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Laparoscopic management of ureteropelvic junction obstruction in pediatric patients: A new approach to crossing vessels, crossing vein division, and upward transposition of the crossing artery
Journal of Pediatric Urology (2010) 6, 161e165
Laparoscopic management of ureteropelvic junction obstruction in pediatric patients: A new approach to crossing vessels, crossing vein division, and upward transposition of the crossing artery Nasser Simforoosh*, Ahmad Javaherforooshzadeh, Alireza Aminsharifi, Mohammad Hossein Soltani, Mohammad Hadi Radfar, Hossein Kilani Shahid Labbafinejad Medical Center, Urology and Nephrology Research Center (UNRC), Shahid Beheshti University, M.C. (SBMU), No#101, Boostan 9th St., Pasdaran Ave., Tehran, Islamic Republic of Iran Received 23 April 2009; accepted 19 July 2009 Available online 19 August 2009
KEYWORDS Child; Crossing; Laparoscopy; Ureteropelvic junction obstruction; Pyeloplasty
Abstract Objective: To demonstrate the role of the laparoscopic approach for management of primary ureteropelvic junction obstruction (UPJO) using two different techniques in the pediatric age group. Material and methods: From April 2005 to October 2008, 63 pediatric patients underwent treatment of primary UPJO via a laparoscopic approach. Dismembered pyeloplasty was elected in 56 renal units while nine patients were managed by upward transposition of accessory renal artery after division of accessory renal vein. No JJ stent was required in these nine patients. Results: Mean age of patients was 61 (2e180) months. Mean operative time was significantly lower in those managed by transposition of aberrant vessels compared with dismembered pyeloplasty. The mean hospital stay was 6.4 (2e14) days for the dismembered technique and 2.1 (1e4) days for the vascular transposition approach. Significant improvement of obstruction was achieved in all of the patients who underwent the modified Hellstrom technique and in 92.81% of the renal units undergoing dismembered pyeloplasty. Conclusion: The technique of laparoscopic transposition of crossing renal artery without violating collecting system may have a role in minimally invasive management of UPJO in selected pediatric patients. Further research with larger samples and a longer follow-up period is required. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ98 21 22567222; fax: þ98 21 22567282. E-mail addresses: [email protected] (N. Simforoosh), [email protected] (A. Javaherforooshzadeh), amin_sharifi@ hotmail.com (A. Aminsharifi), [email protected] (M.H. Soltani), [email protected] (M.H. Radfar), [email protected] (H. Kilani). 1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.07.010
162
Introduction Since the initial reported experience of laparoscopic pyeloplasty (LP) in children in 1995 [1], acceptance of this approach as a minimally invasive procedure to correct ureteropelvic junction obstruction (UPJO) in children and even in infants younger than 6 months has grown rapidly [2]. Although it has been established that transperitoneal and retroperitoneal approaches yield similar outcomes regarding complications and feasibility [3,4], there is controversy regarding the feasibility and benefits of LP in infants, and the role of the lower pole crossing vessels and in this context. Previously, we have reported our results of LP and our novel technique for management of UPJO because of aberrant renal vein and artery in adults [5]. In the present study, we describe our experience with transperitoneal laparoscopic management of UPJO in children using different strategies, involving dismembered pyeloplasty and modified Hellstrom technique in the presence of lower pole crossing vessels, with laparoscopic division of the crossing vein and cephalad relocation of the crossing artery without violating the collecting system [5].
Materials and methods Patient selection From April 2005 to October 2008 a total of 63 infants (<2 years) and children (2e16 years) with UPJO were selected for LP. They were suffering from recurrent UTI (11), intractable ipsilateral flank pain (15), hematuria (3) and asymptomatic prenatal hydronephrosis with failed expectant management (34). The criteria for intervention included more than 10% decrease in split renal function, split renal function less than 40% with progressive hydronephrosis, and breakthrough pyelonephritis despite prophylactic antibiotic therapy. Preoperative images were obtained with 99m Tc DTPA diuretic renal scan, ultrasonography and/or IVU.
Surgical procedure With the patient under general anesthesia, a Foley catheter was inserted and the patient was positioned in lateral decubitus with adequate padding. The abdominal cavity was
N. Simforoosh et al. explored using a three- or four-port transperitoneal laparoscopic approach compromising a 5-mm umbilical camera port, one or two 3.5-mm ports in the lower quadrant area lateral to the rectus muscle at the level of the umbilicus, and one 3.5-mm subxiphoid trocar as working ports. CO2 pneumoperitoneum pressure was kept at 10 mmHg. Transmesoic exposure of UPJ was elected for those with left UPJO and if a dilated renal pelvis was visualized transmesocolically. Otherwise, the colon reflected medially and the renal pelvis, UPJ and proximal ureter were mobilized. On dissection of the UPJ special care was taken to spare the lower pole crossing vessels. In the presence of crossing vessels, renal artery and vein were mobilized proximally and distally to allow upward transposition of the crossing artery. After inspecting ureteral peristalsis across the UPJ and adequate drainage of the renal pelvis, the crossing vein was divided and cauterized in bipolar mode, while the crossing artery was preserved and relocated cephalad and affixed with two or three absorbable sutures (Fig. 1A,B) [5]. With this technique, there is no requirement for double J stent insertion, so repeat anesthesia for ureteral stent removal is avoided. In the absence of crossing vessels or if the pelvic dilatation did not resolve by transposing the crossing vessels, the operation proceeded with standard laparoscopic dismembered pyeloplasty by dividing the UPJ, spatulating the proximal ureter, and ureteropelvic anastomosis over a double J stent with Vicryl 5/0 or 6/0 running stitches. Foley catheter and ureteral stent were removed on the 4th postoperative day and 4e6 weeks after operation, respectively.
Study outcome Children were followed after ureteral stent removal with ultrasonography and 99m Tc DTPA diuretic renal scan or IVU 3 months later. Success was defined as symptom resolution with hydronephrosis improvement on sonographic evaluation and/ or improvement of renal function and drainage of the affected kidney as verified with IVU or 99m Tc DTPA renal scan (Fig. 2A,B).
Results During the study period a total of 63 children (42 male and 21 female) underwent 65 LPs (two patients had bilateral
Figure 1 A. Dilated pelvis because of anterior crossing artery and vein in lower pole of kidney. B. Improvement of dilatation of pelvis after division of anterior crossing vein and cephalad relocation of crossing artery.
Laparoscopic management of UPJO: Different techniques
163
Figure 2 A. Severe dilatation of left lower pole of duplex kidney because of lower pole crossing vessels. B. Improvement of lower pole dilatation after cephalad relocation of crossing artery.
UPJO with asynchronous bilateral LP). One patient had a previous failed open pyeloplasty. Mean patient age was 61 months (range 2e180 months); 23 (36.51%) were 1e24 months (Group 1) and the remainder were 2e16 years (Group 2). Eight patients (12.69%) in Group 1 were younger than 6 months. Laparoscopic management of UPJO was by classic dismembered pyeloplasty in 56 of 65 (86.1%) renal units. UPJ mobilization via the transmesoic approach was done in 10 patients with left-sided UPJO. Cephalad relocation of crossing artery without violating collecting system was applied for the remaining patients. Aberrant lower pole crossing vessels were found in 14 patients (aged 10 months to 12 years) and intraoperative improvement of hydronephrosis with crossing artery upward transposition was seen in nine of these (64.3%). All procedures were completed laparoscopically with no open conversion. In three patients, antegrade stenting was not possible and tubeless dismembered pyeloplasty was accomplished. Mean operative time was 149.2 min (65e235 min), which did not differ significantly between
Table 1
group 1 and group 2 (154.2 min vs 143.3 min; P Z 0.4). Mean operative time was significantly lower in those who underwent cephalad relocation of crossing artery versus those with dismembered pyeloplasty (112.2 min vs 153.7 min; P Z 0.004). Mean hospital stay was 6.4 (2e14) days for the dismembered technique and 2.1 (1e4) days for the vascular transposition approach (Table 1). Postoperative course was uneventful in all of the patients who underwent cephalad relocation of crossing artery and in 40 (71.42%) dismembered pyeloplasty procedures. Postoperative low-grade fever for less than 48 h occurred in 16 (28.57%) of 56 dismembered procedures, which was managed successfully with antibiotic therapy. No significant urine leak or urinoma formation was encountered, even in the patient who underwent tubeless pyeloplasty. One patient was explored at postoperative day 5 because of milky fluid drainage but, after exploring the patient, we found significant mesenteric lymphatic excretion and no intestinal or colonic perforation, so conservative treatment was curative in this patient. Two patients had prolonged fever
Patient and surgical demographics.
No. of patients Mean age Sex distribution Side involved Mean hospital stay Mean operative time No. of complications Success rate
Division of anterior crossing vein and cephalad relocation of crossing artery
Dismembered pyeloplasty
9 7.25 Male: 6, Female: 3 Left: 6, Right: 3 2.1 (1e4) days 112.2 min 0 100%
54 (2 patients had bilateral UPJO) 4.33 Male: 34, Female: 20 Left: 28, Right: 28 6.4 (2-14) days 153.7 min Exploration: 1, Low-grade fever: 16 92.8%
164 (2 weeks), which was resolved by ureteral stent removal (one of these children had concomitant VUR). Mean follow-up was 18.3 months (3e47 months). Followup period for those who had undergone the modified Hellstrom technique was 15.7 (5e29) months. All of the patients remained symptom free during the follow-up period. Significant improvement of hydronephrosis on IVU and noticeable isotope material clearance on 99m Tc DTPA scan occurred in 61 of 65 procedures (93.65%) at 3-month imaging studies. Success rate was 100% in the crossing vessel transposition group and in the dismembered group it was 92.81%. Recurrence of UPJO was noted in one patient who underwent dismembered pyeloplasty (1.78%) at 19month follow-up which was managed by repeat ureteral stent insertion for 6 weeks. In three patients (4.61%), the degree of hydronephrosis decreased but isotope renal scan revealed partial obstruction.
Discussion In the era of minimally invasive reconstructive surgery, there is still debate regarding the benefits of laparoscopic pyeloplasty in the pediatric age group. There is evidence that LP may have an inferior outcome in infancy [6,7]. Chacko and coworkers developed a mini-incision open surgery technique for pyeloplasty in UPJO. They applied their technique to 135 children (66 younger than 1 year) and have shown an acceptable operative time, outcome and postoperative morbidity [8]. To address the benefits of the laparoscopic approach at younger ages, Tanaka et al. have performed an excellent survey using a multi-institutional pediatric health information database system that included the data of 5261 children with LP. They have shown that the benefits of laparoscopy in terms of shorter hospital stay and decreased narcotic use were only present in children older than 10 years. However, as the authors commented, they could not assess outpatient convalescence and return to normal activity [9]. Given the fact that intracorporeal suturing is the most technically demanding skill with a prolonged learning curve, robotically assisted anastomosis was introduced. Franco and his coworkers have demonstrated that robotically assisted anastomosis produced a similar outcome with comparable operative time compared to hand-sewn anastomosis [10]. In the present study, we have shown that LP can be applied as a minimally invasive approach with excellent outcome irrespective of patient age. Magnification and excellent visualization with good experience of laparoscopic reconstructive surgery may facilitate the anastomosis and may have positive effects on the outcome. These results are in concordance with the outcome of LP in the hands of Piaggio and colleagues [11]. They compared the results of pediatric LP and open pyeloplasty, and have indicated that although transperitoneal LP is a more timeconsuming surgery than open pyeloplasty, it may provide a better outcome with fewer complications and better cosmesis [11]. More than one third of our patients (23 of 63, 36.5%) were younger than 2 years and we have shown that a comparable outcome after LP could be achieved in these
N. Simforoosh et al. infants. A similar excellent outcome of LP was demonstrated by Cascio and associates in a series of 11 infants with 12 LPs [12]. Metzelder et al. and Kutikov et al. have also separately shown excellent results from LP in infants younger than 1 year and younger than 6 months, respectively [2,13]. Similar tour study, Lopez et al. have recently reported their experience with LP in 28 patients with a mean age of 63 months. Their mean operative time was 145 min with a success rate of 93% during a mean follow-up period of 18 months [14]. There is significant controversy regarding the role of aberrant lower pole crossing vessels in the pathogenesis of UPJO. While these crossing vessels are associated in up to 40% of adult patients with UPJO, this association in pediatric UPJO is as low as 15%. Furthermore, the extrinsic pressure itself may not be the sole factor interfering with collecting system drainage, as there may be concomitant intrinsic factors [15]. However, there is a subset of UPJO patients in whom releasing the extrinsic pressure caused by the lower pole crossing vessels would be expected to lead to appropriate collecting system drainage. Previously, Simforoosh et al. reported outcomes of division of crossing vein and cephalad relocation of crossing artery in 10 adult patients with UPJO [5]. In the present series, we have shown the value of this technique in pediatrics: 22.2% (14/63) of our patients had lower pole crossing vessels and drainage of the renal pelvis was significantly improved in more than half of them (9/14, 64.3%) after laparoscopic cephalad relocation of crossing artery. We believe that the magnification and anterior approach provided by transperitoneal laparoscopy may help to detect the aberrant crossing vessels and determine their interaction with the UPJ more effectively than in retroperitoneal open or laparoscopic approaches. Moreover, we have demonstrated that intraoperative findings of adequate renal pelvis drainage after vascular transposition could be translated to success in terms of symptom resolution and/ or collecting system drainage without violating the collecting system. Gundeti and co-authors have revealed the feasibility and durability of the laparoscopic vascular hitch technique for management of UPJO in children with similar results to our study [16]. Through this study we have shown the excellent outcomes of different laparoscopic approaches for management of UPJO irrespective of pediatric age. The success rate of this procedure is high and cosmetic appearance seems to be acceptable in comparison to open pyeloplasty. However, we believe that the exact role of transposition of aberrant crossing vessels in the relief of extrinsic pressure over UPJO should be further investigated with a long-term follow-up period. We think that with further experience and the advent of miniaturized laparoscopic instruments, the role of laparoscopy for correction of UPJO in pediatric patients will grow, and future randomized trials may further demonstrate the benefits of this approach [17].
Conflict of interest The authors have no conflict of interest.
Laparoscopic management of UPJO: Different techniques
165
Funding None.
[10]
References [11] [1] Peters CA, Schlussel RN, Retik AB. Pediatric laparoscopic dismembered pyeloplasty. J Urol 1995 Jun;153(6):1962e5. [2] Kutikov A, Resnick M, Casale P. Laparoscopic pyeloplasty in the infant younger than 6 months-is it technically possible? J Urol 2006 Apr;175(4):1477e9. [3] El-Ghoneimi A, Farhat W, Bolduc S, Bagli D, McLorie G, Aigrain Y, et al. Laparoscopic dismembered pyeloplasty by a retroperitoneal approach in children. BJU Int 2003 Jul;92(1):104e8. [4] Yeung CK, Tam YH, Sihoe JD, Lee KH, Liu KW. Retroperitoneoscopic dismembered pyeloplasty for pelvi-ureteric junction obstruction in infants and children. BJU Int 2001 Apr; 87(6):509e13. [5] Simforoosh N, Tabibi A, Nouralizadeh A, NouriMahdavi K, Shayaninasab H. Laparoscopic management of ureteropelvic junction obstruction by division of anterior crossing vein and cephalad relocation of anterior crossing artery. J Endourol 2005 Sep;19(7):827e30. [6] Tan HL. Laparoscopic AndersoneHynes dismembered pyeloplasty in children. J Urol 1999 Sep;162(3 Pt 2):1045e7. [7] Woo HH, Farnsworth RH. Dismembered pyeloplasty in infants under the age of 12 months. Br J Urol 1996 Mar;77(3):449e51. [8] Chacko JK, Koyle MA, Mingin GC, Furness 3rd PD. The minimally invasive open pyeloplasty. J Pediatr Urol 2006 Aug;2(4):368e72. [9] Tanaka ST, Grantham JA, Thomas JC, Adams MC, Brock 3rd JW, Pope 4th JC. A comparison of open vs laparoscopic pediatric pyeloplasty using the pediatric health information system
[12]
[13]
[14]
[15]
[16]
[17]
database e do benefits of laparoscopic approach recede at younger ages? J Urol 2008 Oct;180(4):1479e85. Franco I, Dyer LL, Zelkovic P. Laparoscopic pyeloplasty in the pediatric patient: hand sewn anastomosis versus robotic assisted anastomosise is there a difference? J Urol 2007 Oct; 178(4 Pt 1):1483e6. Piaggio LA, Franc-Guimond J, Noh PH, Wehry M, Figueroa TE, Barthold J, et al. Transperitoneal laparoscopic pyeloplasty for primary repair of ureteropelvic junction obstruction in infants and children: comparison with open surgery. J Urol 2007 Oct; 178(4 Pt 2):1579e83. Cascio S, Tien A, Chee W, Tan HL. Laparoscopic dismembered pyeloplasty in children younger than 2 years. J Urol 2007 Jan; 177(1):335e8. Metzelder ML, Schier F, Petersen C, Truss M, Ure BM. Laparoscopic transabdominal pyeloplasty in children is feasible irrespective of age. J Urol 2006 Feb;175(2):688e91. Lopez M, Guye E, Varlet F. Laparoscopic pyeloplasty for repair of pelvic-ureteric junction obstruction in children. J Pediatr Urol 2009;5(2):25e9. Carr MC, El-Ghoneimi A. Anomalies and surgery of the ureteropelvic junction obstruction in children. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. CampbelleWalsh urology. 9th ed. Philadelphia: Saunders Elsevier; 2007. p. 336e7. Gundeti MS, Reynolds WS, Duffy PG, Mushtaq I. Further experience with the vascular hitch (laparoscopic transposition of lowerpole crossing vessels): an alternate treatment for pediatric ureterovascular ureteropelvic junction obstruction. J Urol 2008 Oct;180(4 Suppl):1832e6. Lee RS, Retik AB, Borer JG, Peters CA. Pediatric robot assisted laparoscopic dismembered pyeloplasty: comparison with a cohort of open surgery. J Urol 2006 Feb;175(2):683e7.
Laparoscopic management of ureteropelvic junction obstruction in pediatric patients: A new approach to crossing vessels, crossing vein division, and upward transposition of the crossing artery Nasser Simforoosh*, Ahmad Javaherforooshzadeh, Alireza Aminsharifi, Mohammad Hossein Soltani, Mohammad Hadi Radfar, Hossein Kilani Shahid Labbafinejad Medical Center, Urology and Nephrology Research Center (UNRC), Shahid Beheshti University, M.C. (SBMU), No#101, Boostan 9th St., Pasdaran Ave., Tehran, Islamic Republic of Iran Received 23 April 2009; accepted 19 July 2009 Available online 19 August 2009
KEYWORDS Child; Crossing; Laparoscopy; Ureteropelvic junction obstruction; Pyeloplasty
Abstract Objective: To demonstrate the role of the laparoscopic approach for management of primary ureteropelvic junction obstruction (UPJO) using two different techniques in the pediatric age group. Material and methods: From April 2005 to October 2008, 63 pediatric patients underwent treatment of primary UPJO via a laparoscopic approach. Dismembered pyeloplasty was elected in 56 renal units while nine patients were managed by upward transposition of accessory renal artery after division of accessory renal vein. No JJ stent was required in these nine patients. Results: Mean age of patients was 61 (2e180) months. Mean operative time was significantly lower in those managed by transposition of aberrant vessels compared with dismembered pyeloplasty. The mean hospital stay was 6.4 (2e14) days for the dismembered technique and 2.1 (1e4) days for the vascular transposition approach. Significant improvement of obstruction was achieved in all of the patients who underwent the modified Hellstrom technique and in 92.81% of the renal units undergoing dismembered pyeloplasty. Conclusion: The technique of laparoscopic transposition of crossing renal artery without violating collecting system may have a role in minimally invasive management of UPJO in selected pediatric patients. Further research with larger samples and a longer follow-up period is required. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ98 21 22567222; fax: þ98 21 22567282. E-mail addresses: [email protected] (N. Simforoosh), [email protected] (A. Javaherforooshzadeh), amin_sharifi@ hotmail.com (A. Aminsharifi), [email protected] (M.H. Soltani), [email protected] (M.H. Radfar), [email protected] (H. Kilani). 1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.07.010
162
Introduction Since the initial reported experience of laparoscopic pyeloplasty (LP) in children in 1995 [1], acceptance of this approach as a minimally invasive procedure to correct ureteropelvic junction obstruction (UPJO) in children and even in infants younger than 6 months has grown rapidly [2]. Although it has been established that transperitoneal and retroperitoneal approaches yield similar outcomes regarding complications and feasibility [3,4], there is controversy regarding the feasibility and benefits of LP in infants, and the role of the lower pole crossing vessels and in this context. Previously, we have reported our results of LP and our novel technique for management of UPJO because of aberrant renal vein and artery in adults [5]. In the present study, we describe our experience with transperitoneal laparoscopic management of UPJO in children using different strategies, involving dismembered pyeloplasty and modified Hellstrom technique in the presence of lower pole crossing vessels, with laparoscopic division of the crossing vein and cephalad relocation of the crossing artery without violating the collecting system [5].
Materials and methods Patient selection From April 2005 to October 2008 a total of 63 infants (<2 years) and children (2e16 years) with UPJO were selected for LP. They were suffering from recurrent UTI (11), intractable ipsilateral flank pain (15), hematuria (3) and asymptomatic prenatal hydronephrosis with failed expectant management (34). The criteria for intervention included more than 10% decrease in split renal function, split renal function less than 40% with progressive hydronephrosis, and breakthrough pyelonephritis despite prophylactic antibiotic therapy. Preoperative images were obtained with 99m Tc DTPA diuretic renal scan, ultrasonography and/or IVU.
Surgical procedure With the patient under general anesthesia, a Foley catheter was inserted and the patient was positioned in lateral decubitus with adequate padding. The abdominal cavity was
N. Simforoosh et al. explored using a three- or four-port transperitoneal laparoscopic approach compromising a 5-mm umbilical camera port, one or two 3.5-mm ports in the lower quadrant area lateral to the rectus muscle at the level of the umbilicus, and one 3.5-mm subxiphoid trocar as working ports. CO2 pneumoperitoneum pressure was kept at 10 mmHg. Transmesoic exposure of UPJ was elected for those with left UPJO and if a dilated renal pelvis was visualized transmesocolically. Otherwise, the colon reflected medially and the renal pelvis, UPJ and proximal ureter were mobilized. On dissection of the UPJ special care was taken to spare the lower pole crossing vessels. In the presence of crossing vessels, renal artery and vein were mobilized proximally and distally to allow upward transposition of the crossing artery. After inspecting ureteral peristalsis across the UPJ and adequate drainage of the renal pelvis, the crossing vein was divided and cauterized in bipolar mode, while the crossing artery was preserved and relocated cephalad and affixed with two or three absorbable sutures (Fig. 1A,B) [5]. With this technique, there is no requirement for double J stent insertion, so repeat anesthesia for ureteral stent removal is avoided. In the absence of crossing vessels or if the pelvic dilatation did not resolve by transposing the crossing vessels, the operation proceeded with standard laparoscopic dismembered pyeloplasty by dividing the UPJ, spatulating the proximal ureter, and ureteropelvic anastomosis over a double J stent with Vicryl 5/0 or 6/0 running stitches. Foley catheter and ureteral stent were removed on the 4th postoperative day and 4e6 weeks after operation, respectively.
Study outcome Children were followed after ureteral stent removal with ultrasonography and 99m Tc DTPA diuretic renal scan or IVU 3 months later. Success was defined as symptom resolution with hydronephrosis improvement on sonographic evaluation and/ or improvement of renal function and drainage of the affected kidney as verified with IVU or 99m Tc DTPA renal scan (Fig. 2A,B).
Results During the study period a total of 63 children (42 male and 21 female) underwent 65 LPs (two patients had bilateral
Figure 1 A. Dilated pelvis because of anterior crossing artery and vein in lower pole of kidney. B. Improvement of dilatation of pelvis after division of anterior crossing vein and cephalad relocation of crossing artery.
Laparoscopic management of UPJO: Different techniques
163
Figure 2 A. Severe dilatation of left lower pole of duplex kidney because of lower pole crossing vessels. B. Improvement of lower pole dilatation after cephalad relocation of crossing artery.
UPJO with asynchronous bilateral LP). One patient had a previous failed open pyeloplasty. Mean patient age was 61 months (range 2e180 months); 23 (36.51%) were 1e24 months (Group 1) and the remainder were 2e16 years (Group 2). Eight patients (12.69%) in Group 1 were younger than 6 months. Laparoscopic management of UPJO was by classic dismembered pyeloplasty in 56 of 65 (86.1%) renal units. UPJ mobilization via the transmesoic approach was done in 10 patients with left-sided UPJO. Cephalad relocation of crossing artery without violating collecting system was applied for the remaining patients. Aberrant lower pole crossing vessels were found in 14 patients (aged 10 months to 12 years) and intraoperative improvement of hydronephrosis with crossing artery upward transposition was seen in nine of these (64.3%). All procedures were completed laparoscopically with no open conversion. In three patients, antegrade stenting was not possible and tubeless dismembered pyeloplasty was accomplished. Mean operative time was 149.2 min (65e235 min), which did not differ significantly between
Table 1
group 1 and group 2 (154.2 min vs 143.3 min; P Z 0.4). Mean operative time was significantly lower in those who underwent cephalad relocation of crossing artery versus those with dismembered pyeloplasty (112.2 min vs 153.7 min; P Z 0.004). Mean hospital stay was 6.4 (2e14) days for the dismembered technique and 2.1 (1e4) days for the vascular transposition approach (Table 1). Postoperative course was uneventful in all of the patients who underwent cephalad relocation of crossing artery and in 40 (71.42%) dismembered pyeloplasty procedures. Postoperative low-grade fever for less than 48 h occurred in 16 (28.57%) of 56 dismembered procedures, which was managed successfully with antibiotic therapy. No significant urine leak or urinoma formation was encountered, even in the patient who underwent tubeless pyeloplasty. One patient was explored at postoperative day 5 because of milky fluid drainage but, after exploring the patient, we found significant mesenteric lymphatic excretion and no intestinal or colonic perforation, so conservative treatment was curative in this patient. Two patients had prolonged fever
Patient and surgical demographics.
No. of patients Mean age Sex distribution Side involved Mean hospital stay Mean operative time No. of complications Success rate
Division of anterior crossing vein and cephalad relocation of crossing artery
Dismembered pyeloplasty
9 7.25 Male: 6, Female: 3 Left: 6, Right: 3 2.1 (1e4) days 112.2 min 0 100%
54 (2 patients had bilateral UPJO) 4.33 Male: 34, Female: 20 Left: 28, Right: 28 6.4 (2-14) days 153.7 min Exploration: 1, Low-grade fever: 16 92.8%
164 (2 weeks), which was resolved by ureteral stent removal (one of these children had concomitant VUR). Mean follow-up was 18.3 months (3e47 months). Followup period for those who had undergone the modified Hellstrom technique was 15.7 (5e29) months. All of the patients remained symptom free during the follow-up period. Significant improvement of hydronephrosis on IVU and noticeable isotope material clearance on 99m Tc DTPA scan occurred in 61 of 65 procedures (93.65%) at 3-month imaging studies. Success rate was 100% in the crossing vessel transposition group and in the dismembered group it was 92.81%. Recurrence of UPJO was noted in one patient who underwent dismembered pyeloplasty (1.78%) at 19month follow-up which was managed by repeat ureteral stent insertion for 6 weeks. In three patients (4.61%), the degree of hydronephrosis decreased but isotope renal scan revealed partial obstruction.
Discussion In the era of minimally invasive reconstructive surgery, there is still debate regarding the benefits of laparoscopic pyeloplasty in the pediatric age group. There is evidence that LP may have an inferior outcome in infancy [6,7]. Chacko and coworkers developed a mini-incision open surgery technique for pyeloplasty in UPJO. They applied their technique to 135 children (66 younger than 1 year) and have shown an acceptable operative time, outcome and postoperative morbidity [8]. To address the benefits of the laparoscopic approach at younger ages, Tanaka et al. have performed an excellent survey using a multi-institutional pediatric health information database system that included the data of 5261 children with LP. They have shown that the benefits of laparoscopy in terms of shorter hospital stay and decreased narcotic use were only present in children older than 10 years. However, as the authors commented, they could not assess outpatient convalescence and return to normal activity [9]. Given the fact that intracorporeal suturing is the most technically demanding skill with a prolonged learning curve, robotically assisted anastomosis was introduced. Franco and his coworkers have demonstrated that robotically assisted anastomosis produced a similar outcome with comparable operative time compared to hand-sewn anastomosis [10]. In the present study, we have shown that LP can be applied as a minimally invasive approach with excellent outcome irrespective of patient age. Magnification and excellent visualization with good experience of laparoscopic reconstructive surgery may facilitate the anastomosis and may have positive effects on the outcome. These results are in concordance with the outcome of LP in the hands of Piaggio and colleagues [11]. They compared the results of pediatric LP and open pyeloplasty, and have indicated that although transperitoneal LP is a more timeconsuming surgery than open pyeloplasty, it may provide a better outcome with fewer complications and better cosmesis [11]. More than one third of our patients (23 of 63, 36.5%) were younger than 2 years and we have shown that a comparable outcome after LP could be achieved in these
N. Simforoosh et al. infants. A similar excellent outcome of LP was demonstrated by Cascio and associates in a series of 11 infants with 12 LPs [12]. Metzelder et al. and Kutikov et al. have also separately shown excellent results from LP in infants younger than 1 year and younger than 6 months, respectively [2,13]. Similar tour study, Lopez et al. have recently reported their experience with LP in 28 patients with a mean age of 63 months. Their mean operative time was 145 min with a success rate of 93% during a mean follow-up period of 18 months [14]. There is significant controversy regarding the role of aberrant lower pole crossing vessels in the pathogenesis of UPJO. While these crossing vessels are associated in up to 40% of adult patients with UPJO, this association in pediatric UPJO is as low as 15%. Furthermore, the extrinsic pressure itself may not be the sole factor interfering with collecting system drainage, as there may be concomitant intrinsic factors [15]. However, there is a subset of UPJO patients in whom releasing the extrinsic pressure caused by the lower pole crossing vessels would be expected to lead to appropriate collecting system drainage. Previously, Simforoosh et al. reported outcomes of division of crossing vein and cephalad relocation of crossing artery in 10 adult patients with UPJO [5]. In the present series, we have shown the value of this technique in pediatrics: 22.2% (14/63) of our patients had lower pole crossing vessels and drainage of the renal pelvis was significantly improved in more than half of them (9/14, 64.3%) after laparoscopic cephalad relocation of crossing artery. We believe that the magnification and anterior approach provided by transperitoneal laparoscopy may help to detect the aberrant crossing vessels and determine their interaction with the UPJ more effectively than in retroperitoneal open or laparoscopic approaches. Moreover, we have demonstrated that intraoperative findings of adequate renal pelvis drainage after vascular transposition could be translated to success in terms of symptom resolution and/ or collecting system drainage without violating the collecting system. Gundeti and co-authors have revealed the feasibility and durability of the laparoscopic vascular hitch technique for management of UPJO in children with similar results to our study [16]. Through this study we have shown the excellent outcomes of different laparoscopic approaches for management of UPJO irrespective of pediatric age. The success rate of this procedure is high and cosmetic appearance seems to be acceptable in comparison to open pyeloplasty. However, we believe that the exact role of transposition of aberrant crossing vessels in the relief of extrinsic pressure over UPJO should be further investigated with a long-term follow-up period. We think that with further experience and the advent of miniaturized laparoscopic instruments, the role of laparoscopy for correction of UPJO in pediatric patients will grow, and future randomized trials may further demonstrate the benefits of this approach [17].
Conflict of interest The authors have no conflict of interest.
Laparoscopic management of UPJO: Different techniques
165
Funding None.
[10]
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