrenal puncture using a specially constructed spear (n=5). End points of the analysis were stent-related technical problems and complications and the need for reoperation. Sixty-two boys and 24 girls with a mean age of 5.6 years (range, 78 days-17.3 years) and mean weight of 22.1 kg (range, 5.5-71 kg) underwent laparoscopic transabdominal pyeloplasty. The most common technical problem in the double J group was inability to place the double J catheter in 9 of the 48 patients. In combination with other complications such as dislocations, urinary tract infections, or catheter occlusions, this led to an overall complication rate of 35% in the group that underwent double J catheter insertion versus 13% in the group with transrenal stenting (P<.05). In the whole series, 4 patients required a redo pyeloplasty, all of them in the double J group. We recommend transrenal stents to facilitate stent removal without general anesthesia and to minimize complications such as stent dislocation. The initial experience with our simple device for transrenal puncture and stent placement is promising.

Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Infants

Laparoscopic pyeloplasty and open pyeloplasty have comparable efficacy for ureteropelvic junction obstruction in pediatric patients. The role of laparoscopic pyeloplasty in infants is less well defined. We present our updated experience with laparoscopic pyeloplasty in children younger than 1 year. We retrospectively reviewed the records of all 29 infants treated with transperitoneal laparoscopic pyeloplasty for symptomatic and/or radiographic ureteropelvic junction obstruction from May 2005 to February 2012. Patients were followed with renal ultrasound at regular intervals. Treatment failure was defined as the inability to complete the intended procedure, persistent radiographic evidence of obstruction and/or the need for definitive adjunctive procedures. Transperitoneal laparoscopic pyeloplasty was performed in 29 infants 2 to 11 months old (mean age 6.0 months) weighing 4.1 to 10.9 kg (mean ± SD 7.9 ± 1.6). Followup was available in all except 5 patients (median 13.9 months, IQR 7.7-23.8). Mean operative time was 245 ± 44 minutes. All cases were completed laparoscopically. Three postoperative complications were reported, including ileus, superficial wound infection and pyelonephritis. Two patients had persistent symptomatic and/or radiographic evidence of obstruction, and required reoperative pyeloplasty. The overall success rate was 92%. Laparoscopic pyeloplasty in infants remains a technically challenging procedure limited to select centers. Our early experience revealed a success rate comparable to that of other treatment modalities with minimal morbidity.

A simple technique of ureteric spatulation & handling during laparoscopic pyeloplasty in infants & children

Laparoscopic pyeloplasty is being performed successfully in children with results comparable to open pyeloplasty. Pediatric laparoscopic pyeloplasty, however, remains a technically demanding procedure. Some of the most difficult, time-consuming, and at the same time critical steps of the procedure are ureteral spatulation and intracorporeal suturing of the anastomosis [1,2,3]. It is also preferable to avoid grasping the ureter with any instrument. The difficulty of ureteral spatulation has led to the development of some technical modifications [1,2], including an ex-vivo spatulation technique [2]. In our own practice, we tried some modifications to overcome this challenging part of the procedure. We have finally developed a technique that simplifies this surgical step. This technique can be performed with simple conventional laparoscopic instruments and is easily reproducible.

Transperitoneal Dismembered Laparoscopic Pyeloplasty in Infants: Points of Technique

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

Transperitoneal Laparoscopic Pyeloplasty for Primary Repair of Ureteropelvic Junction Obstruction in Infants and Children: Comparison With Open Surgery

Pediatric laparoscopic pyeloplasty to treat ureteropelvic junction obstruction has been reported to decrease hospitalization stay and the analgesic requirement compared to open pyeloplasty. It is not clear if all age groups benefit from this procedure. We compared primary laparoscopic and open pyeloplasty in infants and children. We retrospectively reviewed the records of consecutive primary pyeloplasties at a single institution during a 4.5-year period. Demographic data, body measurements, presentation, indications for surgery, operation type, surgical time, complications, analgesia requirement, hospital stay and outcome were recorded. Patients were divided in the open pyeloplasty group of 41 and the laparoscopic pyeloplasty group of 37. The groups were similar with regard to sex and laterality. There were more patients 14 months or younger in the open pyeloplasty group. Mean surgical time was longer in laparoscopic pyeloplasty but it decreased significantly after the first 15 cases (each p <0.001). Hospitalization and postoperative analgesia requirements were similar in the 2 groups. There was a higher success rate for laparoscopic pyeloplasty in patients older than 14 months (p <0.05). In the open pyeloplasty group there were more re-interventions as well as a trend toward more complications and readmissions. Transperitoneal laparoscopic pyeloplasty was performed safely in all pediatric age groups with minimal morbidity and excellent short-term results. In our experience laparoscopic pyeloplasty in infants and children is more difficult and time-consuming surgery than open pyeloplasty. However, it may provide a better outcome with fewer complications and better cosmesis. Prospective studies are needed to confirm these results.

Laparoscopic Dismembered Pyeloplasty in Children Younger Than 2 Years

Since the first laparoscopic pyeloplasty was described in a child in 1995, there have been several reports of pyeloplasty in older children. However, to date there have been few reports of laparoscopic pyeloplasty in infants and toddlers. The aim of this study was to evaluate the results of laparoscopic pyeloplasty in children younger than 2 years. All laparoscopic Anderson-Hynes pyeloplasties performed in children younger than 2 years were retrospectively reviewed. The diagnosis of ureteropelvic junction obstruction was confirmed on renal sonography and diuretic renogram. Laparoscopic pyeloplasties were performed via a transperitoneal route as originally described, with key modifications. All children were investigated with postoperative diuretic renogram and renal ultrasonography. A total of 38 children with ureteropelvic junction obstruction underwent laparoscopic Anderson-Hynes pyeloplasty between January 2001 and December 2005. Of these patients 11 (7 males and 4 females) were younger than 2 years at surgery (median 1.4, range 2 to 22 months) and 1 had bilateral ureteropelvic junction obstruction, for a total of 12 primary repairs. However, 2 patients (17%) required redo laparoscopic pyeloplasty, for a total of 14 laparoscopic dismembered pyeloplasties in this age group. Operative time ranged from 70 to 140 minutes (mean 100) and median hospital stay was 2 days. Followup studies showed normal drainage in all patients except 1, who after redo pyeloplasty exhibited significantly improved but still prolonged drainage. This study suggests that laparoscopic pyeloplasty can now be performed in young children with good results.