LAPAROSCOPIC ANDERSON-HYNES DISMEMBERED PYELOPLASTY IN CHILDREN

0022-5347/99/1623-1045/0

Vol. 162, 1045-1048, September 1999 Printed in 1I.S.A.

THE JOURNAL OF UROLOGY Copyright 0 1999 by

h I E R I C h V UROLOCICAL ASSOCIATION, I N C

LAPAROSCOPIC ANDERSON-HYNES DISMEMBERED PYELOPLASTY IN CHILDREN H. L. TAN From the Department o f Urology, Great Ormond Street Hospital for Children, London, United Kingdom

ABSTRACT

Purpose: The feasibility and results of laparoscopic Anderson-Hynes dismembered pyeloplasty in children were evaluated. Materials and Methods: All laparoscopic Anderson-Hynes pyeloplasties performed by the author were retrospectively reviewed. A total of 18 children 3 months to 15 years old (mean age 17 months) with proved ureteropelvic junction obstruction underwent laparoscopic AndersonHynes dismembered pyeloplasty between August 1994 and June 1998. Of the 18 pyeloplasties 15 were performed in children who had not undergone previous upper tract surgery, and 3 had undergone previous upper tract surgery, including laparoscopic pyeloplasty in 2 and emergency percutaneous nephrostomy drainage of pyonephrosis 6 weeks earlier in 1. All operations were performed via a transperitoneal route. Results: Postoperative evaluation is complete in 16 patients and pending in 2. Of the 16 patients 14 (87%) have no demonstrable evidence of obstruction. Two patients with persistent obstruction underwent repeat laparoscopic pyeloplasty. There was no conversion to open surgery. Mean operative time was 89 minutes. In 1 patient trocar hematoma resolved with bed rest. In another case the stent was misplaced with its distal end reaching the lower ureter, and was removed via ureteroscopy 6 weeks postoperatively. There was no other operation related morbidity. Conclusions: Laparoscopic Anderson-Hynes pyeloplasty represents a n attractive alternative to conventional open pyeloplasty. It is technically challenging but with practice it may be completed in the same time as conventional open pyeloplasty. It offers results approaching those of conventional dismembered pyeloplasty. KEYWORDS:laparoscopic surgical procedure; kidney; obstruction, ureteral

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Although endopyelotomyl (pyelolysis) and retrograde dilatiOn2,3are alternative methods Of managing WekrOpelViCJUnCtion obstruction in children, the success of these 2 procedures is inferior to that reported for conventional dimxmbered PYeloplasty. Hence, Anderson-Hmes PyeloplastY remains the gold standard and the preferred method Of managing ureteropelvic junction obstruction in children.* However, laparoscopic Anderson-Hynes pyeloplasty is rarely performed. There have been only 2 other reports of laparoscopic Anderson-Hynes dismembered pyeloplasty in children to date536 since its description by &voussi and peters,7The feasibility and results of ~aparoscopicAnderson-Hynes dismembered pye~oplastyin children are evaluated.

MATERIALS AND METHODS

Between August 1994 and June 1998, 18 children presenting with confirmed ureteropelvic junction obstruction underwent laparoscopic dismembered pyeloplasty regardless of age, There were 15 primary procedures. Three patients had undergone previous surgical intervention to the upper tract, including failed dismembered pyeloplasty in and percutaneous nephrostomy for pyonephrosis in 1. Patient age at surgery was 3 months to 15 years (mean 17 months). were preoperatively with mercaptoacetyltriglycine or diethyhetetramine pentaacetic acid isotopic renography, ultrasound and excretory urography (IVP).

FIG. 1. A, ureteropelvic junction is identified by lifting renal pelvis toward anterior abdominal wall. B,stabilizing hitch stitch in situ 1045

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LAPAROSCOPIC ANDERSON-HYNES DISMEMBERED PYELOPLASTY

FIG.2. A, ureteropelvic junction is dismembered. B, spatulating ureter. C , ureter is reattached to renal pelvis

Preoperatively IVF’ was performed in all patients for anatomical studies and also because many were referred from surrounding regional centers that often lacked isotope renography facilities. Followup studies were performed when possible with isotope renography but in patients from remote areas IVP was done instead by the local referring physician and referred for postoperative evaluation.

to drop back into the renal bed, and the proximal ureter and pelvis are inspected to ensure no kinking before desufflating

the abdominal cavity. Unlike others who have reported avthe entire erage operative time of 120 t o 530 minutes,s%9 operation is completed within a n average of 90 minutes (range 70 to 160) by manual intracorporeal suturing of all anastomoses. This decreased operative time has been gained through a process of refinement by recording each operation in its entirety and critically reviewing each video to improve LAPAROSCOPIC TECHNIQUE the ergonomics of this procedure. The laparoscopic technique has been described p r e v i ~ u s l y . ~ Laparoscopic intracorporeal micro-suturing is technically It has changed little since the original description except that challenging and is perhaps one of the most daunting tasks anastomosis was completed in the last 8 patients with 6-zero facing even a skilled laparoscopic surgeon. However, several polydioxanone suture due to the availability of laparoscopic steps in this operation enhance the ease of endoscopic suturmicro-instnunents. The procedure is now performed using a 7 ing. An important key to fine intracorporeal endoscopic summ. umbilical Hasson trocar and 2,6 mm. instrument trocars. turing is to provide stability along the anastomotic line. As Another trocar, previously reported as necessary for retracting described, the hitch stitch provides this stability and greatly the liver for surgery on the right side, is no longer used. facilitates suturing. However, a second hitch stitch on the Gerota’s fascia is opened with limited mobilization, and the ureter is not recommended, since this only serves to distract ureteropelvic junction is identified by tracing the dilated the anastomosis and makes it difficult to oppose the ureter renal pelvis medially until the gonadal vessels are seen crossto the pelvis. It is also important t o leave a long length of ing the pelvis. The ureteropelvic junction, which is intimately suture on the outside of the abdominal wall, so that tension associated with the gonadal vessels, may be identified by on the anastomosis may be relaxed as necessary. lifting the renal pelvis up toward the anterior abdominal wall Unlike others who have reported the preoperative place(fig. 1, A). It has not been necessary t o insert a ureteral ment of balloon catheters9 or stents,I0 these maneuvers only catheter as a preoperative measure for identifymg the urethinder anastomotic suturing. The automatic laparoscopic sueropelvic junction. The pelvis is then stabilized with a hitch turing machine is not used because the suture material is not stitch by passing a straight suture through the anterior absufficiently fine for pediatric cases. Concern must also be dominal wall, suturing the pelvis and passing the suture expressed at the use of course suture material, since calculi through the same entry point on the abdominal wall (fig. 1, have been reported as a postoperative complication after the B ) . External traction on the suture stabilizes the pelvis suf- use of 4-zero suture material.l().” It has not been necessary ficiently to create the anastomosis. to use fibrin glue12 or other methods of tissue approximation, The pelvis is dismembered with the proximal ureter (fig. 2, as advocated by others, because an adequate anastomosis is A). This ureter is then spatulated along its lateral margin created in all cases. A perinephric external drain has not using the renal pelvis to orient the ureter correctly (fig. 2, B ) . been used in any patient. All anastomoses are stented with The ureteropelvic junction is sacrificed after spatulating a an internal pigtail catheter to prevent anastomotic leakage.I3 sufficient length of ureter t o create a wide anastomosis to the A wound drain would not be effective, since urine would renal pelvis. Anastomosis is begun by accurate placement of merely leak into the peritoneal cavity. a suture at the apex of the spatulated ureter, taking care not to create a mucosal flap. The ureter is sutured to the most RESULTS dependent part of the pyelotomy and the 2 dismembered ends are re-approximated with an intracorporeal knot (fig. 2, C). There was no conversion to open surgery and all operations were completed laparoscopically. In 1 patient a trocar hemaNo attempt is made to reduce the size of the pelvis. The posterior anastomosis is completed with a continuous toma required 4 days of bed rest to resolve. With the excepsuture locked at the apex (fig. 3, A). A trans-anastomotic tion of this patient all were discharged home on day 2 poststent is placed by inserting a long 19F polytetrafluoroethyl- operatively. One patient had a misplaced stent with the ene (Teflon) catheter through the anterior abdominal wall distal end lying in the distal ureter and the stent was reand steering it into the proximal ureter. A straight guide moved at 6 weeks via ureteroscopy. There were no other wire is passed through the catheter into the bladder. The technically related complications in our series. Blood loss was polytetrafluoroethylene catheter is withdrawn and a 3.8 or negligible in all patients. All stents were removed after 6 to 5F variable length double pigtail catheter is passed over this 8 weeks and postoperative diethylenetetramine pentaacetic guide wire in an antegrade fashion into the bladder. The acid or mercaptoacetyltriglycinerenography, or Tvp was perproximal end is placed in the renal pelvis (fig. 3, B). The anas- formed at 6 months or earlier, as indicated. tomosis is then completed by closing the pyelotomy and anTwo patients who underwent pyeloplasty at age 3 months terior layer with a second continuous suture (fig. 3 , C). The represent treatment failure. In each case the respective kidhitch stitch is removed, the ureteropelvic junction is allowed ney became palpable after removal of the double pigtail cath-

LAPAROSCOPIC ANDERSON-HYNES DISMEMBERED PYELOPLASTY

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FIG.3. A , posterior anastomosis is completed. B , double-pigtail stent is inserted into renal pelvis. C , anterior anastomosis is completed

eter and clinical signs of acute obstruction developed with vomiting. Complete obstruction was demonstrated in each case. One of these 2 patients underwent repeat laparoscopic dismembered pyeloplasty after the immediate diagnosis of persistent obstruction. Postoperative evaluation revealed good drainage. In the other patient a percutaneous nephrostomy tube was placed by others as an emergency procedure. He has also undergone repeat laparoscopic dismembered pyeloplasty and the pigtail catheter has been removed. The patient is well and awaits further evaluation. Of the 18 patients postoperative evaluation of the dismembered pyeloplasty renal units has been completed in 16 with only 2 remaining to be evaluated, including the second patient in whom treatment failed. Obstruction was relieved in 14 of the 16 patients for an 87% success rate. Although this is not as good a result as reported for open pyeloplasty, it clearly approaches the result attainable with conventional open surgery. The 2 failures to date have been in children who were 3 months old at surgery. Each failure was a result of anastomotic stenosis despite trans-anastomotic stenting. Retrospectively these operations were extremely challenging technically and the anastomosis was particularly difficult due t o small ureteral caliber, which was further compounded by the inability to pass a 3.8F trans-anastomotic stent through the ureterovesical junction. Smaller 3F stents were used instead. In light of these problems laparoscopic Anderson-Hynes dismembered pyeloplasty should not be performed in children younger than 6 months. DISCUSSION

Although Janetschek et a1 discounted laparoscopic dismembered pyeloplasty as too difficult to become an acceptable procedure,14 the aforementioned refinements make it possible for a skilled laparoscopic surgeon to perform a good anastomosis in good time.6 The results achievable with laparoscopic dismembered pyeloplasty are also fast approaching those of conventional open dismembered pyeloplasty. Today one must consider laparoscopic Anderson-Hynes dismembered pyeloplasty as an attractive and viable alternative to conventional surgery. It provides far superior cosmetic results and is far less debilitating to the patient. However, it is not recommended in children younger than 6 months at this time. A trans-anastomotic stent was inserted in all cases. While this requires a second outpatient procedure to remove the stent subsequently, the advantages of a trans-anastomotic stent for preventing urinary leakage outweigh its disadvantages. Furthermore, stents also are routinely used in cases of open Anderson-Hynes pyeloplasty. That this is a transperitoneal operation may raise some concern about adhesion formation. However, there is only minimal mobilization of the spleenocolic ligament, which at the end of the procedure is completely covered by the colon

when it is returned to its place. This amount of mobilization is no more than that at laparoscopy for undescended testis or varicocelectomy. There is also no bowel handling at all throughout the procedure. With refinements in technique it may be possible to perform this surgery retroperitoneally in its entirety. Presently the transperitoneal route is preferred because of the space required to perform intracorporeal suturing. CONCLUSIONS

Laparoscopic Anderson-Hynes dismembered pyeloplasty is now a feasible and attractive alternative to open surgery. While it undoubtedly requires a high level of skill and understanding of the ergonomics of laparoscopic surgery, it may nevertheless be learned and performed in the same time as conventional open surgery.6 Its results approach those of conventional open surgery. REFERENCES

1. Tan, H. L., Najmaldin, A. and Webb, D. R.: Endopyelotomy for pelvi-ureteric junction obstruction in children. Eur. Urol., 2 4 84, 1993. 2. Tan, H. L., Roberts, J. P. and Grattan-Smith, D.: Retrograde balloon dilatation of ureteropelvic obstructions in infants and children: early results. Urology, 4 6 89, 1995. 3. Doraiswamy, N. V.: Retrograde ureteroplasty using balloon dilatation in children with pelviureteric obstruction. Brit. J. Urol., 71: 152, 1993. 4. Ahmed, S., Crankson, S. and Sripathy, V.: Pelviureteric obstruction in children: conventional pyeloplasty is superior to endourology. Aust. New Zeal. J . Surg., 6 8 641, 1998. 5. Tan, H. L. and Roberts, J. P.: Laparuscopic dismembered pyeloplasty in children: p r e b a r y results. Brit. J . Uml., 77: 909,1996. 6. Schier, F.: Laparoscopic Anderson-Hynes pyeloplasty in children. Ped. Surg. Int., 13 497, 1998. 7. Kavoussi, L. R. and Peters, C. A.: Laparoscopic pyeloplasty. J. Urol., 150 1891, 1993. 8. Brunet, P., Leroy, J. and Danjou, P.: Eight cases of pyeloureteral junction syndrome treated by laparoscopic surgery. Chirurgerie, 121:415, 1996. 9. Nakada, S. Y., McDougall, E. M. and Clayman, R. V.: Laparoscopic pyeloplasty for secondary ureteropelvic junction obstruction: preliminary experience. Urology, 4 6 257, 1995. 10. Moore, R. G., Averch, T. D., Schulam, P. G., Adams. J. B., Chen, R. N. and Kavoussi, L. R.: Laparoscopic pyeloplasty: experience with the initial 30 cases. J. Urol., 157:459, 1997. 11. Eden, C. G., Sultana, S. R., Murray, K. H. and Carruthers, R. K.: Extraperitoneal laparoscopic dismembered fibrin glued pyeloplasty: medium term results. Brit. J. Urol., 80: 382, 1997. 12. Eden, C. G. and Coptcoat, M. J.: Assessment of alternative tissue approximation techniques for laparoscopy. Brit. J. Urol., 7 8 234, 1996. 13. Woo, H. H. and Farnsworth, R. H.: Ihsmembered pyeloplasty in infants under the age of 12 months. Brit. J . Uml., 77: 449,1996. 14. Janetschek, G., Peschel, R. and Bartsch, G.: Laparoscopic and retroperitoneoscopic kidney pyeloplasty. Urologe, 3 5 202, 1996.