Minimally invasive surgery has been increasingly applied in paediatric urology, including the treatment of ureteropelvic junction obstruction. To the best of our knowledge, we describe the first laparoscopic bypass pyeloureterostomy in a 3-month-old male infant, with giant hydronephrosis and high insertion of the ureter into the renal pelvis.
Abbreviations:UPJO (ureteropelvic junction obstruction)
The Anderson–Hynes dismembered pyeloplasty, first introduced in 1949, has been the historical gold standard for treating ureteropelvic junction obstruction (UPJO) [
]. Laparoscopic pyeloplasty has become increasingly more common in the paediatric population as a minimally invasive alternative to the classic open approach, in an effort to minimize morbidity while not compromising success and outcome [
- Anderson J.C.
- Hynes W.
Retrocaval ureter: a case diagnosed preoperatively and treated successfully by a plastic operation.
Br J Urol. 1949; 21: 209-214
]. Success with the laparoscopic procedure parallels that of the open procedure. We present another minimally invasive reconstructive option to manage UPJO.
- Mei H.
- Pu J.
- Yang C.
- Zhang H.
- Zheng L.
- Tong Q.
Laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children: a systematic review and meta-analysis.
J Endourol. 2011; 25: 727-736
The patient is a 3-month-old boy who was evaluated for prenatally detected bilateral hydronephrosis. Postnatal ultrasound demonstrated severe left hydronephrosis and moderate to severe right hydronephrosis. Postnatal voiding cystourethrogram was normal. A diuretic renogram demonstrated delayed drainage of the left kidney with a post diuretic half-time of 116 min and 45% relative function. The right kidney drained with a post diuretic half-time of 18 min. A laparoscopic left pyeloplasty was scheduled.
Cystoscopy with a retrograde ureteropyelogram was performed, demonstrating the anatomy (Fig. 1). A 3 French ureteral catheter was advanced retrograde into the left proximal ureter. The patient was positioned for a transperitoneal laparoscopic procedure. A 5-mm umbilical trocar was placed. Two stab incisions, with traditional placement for triangulation, were made to introduce 3-mm instrumentation. A transmesenteric approach was utilized for the reconstruction. Due to the high insertion and an area of narrowing in the proximal ureter, a pyeloureterostomy was performed with a side-to-side anastomosis without dismemberment. The renal pelvis was suspended towards the abdominal wall percutaneously with a 4–0 polypropylene suture, to optimize exposure during the dissection and anastomosis. A longitudinal incision was made in the ureter distal to the obstruction. A corresponding incision was made at the most dependent position of the dilated renal pelvis. The high insertion did not move to a dependent position, after the renal pelvis decompressed. The anastomosis was performed with a running 6–0 polydioxanone suture (Fig. 2a, b). The excess renal pelvis tissue was not excised, nor was the obstructed area excised. A 3.7 French ureteral stent was placed antegrade during the anastomosis. No external drain was used. There were no intraoperative complications or blood loss. The operative time was 196 min. An indwelling urethral catheter was removed the next morning, and the patient was discharged. The ureteral stent was removed one month after the repair.
A 3 month postoperative renal ultrasound demonstrated improvement of the left hydronephrosis, as well as worsening right hydronephrosis. A 4 month postoperative diuretic renogram demonstrated a post diuretic drainage half-time of 7 min for the left kidney and 50 min for the right kidney, which was subsequently treated with a standard laparoscopic pyeloplasty. The patient remains asymptomatic with stable improvement of hydronephrosis in both kidneys at 24 month follow-up.
To the best of our knowledge, we report the first case of a laparoscopic bypass pyeloureterostomy for UPJO. One case series has been reported describing an open approach to perform a bypass pyeloplasty in a small group of paediatric patients [
]. Our patient seemed well suited to this type of reconstruction, due to the high insertion of the ureteropelvic junction with another area of concern for obstruction in the proximal ureter. Other authors have demonstrated that renal pelvis reduction is not needed during paediatric laparoscopic pyeloplasty [
- Mesrobian H.G.
Bypass pyeloplasty: description of a procedure and initial results.
J Pediatr Urol. 2009; 5: 34-36
- Reismann M.
- Gratz K.F.
- Metzelder M.
- Ure B.
- Gluer S.
Excision of the dilated pelvis is not necessary in laparoscopic dismembered pyeloplasty.
Eur J Pediatr Surg. 2008; 18: 19-21
5]. This has been shown to be true in our case as well, demonstrated by the postoperative diuretic renogram. A dismembered pyeloplasty was not absolutely contraindicated for our patient. Crossing vessels have been managed in paediatric patients with a vascular hitch procedure [
- Morsi H.A.
- Mursi K.
- Abdelaziz A.Y.
- ElSheemy M.S.
- Salah M.
- Eissa M.
Renal pelvis reduction during dismembered pyeloplasty: is it necessary?.
J Pediatr Urol. 2012; ([Epub ahead of print])
]. The bypass procedure may potentially be amenable in select cases of lower pole crossing vessels, if a tension free anastomosis can be achieved, by excluding the vessels or other extrinsic obstructions. As experience and skill level improve to perform complex paediatric laparoscopic upper urinary tract reconstruction, surgeons may apply different reconstructive procedures to meet the needs of each individual patient. Laparoscopic bypass pyeloureterostomy may be an option in the armamentarium of surgeons utilizing minimally invasive surgery to correct UPJO.
- Gundeti M.S.
- Reynolds W.S.
- Duffy P.G.
- Mushtaq I.
Further experience with the vascular hitch (laparoscopic transposition of lower pole crossing vessels): an alternate treatment for pediatric ureterovascular ureteropelvic junction obstruction.
J Urol. 2008; 180: 1832-1836
Laparoscopic bypass pyeloureterostomy is technically feasible, safe, and effective for infant UPJO with giant hydronephrosis with a high insertion of the ureteropelvic junction. Further evaluation is warranted to validate its use as an option for treating select cases of UPJO and its long-term outcomes.
Approval was not required.
Conflict of interest statement
The authors have no conflicts of interest.
- Retrocaval ureter: a case diagnosed preoperatively and treated successfully by a plastic operation.Br J Urol. 1949; 21: 209-214
- Laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children: a systematic review and meta-analysis.J Endourol. 2011; 25: 727-736
- Bypass pyeloplasty: description of a procedure and initial results.J Pediatr Urol. 2009; 5: 34-36
- Excision of the dilated pelvis is not necessary in laparoscopic dismembered pyeloplasty.Eur J Pediatr Surg. 2008; 18: 19-21
- Renal pelvis reduction during dismembered pyeloplasty: is it necessary?.J Pediatr Urol. 2012; ([Epub ahead of print])
- Further experience with the vascular hitch (laparoscopic transposition of lower pole crossing vessels): an alternate treatment for pediatric ureterovascular ureteropelvic junction obstruction.J Urol. 2008; 180: 1832-1836
Published online: August 13, 2012
Accepted: July 9, 2012
Received: March 30, 2012
© 2012 Journal of Pediatric Urology Company. Published by Elsevier Inc. All rights reserved.