Ureteropelvic Anastomosis Research Articles

Pelvi-ureteric junction obstruction in a case of horseshoe kidneys with lower pole crossing vessels:a rare case and its management

Pelvi-ureteric junction obstruction is one of the most common urological conditions found in children. Horseshoe kidneys are a predisposing factor and to find a vascular anomaly causing the obstruction is rare. A 2-year-old girl with two episodes of culture-positive febrile urinary tract infections (UTI), was found to have right sided hydronephrosis. Renal scan revealed decreased functioning of right kidney with scars. A contrast CT scan showed a horseshoe kidney with pelvi-ureteric junction obstruction on right side with dilatation of renal pelvis. During laparoscopic pyeloplasty, lower pole crossing vessels were detected, not reported on CT scan. A dismembered pyeloplasty with transposition of uretero-pelvic anastomosis anterior to lower pole vessels was done. Anomalous vasculature of kidney should be kept in mind during surgery in such cases. A dismembered pyeloplasty along with transposition of anastomosis is necessary to prevent recurrence.

Comparative Study between Continuous and Interrupted Suturing in Laparoscopic Pyeloplasty

Background: Ureteropelvic junction obstruction (UPJO) is a common cause of symptomatic ureteral obstruction. Dismembered pyeloplasty is the most commonly employed procedure for the repair of UPJO. Both interrupted and continuous suturing is being practiced in laparoscopy. As satisfactory anastomosis determines the success of dismembered pyeloplasty and recovery of renal function, the success rate and the complications associated with the suturing technique need to be evaluated. Objective: To compare the outcome between continuous and interrupted suturing in laparoscopic pyeloplasty. Methods: This hospital-based, quasi-experimental study was done in the Department of Urology, Dhaka Medical College Hospital (DMCH), Dhaka and the National Institute of Kidney Diseases & Urology (NIKDU), Dhaka from July 2022- June 2023. A total of 60 patients were purposively selected for the study. According to the suture method for ureteropelvic anastomosis, patients were divided into two groups: 30 patients (group A) underwent surgery with the continuous suture method, and 30 patients (group B) underwent surgery with the interrupted suture method. Data on suturing time, post-operative drain output, post-operative hospital stay and post-operative complications were collected. Patients were followed up at 01, 03 and 06 months. At 06 months, a DTPA renogram with split GFR was done to evaluate the patients. Results: The mean ages were 30.0 (±8.3) years for Group A and 33.9 (±9.3) years for Group B, with males comprising 56.7% and 63.3% of each group, respectively. Group B had significantly higher mean suturing time, post-operative drain output, and hospital stay compared to Group A (p<0.001). No significant differences in GFR were noted between the groups (p>0.05). Post-operative complications were observed in 10.0% of Group A and 23.3% of Group B (p=0.166). Conclusion: Continuous suturing technique for pyeloplasty is found to have a lower mean suturing time, mean drain output and post-operative hospital stay.

Low anterolateral incision for single-port extraperitoneal robot-assisted pyeloplasty: description of technique and initial experience

PurposeThis study aims to describe the surgical steps for the single-port low anterolateral extraperitoneal approach to pyeloplasty, report its feasibility, and share the initial outcomes of our experience.MethodsWe analyzed all consecutive patients who underwent single-port low anterolateral extraperitoneal pyeloplasty due to ureteropelvic junction obstruction (UPJO). The surgical steps included a pure single-port approach through a 3.5 cm low anterolateral incision two fingerbreadths above the superior pubic ramus. The ureter was localized and followed cranially, a dismembered pyeloplasty was performed, and a running ureteropelvic anastomosis was completed. No drains were placed. The urinary catheter was removed upon discharge, and the ureteral stent after 3–5 weeks.ResultsA total of eight cases (two adults and six children) were completed successfully, without complications or conversions. Median operative time, console time, and estimated blood loss were 208.5 min, 114.5 min, and 10.0 ml, respectively. All patients were discharged within 24 h, except for one that required urinary output observation due to retention. There were no major postoperative complications. The median pain score at discharge was 0/10. Only one patient was prescribed PRN opioids at discharge. The readmission rate was 0.0%. All patients were asymptomatic on their last follow-up with no definitive obstruction on imaging, and no requirement for additional procedures or stents.ConclusionSingle-port low anterolateral extraperitoneal pyeloplasty is a feasible alternative for surgical treatment of UPJO in adult and pediatric patients with improved recovery outcomes.

Comparative analysis of suturing technique in pediatric pyeloplasty on surgical outcomes.

Pyeloplasty for ureteropelvic junction obstruction is the gold standard for surgical repair. There are currently no reports outlining optimal suturing technique. This paper compares the effect of suturing technique in dismembered pediatric pyeloplasty (open and laparoscopic) on post-operative outcomes. A non-concurrent cohort study assessed different suturing techniques in both open and laparoscopic dismembered pyeloplasty performed two senior urologists at a tertiary referral pediatric center. Cases were stratified according to different suturing techniques for ureteropelvic anastomosis and subgroup analysis was performed according to open or laparoscopic approach. A total of 185 renal units were evaluated. The overall comparative analysis of different anastomotic suturing techniques and clustered analysis according to open and laparoscopic approach showed no significant differences on post-operative complication rate, leakage, stenosis, redo-pyeloplasties, operative time and hospital stay. There was a significant difference between suturing techniques on stent duration, age and weight of the patient. There was no effect of suture type or size on post-operative complication rate, leakage, UPJ stenosis and redo pyeloplasty rates, however, sample sizes were small. Suturing technique has no significant effect on the surgical outcomes assessed regardless of open or laparoscopic technique.

A Rare Cause of Hydronephrosis: Retrocaval ureter

Retrocaval ureter is a rare congenital anomaly that can cause hydroureteronephrosis. The right ureter winds posterior to the inferior vena cava and then continues to cours anteriorly due to abnormal embryogenesis of vena cava. Retrocaval ureter is seen mostly on the right side except patients with situs inversus. Although retrocaval ureter is a congenital disease, patients become symptomatic during the third or fourth decade of their lives. Flank pain, hematuria, upper tract urinary infections and urolithiasis are the symptoms can be seen. Ultrasound can show the dilation of the kidney but it is far from accurate diagnosis. Retrocaval ureter is diagnosed with intravenous pyelography (IVP), computed tomography urography (CTU) and magnetic resonance urography (MRU). Mild hydronephrosis with good excretory times can be followed without surgical intervention. But severe hydronephrosis with symptoms should be corrected with surgery. The surgical treatment involves excision of the retrocaval part of the ureter then bringing it anterior to the vena cava followed by ureteroureteral or ureteropelvic anastomosis. Open, laparoscopic and robotic surgeries are the different treatment modalities. Transperitoneal and retroperitoneal approaches are different options for the surgery. In this paper we report a retrocaval ureter case managed with laparoscopic ureteroureterostomy.

185 Vascular Hitch Procedure for Accessory Lower Pole Vessels

Abstract Introduction The gold standard procedure for pelvi-ureteric junction obstruction has been the Anderson-Hynes dismembered pyeloplasty; involving the repositioning of the ureter and ureteropelvic anastomosis. However, the Hellstroem 'Vascular Hitch Procedure’ dictates the superior translocation of the accessory vessel and its fixation to the anterior pelvic wall. The latter has an estimated success rate >90%. Method During 2016-2020, at Leicester Royal Infirmary, 16 operations occurred on paediatric patients with pelvi-ureteric junction obstruction. The dismembered pyeloplasty was performed on 5 patients, 9 patients underwent the vascular hitch procedure, and 2 patients are currently awaiting the latter operation. All patients had a pre-operative functional magnetic resonance urography (fMRU) to identify and localise the accessory lower pole vessel. Results The mean hospital stay for the vascular hitch procedure was 1.5 days (range=1-2) in comparison to 4 days (range=3-5) for the dismembered pyeloplasty. The follow-up period ranged from 6 months to 3 years. Overall, it was noted that the patients were asymptomatic, had markedly reduced hydronephrosis on imaging as well as stable renal function noted on the MAG 3 renogram scan. Conclusions The laparoscopic vascular hitch procedure appears to be the superior operation for the management of pelvi-uteric junction obstruction as the patients had notably reduced hospital stay lengths.

Needle Loss in Minimal Invasive Surgery Is a Real Challenge: Innovative Technique for Retrieval

Introduction: Intraoperative retained needles is reported to be ~0.06% to 0.11% with its consequence medical and ethical significance.1 Such small needles can be detached from the sutures and fly away from the limited laparoscopic vision or hidden between bowel loops that makes its localization and retrieval extremely difficult even in the hands of best experienced surgeons.2 However, intraoperative radiographic images maybe used in detecting lost needle; smallest needle <13 mm can be unhelpful.3 Kandioler-Eckersberger et al. reported two cases in which a novel laparoscopic magnetic retrieval device was utilized along with fluoroscopy in retrieval of broken fragments without the need to convert to open surgery.4 Herein, we demonstrate an innovative technique in retrieving a small suture needle that was lost during robotic pyeloplasty. Methods and Materials: This is a 7-year-old boy who was recently found to have left-sided pelviureteral junction obstruction after frequent emergency department visits with colicky abdominal pain. Ultrasonography and nuclear scans showed high-grade hydronephrosis with an obstructive curve; therefore, he was posted for robotic pyeloplasty. During the procedure and while doing the ureteropelvic anastomosis through 6/0 polydioxanone suture, the needle detached from the suture and was lost from the camera vision. At the end of the procedure, exploration of the abdominal cavity was accomplished through laparoscopic camera without the ability to detect the small needle. We used the retrieval device of the magnetic Double-J stent that consists of Tiemann-type with 15F diameter and magnet through one of the working ports and started to scan the abdominal cavity in systemic way under supervision of the laparoscopic camera. This magnetic retrieval device is semifixable that does not damage the intra-abdominal organs and has a strong magnetic power that can attach with metallic foreign bodies such needles efficiently. Results and Conclusion: The lost small needle was retrieved easily and safely without the need for conversion to open surgery or exposure to radiation. The innovative technique of using the magnetic retrieval device of Double-J stents as an intracorporeal laparoscopic device can be a valid and safe alternative in the retrieval of small metallic objects such as needles. Source of the study: A clinical case was encountered during practice. No competing financial interests exist. Runtime of video: 3 mins 54 secs

Simulated training model of ureteropyelic anastomosis in laparoscopic pyeloplasty.

Purpose:To develop a model for simulated training of ureteropyelic anastomosis in laparoscopicpyeloplasty.Methods:Longitudinal and experimental study, with 16 participants. A synthetic instrument was produced to simulate the renal pelvis and the proximal portion of the ureter positioned on a platform within laparoscopic simulators, thereby resulting in the realistic simulation of the ureteropelvic anastomosis. A step-by-step guide was also developed for the accomplishment of the ureteropelvic anastomosis training model.Results:In the evaluation of all participants’ suture training, a decrease was found in the time needed to perform the anastomosis, with a median of 17.83 min in the 1st step and 14.21 min in the last one (p = 0.01). Regarding the knots, in the 1st step, 5% of them were considered firm, with an evolution to 30% in the last step (p = 0.011).Conclusion:We noticed improvement in the ability to perform the ureteropelvic anastomosis by participants with no experience with it. Therefore, even unexperienced participants can improve their skills with this training. Moreover, we observed the effectiveness of the model use, confirmed by the participants’ opinion and its validation by expert surgeons.

Successful outcomes in laparoscopic pyeloplasty using knotless self-anchoring barbed suture in children

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in children has gained increasing importance over the last decade. Intracorporeal knot tying still remains a technical challenge for the surgeon. Self-anchoring suture incorporates a new concept for tissue approximation and reduces intracorporeal knot tying problems. There are very few reports on self-anchoring knotless suture and its application for laparoscopic pyeloplasty in children. We present our results of a series of consecutive children undergoing laparoscopic pyeloplasty with knotless barbed sutures. We prospectively evaluate 15 consecutive patients who underwent laparoscopic pyeloplasty with knotless barbed sutures (V-LocTM, Covidien) for ureteropelvic anastomosis. The decision of the operation was given by pediatric nephrology-urology-radiologic imaging diagnostic team, and all patients were operated by a single surgeon. Pyeloplasty was performed without pelvic reduction, and the anastomosis was made by barbed sutures using running fashion. The mean age of the patients were 5.39 (3 months-17 years). Two cases had undergone a right-sided pyeloplasty, and thirteen had undergone a left-sided pyeloplasty. The duration of the operative procedure was 60-110min. Neither intraoperative nor postoperative complication was encountered in any of the cases. Patients were followed by ultrasonographic evaluation. The anteroposterior diameter (AP) diameter of renal pelvis and hydronephrosis grade Society for Fetal Urology (SFU) are significantly different when compared with pre-operative and postoperative period (p=0.001 and p=0.001, respectively). Owing to the renal parenchymal thickness change by age pre-operative and postoperative thickness comparison is adjusted by age, because age is considered as a covariate (confounder variable). We observed statistically significant (p=0.003) difference in parenchymal thickness in all cases. Follow-up periods of the 15 consecutive pediatric pyeloplasty cases were 6-54 months. In the present study, successful outcome of the laparoscopic pyeloplasty using barbed suture was shown for the first time in children in literature. We believe that successful outcome of laparoscopic pyeloplasty could be achieved by eliminating knots and less manipulation on the wound edge also minimizes tissue injury during the procedure.

Proximal ureteral atresia in a duplex kidney with preserved renal function: A case report and review of literature

Ureteral atresia is a rare congenital anomaly and is usually associated with renal dysplasia. Distal atresia is more common and other associated urinary anomalies are rare. We report a case of an eight year old boy who presented with left flank pain and vomiting. Ultrasound abdomen and pelvis and renal scinitigraphy were suggestive of hydro-ureteronephrosis with obstructed drainage. He was suspected to have ureteric stricture and taken up for surgery. Cystoscopy and retrograde pyelogram revealed an incomplete duplication with lower moiety ureter ending blindly. Exploration of left renal fossa showed a duplex anomaly with normal upper moiety and hydronephrosis of lower moiety with an ureteric stump. Ureteropelvic anastomosis was done between the dilated renal pelvis and the blind ending ureter. Patient was doing well post operatively with good function in both moieties. Review of literature shows only two previously reported cases of proximal ureteric atresia. Preservation of renal function in an older child has also been reported only once. Ureteral atresia is usually diagnosed intra-operatively and various reconstruction options are available in patients with preserved function.

A New Touchless Technique for Suturing in Transperitoneal Laparoscopic Pyeloplasty.

The most difficult, time-consuming, and critical steps of laparoscopic pyeloplasty (LPP) are ureteral spatulation, apical ureteral stitch placement, and ureteropelvic anastomosis. To simplify these critical steps, avoid the risk of ureteral shortening, and also minimize ureteral manipulation, we present a modified dismembered technique for suturing with the outcome of patients who underwent LPP using this technique. This study included 23 patients who were candidates for transperitoneal dismembered Anderson-Hynes LPP. The ureter was partially cut just below the ureteropelvic junction. The ureter was spatulated at its lateral aspect to cross the obstruction site and reach the normal ureter. The renal pelvis was obliquely cut equal to the size of ureteral spatulation. The ureter and pelvis were still connected partially. At this point, the first stitch was placed between the lower point of the spatulated ureter and the lowest corner of the renal pelvis. Anastomosis was performed by running sutures. No cases of internal organ injury and no cases of open surgery conversion were encountered. The radiologic success rate was 96%. After operation, in 1 patient, obstruction still existed and the patient underwent nephrectomy due to a nonfunctional obstructive kidney. This modification preserves total ureteral length and facilitates spatulation and suturing in transperitoneal laparoscopic dismembered pyeloplasty. The results showed that it is a useful method, especially for less-experienced surgeons.

Retrocaval ureter a rare cause of intermittent right flank pain in a 37 years old lady

A 37 years old female presented with 6 months history of intermittent right flank pain. She was otherwise fit and had no other complaints. Her lab investigations were normal. Abdominal ultrsonography revealed moderate hydronephrosis and proximal hydroureter but no calculus. Retrograde ureteropyelography findings were consistent with the diagnosis of retrocaval ureter, a rare clinical condition. Surgical exploration confirmed the presence of right retrocaval ureter. The ureter was transected and transposed anterior to inferior vena cava and ureteropelvic anastomosis was performed. Postoperative recovery was uneventful.

Retrospective comparison of outcomes of laparoscopic pyeloplasty using barbed suture versus nonbarbed suture: A single-center experience.

Introduction:laparoscopic pyeloplasty is an important tool in urology armamentarium. The most important & also the difficult part of this surgery is intracorporial suturing and knotting. There are only a few reports of knotless Barbed sutures for upper tract reconstruction. We report the comparative outcomes of Laparoscopic Pyeloplasty with barbed suture vs non barbed sutures used for uretero-pelvic anastomosis.Materials and Methods:We retrospectively reviewed patients' records that underwent Laparoscopic pyeloplasty at our Institution from January 2013 to May 2014. Total 37 patients were underwent LP in this period. Whole of the procedure was same as conventional LP except suture material. 3-0 barbed suture was used in 21 patients and 3-0 vicryl used in 16 patients for uretero-pelvic anastomosis and continuous suturing technique was employed. Patients' demographics, total operative time, intracorporial suturing time, post operative complications, symptoms & renal isotope scan were recorded.Results:Average total operative time was significantly less in barbed suture group vs vicryl group (162 vs 208 minutes) (p=0.0811). Average time taken for intracorporial suturing was 31.2 minutes vs 70 minutes (p=0.0576). 1 patient developed post operative urine leak which persisted for 5 days in barbed group (4.76 %) vs no leak in vicryl group. Most common complication was UTI presented in 2 patients (9.5 %) vs 2 in vicryl (12.5%). JJ stent was removed at 4 weeks. Median follow up was 3 months with 7 patients lost to follow up. None of the patients found to have obstructive drainage or deterioration of split function on follow up isotope renogram at 3 months.Conclusions:In this study, Laparoscopic pyeloplasty with barbed suture has acceptable outcome when compared to conventional non barbed suture on short term basis. Laparoscopic Pyeloplasty with barbed suture can potentially become the standard approach in near future.

The application of retrograde pyelography in the diagnosis of traumatic ureteropelvic junction disruption in children

Objective To explore the application of retrograde pyelography with traumatic ureteropelvic junction disruption in children. Methods A retrospective study was conducted for a total of 26 children with doubt of traumatic UPJ disruption in image from 2009 January to 2017 September. There were 19 males and 7 females with a mean age of 5.4 (1-11) years. And the causes were traffic accident (n=15), fall injury (n=4) and fall damage (n=7). Ultrasound and CT examination indicated different degrees of urinary extravasation in all cases. Enhanced CT delayed imaging had no ureteral enhancement, and could not specify whether UPJ was disrupted. All the patients underwent retrograde pyelography through cystoscope under the general anesthesia. If the retrograde tube entered the renal pelvis smoothly, and the ureter and renal were complete, which was considered to be renal injury. If it was difficult for the tube to reach the UPJ, and the ureteral blind end was shown by contrast angiography, UPJ fracture was considered. Results UPJ was not broken in 9 patients (34.6%), and the peritoneal urine was gradually absorbed after conservative treatment. Retrograde pyelography showed no sign of kidney in 16 cases (61.5%). UPJ disrupture was considered and performed renal exploration. These 16 cases were all confirmed as UPJ disrupture during operation. 15 patients underwent ureteropelvic anastomosis, 1 patient underwent ureteral anastomosis by using appendix because of long segment defect, and intravenous pyelography after surgery showed that the ureter was unobstructed. Urinoma but not renal was enhanced in 1 patient (3.9%). One case (3.9%) retrograde pyelography showed the perirenal urinary cyst was enhanced, the kidney was not enhanced, and the possibility of UPJ fracture was considered .But this patient was confirmed UPJ not disrupted in the operation and underwent pyeloplasty. Intravenous pyelography showed no contrast agent extravasation after surgery. The sensitivity and specificity of retrograde pyelography in this group were 100% (16/16) and 90% (9/10), respectively. Conclusions The sensitivity and specificity of retrograde pyelography were higher, and retrograde pyelography was reliable and irreplaceable in the early diagnosis of UPJ disrupture. Key words: Retrograde pyelography; Ureteropelvic junction disruption; Traumatic; Children

W-type suture in Anderson-Hynes laparoscopic pyeloplasty: a novel approach to an old technique.

IntroductionAnderson-Hynes (A-H) dismembered pyeloplasty has remained nearly unchanged since its introduction in 1949. The authors present a modification of the uretero-pelvic anastomosis as described by Anderson and Hynes. The new approach, called the W-type suture, is thought to be more watertight and associated with fewer complications than the original.AimTo assess the effectiveness of the modification of Anderson-Hynes dismembered pyeloplasty named the W-type suture.Material and methodsThe research is a retrospective study of 99 patients who underwent laparoscopic A-H pyeloplasty. In 49 patients unmodified laparoscopic A-H pyeloplasty was carried out. Fifty patients underwent laparoscopic A-H pyeloplasty with the anastomosis made using the aforementioned W-type suture. To assess the effectiveness of the W-type suture, we compared urine leakage duration – a direct indicator of anastomosis tightness – and frequency of postoperative complications.ResultsThe mean duration of urinary leakage was 3 ±1.16 days for the W-type suture anastomosis group and 3.57 ±1.14 days for the unmodified A-H pyeloplasty group (p < 0.05). The frequency of post-operative complications did not statistically significantly differ between the groups except for fever (18.4% vs. 4%; p < 0.05).ConclusionsThe analysis of the collected data showed that the W-type suture might be a promising alternative to a traditional approach of performing the ureteropelvic anastomosis. Further research should be done to minimize biases present in this study, which might have influenced our results.

Robotic Postanastomotic Dismembered Pyeloplasty in Ectopic Pelvic Kidney in an Adolescent—Technical Nuances

Introduction and Objective: Laparoscopic dismembered Anderson–Hynes pyeloplasty (AHP) has a steep learning curve. Postanastomotic dismembered (PAD) pyeloplasty is a technical modification combining the ease of nondismembered with the excellent outcomes of dismembered pyeloplasty. The addition of dexterity of the robotic endowrist to this technique ensures replication of gold standard open AHP. Herein we present a case of robotic PAD pyeloplasty in a malrotated ectopic pelvic kidney in an adolescent. Methods: A 16-year-old male presented with pelviureteral junction obstruction in left ectopic pelvic kidney. A preoperative three-dimensional reconstruction of the complicated vascular supply and pelvic anatomy was created using contrast enhanced CT of kidney, ureter, bladder. Robotic PAD pyeloplasty was performed by initial partial division of the dilated pelvis and ureteral spatulation without dismembering the ureteropelvic junction. Both layers of ureteropelvic anastomosis are completed before dismemberment. Results: The estimated blood loss was 50 mL, console time was 60 minutes, and hospital stay was 3 days. Conclusions: The PAD technique has several practical advantages such as preserving orientation, providing a tissue handle for traction, and decreasing the operative time. Effective application of robotic PAD to an ectopic pelvic kidney is dependent on familiarity with pelvic anatomy, optimal positioning and port placement, and preprocedure knowledge of the anomalous vascular anatomy. No competing financial interests exist. Runtime of video: 7 mins 37 secs

A modified technique of paraumbilical three-port laparoscopic dismembered pyeloplasty for infants and children.

Common causes of complications of laparoscopic pyeloplasty in children include anastomotic stricture, poor drainage due to high ureteropelvic anastomosis, and torsion of ureter. Herewith, we described our modified technique of paraumbilical three-port laparoscopic dismembered pyeloplasty (PTLDP) to minimize these complications. Data from 62 patients (age: 1-180months, median: 12months) with ureteropelvic junction obstruction (UPJO) who underwent pyeloplasty using our modified technique of PTLDP between February 2014 and September 2014 at our institution were reviewed. The key steps of our modified method involve identifying the lowest point of the renal pelvis and the lateral aspect of the ureter to guarantee a low pelviureteric and correct orientation anastomosis, and using a 4-0 silk for assistant suturing to avoid crushing of the anastomotic tissue. All surgeries were successfully completed without conversion. Three patients required an accessory port for the anastomosis. All the patients achieved complete clinical or radiologic resolution after the operation. The mean operative time was 103.4min, and mean estimated blood loss was 14.4mL. Mean postoperative differential function of affected kidney was 43.0±16.3% (range 24-100%), increased from 39.7±18.0% (range 18-100%), preoperatively (p<0.001). The success rate was 100% at a mean follow-up of 18.3±2.9 (range 13-25) months. Our modified technique of PTLDP is safe and feasible and to allow high success rate for the treatment of pelviureteric junction obstruction in children.

Successful Outcomes in Robot-Assisted Laparoscopic Pyeloplasty Using a Unidirectional Barbed Suture.

Intracorporeal suturing is considered to be the most challenging aspect of laparoscopic and robotic surgery. To overcome this problem, barbed self-retaining sutures have been effectively employed in various minimally invasive endourologic surgeries. However, the use of this suture has been recently cautioned for pyeloplasty due to a high failure rate. Our objective was to report our experience using barbed suture during robotic pyeloplasty. We retrospectively identified 13 consecutive patients who underwent robotic pyeloplasty with a barbed monofilament (4-0 V-Loc™) suture for the ureteropelvic anastomosis from 2011 to 2014. We compared these patients to 12 consecutive patients who underwent robotic pyeloplasty with a 4-0 nonbarbed suture from 2007 to 2011. We evaluated patient demographics, operative times, preoperative and postoperative symptoms, renal function, and diuretic renograms (DRG). Successful repair was defined as resolution of preoperative symptoms and/or T½ improvement on DRG to less than 20 minutes. The median age was 26 (interquartile range [IQR] 20.7-38) years and 35 (IQR 18.3-44) years for the barbed and nonbarbed suture groups, respectively. In the barbed suture group, preoperative DRG revealed ureteropelvic junction obstruction (UPJO) in 11 patients, equivocal UPJO (T½ 10-20 minutes) in one patient, and no obstruction in one patient. In the nonbarbed group, preoperative DRG revealed UPJO in 10 patients, equivocal UPJO in one patient, and no obstruction in one patient. In the barbed suture group, postoperative DRG was obtained in 11 patients, which showed no obstruction in 10/11 patients with 92% of patients experiencing symptom resolution. Similarly, postoperative DRG was obtained in 11 patients in the nonbarbed group, which showed no obstruction in 10/11 patients with 100% postoperative symptom resolution. In the largest series reporting use of V-Loc suture for robotic pyeloplasty, the V-Loc suture was safely and effectively used for robotic pyeloplasty repair.

Laparoscopic modified bypass pyeloplasty: a simple procedure for straightforward ureteral spatulation and intracorporeal suturing.

Bypass pyeloplasty (BP) is a simple, non-dismembered procedure that is a side-to-side anastomosis without dividing the ureteropelvic junction (UPJ). BP has been considered more suitable especially for novice surgeons than dismembered pyeloplasty via the laparoscopic approach, but not reported. However, the disadvantage of laparoscopic BP is that it is difficult to suture the side of the anastomosis that is far from the camera. To overcome this disadvantage, a modified technique was developed. This procedure and its initial results are reported. Twenty-six consecutive patients underwent laparoscopic modified BP. The patients' median age at surgery was 10.5 years. Ten patients were adults and 16 were children. The key step of modified BP involves dividing the UPJ after ureteral spatulation and suture of the dependent portion. This provides both better visualization of the anastomosis portion and easy anastomosis. All procedures were completed by laparoscopic modified BP. The median operative time was 246 (range 170-357) min. The median time for ureteropelvic anastomosis was 205 (range 145-311) min. There were no significant differences in mean operative time and ureteropelvic anastomotic time between adults and children (adults/children = 243 ± 49 min:252 ± 58 min, p = 0.66, 192 ± 33 min:214 ± 48 min, p = 0.21, respectively). Successful resolution of UPJO was observed in 96 % of cases. Laparoscopic modified BP combines the advantages of non-dismembered and dismembered pyeloplasty. Because there were no differences in mean operative and anastomotic times between adults and children, laparoscopic modified BP might be an efficient procedure for all ages, especially children.

Long-Term Bladder Function after Ureterocele Decompression in Children

There is limited knowledge of long-term bladder function after ureterocele decompression. We studied bladder function in patients who underwent surgery in childhood for duplex system ureteroceles. Toilet trained children treated for duplex system ureteroceles between 1990 and 2010 were included in study. We evaluated voiding dysfunction by the valid DVSS questionnaire and noninvasive studies, including uroflowmetry, electromyogram and post-void residual urine measurement. Urodynamics were done only in patients with abnormal DVSS or abnormal noninvasive studies. Patients were divided into group 1-ureterocele decompression (endoscopic incision), upper pole partial nephrectomy and ureteropelvic anastomosis, and group 2-primary or secondary bladder surgery (ureterocelectomy, ureterovesical reimplantation and bladder floor reconstruction). Of 62 operated patients 17 were lost to followup and 45 were fully studied at a mean followup of 9.5 years (range 3 to 20). Initial surgery was done at mean age of 5.1 months (range 6 days to 48 months). In the 33 group 1 patients, of whom 70% underwent endoscopic incision, the mean DVSS score was 1.5 (range 0 to 6), 7 patients (22%) had abnormal uroflowmetry or significant post-void residual urine and none had abnormal DVSS results. In the 12 patients in group 2 the mean DVSS score was 4 (range 0 to 11), 8 patients (66%) had abnormal uroflowmetry and significant post-void residual urine, and 3 had abnormal DVSS findings (p = 0.036). All group 2 patients underwent bladder surgery after decompression, including endoscopic incision in 2 and upper pole partial nephrectomy in 1. Only 1 child needed clean intermittent catheterization at age 3 years for hypocontractile megacystis and repeat febrile urinary tract infections. Ureterocele decompression alone in early childhood does not leadtomajor bladder dysfunction at long-term evaluation. Even if secondary bladdersurgery is needed, significant bladder dysfunction is rare.