Laparoscopic pyeloplasty in infants: single-surgeon experience

A simple technique for percutaneous antegrade retrieval of proximally migrated double J stents after pyeloplasty in infants

Proximal migration of double J (DJ) stent after pyeloplasty poses a difficult problem in infants whose small ureter renders retrograde ureteroscopic retrieval difficult. Previously described antegrade techniques used large access sheaths or blind removal under fluoroscopic guidance. We describe a technique for antegrade retrieval of the stent under direct vision. A 8F vascular access sheath is placed into the renal pelvis under ultrasound guidance. A 6F nephroscope with 3F forceps placed through the sheath grasps and retrieves the stent under direct visualization. This technique is simple, quick, avoids radiation exposure and was used by us successfully in 2 small infants.

Techniques in minimally invasive transperitoneal pyeloplasty: A compilation

Context

Minimally invasive management (laparoscopic/robot assisted) is currently the standard of care for managing pelvi ureteric junction obstruction (PUJO). Open techniques of management of PUJO are well described in literature. However, there appears to be relative lack of description of minimally invasive techniques in the literature.

Objective

This article is aimed at describing in detail, with images, the various techniques and modifications in laparoscopic or robot-assisted management of PUJO.

Evidence Acquisition

A review of literature on PubMed was performed and all articles which detailed any technique of minimally invasive pyeloplasty were included.

Evidence Synthesis

The various techniques of minimally invasive pyeloplasty as well as the authors' techniques are compiled and described in detail with intraoperative images.

Conclusions

Operative techniques of minimally invasive pyeloplasty are not well described in literature. We have attempted to present a comprehensive resource of different techniques of minimally invasive pyeloplasty and the clinical scenarios in which they may be appropriate. This should prove to be a useful reference to the practicing urologist.

Patient Summary

In this paper, we have compiled the various surgical techniques of treating obstruction at the PUJ of the kidney along with intraoperative photograph.

Feasibility, safety and effectiveness of laparoscopic transperitoneal pyeloplasty in children: Ain Shams University early experience

Background/purpose

Laparoscopic pyeloplasty (LP) is now widely recognized as a minimally invasive alternative for the surgical repair of ureteropelvic junction obstruction (UPJO) in paediatrics. In this work, we aim to evaluate the feasibility, safety and effectiveness of LP in our early experience.

Patients and methods

Between April 2019 and April 2020, patients presented with indication for surgical repair of UPJO were offered laparoscopic transperitoneal Anderson-Hynes pyeloplasty. Demographic data, preoperative investigations, operative data and intra- or postoperative complications, as well as short and mid-term follow-ups were recorded.

Results

During the specified period, 13 patients underwent LP (8 girls and 5 boys) with a median age of 12 months (range from 5 to 150 months). There was no conversion to open approach with operative time ranging from 120 to 240 min (mean = 175 ± 34 min). No intra- or postoperative complications were encountered. One to 2 years postoperative follow-up was performed (median = 18 months) in 11 patients. One patient discontinued follow-up after 1 month and another after 6 months. Follow-up PAUS showed a reduction in the anteroposterior diameter of the renal pelvis in all cases. Postoperative diuretic renal scans (DTPA renography) were done for three patients with a persistent anteroposterior diameter of the renal pelvis greater than 20 mm which showed improvement in the washout. All patients had a good cosmetic outcome.

Conclusion

In our early experience in LP, we found the procedure a safe, feasible and effective technique in managing UPJO in children and infants with good cosmetic outcome.

Level of evidence

This is a case series study (level IV evidence).

Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and meta-analysis

INTRODUCTION

The historical gold standard treatment for ureteropelvic junction obstruction (UPJO) was the open Anderson-Hynes dismembered pyeloplasty (OP). Minimally invasive surgery (MIS) procedures, including laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP), have been reported to achieve better outcomes (i.e., decreased morbidity, reduced postoperative pain, superior esthetic results, and shortened length of hospital stay, LOS), with a success rate similar to OP. The main limitation of the MIS approach is the age and weight of patients, limiting these procedures to children >1 year. This study aims to evaluate the feasibility and benefits of MIS pyeloplasty compared to OP to surgically treat UPJO in children <1 year of age.

MATERIALS AND METHODS

A systematic review was independently performed by two authors. Papers comparing both techniques (MIS pyeloplasty vs. OP) in infants were included in the meta-analysis. Data (mean ± DS or percentage) were analyzed using Rev.Man 5.4 A p < 0.05 was considered significant.

RESULTS

Nine studies (eight retrospective and one prospective) meet the inclusion criteria. A total of 3,145 pyeloplasties have been included, with 2,859 (90.9%) OP and 286 (9.1%) MIS. Age at operation was 4.9 ± 1.4 months in OP vs. 5.8 ± 2.2 months in MIS, p = ns. Weight at surgery was 6.4 ± 1.4 kg in OP vs. 6.9 ± 1.4 kg in MIS, p = ns. Operative time was 129.4 ± 24.1 min for OP vs. 144.0 ± 32.3 min for MIS, p < 0.001. LOS was 3.2 ± 1.9 days for OP vs. 2.2 ± 0.9 days for MIS, p < 0.01. Postoperative complications were present in 10.0 ± 12.9% of OP vs. 10.9 ± 11.6% in MIS, p = ns. Failure of surgery was 5.2 ± 3.5% for OP vs. 4.2 ± 3.3% for MIS, p = ns.

CONCLUSION

The development of miniaturized instruments and technical modifications has made MIS feasible and safe in infants and small children. MIS presented a longer operative time than OP. However, MIS seemed effective for treating UPJO in infants, showing shortened LOS compared to OP. No differences have been reported with regard to the incidence of postoperative complications and failure of pyeloplasty. Given the low quality of evidence of the meta-analysis according to the GRADE methodology, we would suggest limiting MIS procedures in infants to only those high-volume centers with experienced surgeons.

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

AIMS

This study aimed to test the efficacy of SGPGI protocol to minimise bowel distension and optimise working space for laparoscopic pyeloplasty in infants.

METHODOLOGY

All infants who underwent laparoscopic pyeloplasty for unilateral pelvi-ureteric junction obstruction (PUJO) between January 2017 and March 2020 were included in the study. The patient cohort was divided into two groups: Group A and B. Group A included patients who underwent routine pre-operative preparation. Group B included patients wherein the SGPGI protocol was used. The key features of the protocol were fasting for 8 h, enemas, inserting a nasogastric tube in the pre-operative period and decompressing the colon on the operation table. Demographic features, pre-operative, intraoperative and post-operative parameters were compared between the two groups.

RESULTS

A total of 26 infants with unilateral PUJO underwent laparoscopic pyeloplasty during the study period. Group A included 12 patients and Group B included 14 patients. Both the groups were similar in age, weight and sex distribution. The median surgeon's rating score for suturing conditions was 2 for Group A and 5 for Group B patients (P > 0.05). The operating time was significantly longer in Group A (196 ± 21 min) as compared to Group B (114 ± 18 min) (P < 0.05). In Group A, intra-abdominal pressure (IAP) varied between 9 and 14 mmHg (median 12 mmHg), while in Group B, IAP varied between 6 and 9 mmHg (median 8 mmHg) (P < 0.05). In Group A, in 2/12 cases (16.7%), conversion to an open procedure was necessary because of inadequate working space owing to gross intestinal distension. Two patients in Group A also had intraoperative injuries to adjacent structures due to poor working space.

CONCLUSIONS

Optimal working space is critical to the performance of advanced laparoscopic surgery like pyeloplasty in infants. SGPGI protocol significantly improves working space, which permits a faster and safer surgery with a lower intra-abdominal working pressure. This protocol is simple, safe and easy to replicate at most centres in our country.

Quality of YouTube Videos on Laparoscopic Pyeloplasty in Children: An Independent Assessment by Two Pediatric Surgeons

Background YouTube (YT) is the most common video platform accessed by surgical trainees for the preparation of surgery. However, the quality of the YT videos has been questioned time and again. This study was performed to comprehensively assess the quality of the available YT videos on pediatric laparoscopic pyeloplasty (LP). Materials and Methods The term "laparoscopic pyeloplasty in children" was searched in YT on June 3, 2021, and ten most-viewed videos on LP were included. The percentage video power index (%VPI), the Journal of American Medical Association (JAMA) benchmark criteria, and the laparoscopic surgery video educational guidelines (LAP-VEGaS) video assessment tool were used to assess the video popularity, the quality of medical information, and the overall quality of the included videos respectively. Videos were defined as acceptable (score of 11 or more) or poor quality (score <11) based on LAP-VEGaS scores. The inter-observer agreement, in terms of the LAP-VEGaS scoring, was observed among two surgeons using the kappa statistics. Results The median values of the %VPI and JAMA scores of the included YT videos were 68.1 (range 0-13570) and 2 (range 1-2) respectively. The median LAP-VEGaS score of these videos was 6.75 (range 2-16.5) with only two videos having acceptable quality. The quality of these videos was poor in 7/9 domains of the LAP-VEGaS tool. A moderate inter-observer agreement (kappa=0.542) was observed in terms of the LAP-VEGaS scores assigned to the videos (p<0.0001). Conclusion A comprehensive assessment of the ten most-viewed YT videos on pediatric LP revealed poor overall quality. The included videos depicted sub-optimal presentation of the medical information and weak conformity to the LAP-VEGaS guidelines.

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

OBJECTIVE

While there are several reports confirming the safety and efficacy of laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children there have been none comparing LP and RALP specifically in infants. In this meta-analysis, we have compared the outcomes of LP and RALP in infants.

METHODS

Pubmed (Medline), Publon, Index Medicus and Embase were searched using the search terms: pyeloplasty (laparoscopic OR robot-assisted) AND (infant), to identify all papers pertaining to LP and RALP. Systematic review was performed to identify information regarding number of patients/renal units, age, body weight, operating time, hospital stay, success and complications. Meta-analysis of heterogeneity was reported with I2statistics. Once heterogeneity was found low, the pooled outcomes were compared with student's t test and Fishers exact test, wherever appropriate.

RESULTS

After screening a total of 267 articles, 18 articles were included (10 articles on LP, 7 on RALP, 1 reporting both), comprising 323 renal units for LP and 173 renal units for RALP. With low heterogeneity (I2: 0%) both groups were considered to have been conducted under similar conditions for fixed effect model. There was no significant difference between the success rates of LP or RALP (97.5% vs 94.8%; p = 0.21). The mean age at operation was significantly lower for LP (5.6 ± 1.8 months) than RALP (7.2 ± 1.2 months, P = 0.0001). The duration of surgery was 137 ± 45 min for LP while significantly higher at 179 ± 49 min for RALP (p = 0.0001). The mean (s.d) time to discharge was 2.0 (1.9) days for LP while 1.3 (0.4) days for RALP. The overall complication rate was significantly higher (summary table) for RALP than LP (p = 0.03), mainly due to more port-site hernias in RALP.

DISCUSSION

In the present study, we found that the success of LP and RALP in infants was similar. RALP in infants had longer duration of surgery, similar hospital stay and higher Clavien-3 complications than LP. While several studies have reported favorable outcomes for RALP over LP in children, this was not the case in infants. The smaller workspace, in an infant, can significantly limit the mobility of robotic instruments and increase the chance of port-site conflicts or trocar collisions. The use of larger robotic ports and instruments in the small space of infant abdomen might have been responsible for higher complications in RALP, including significantly larger number of port-site hernias. This meta-analysis represents the early experience of most RALP in infants, and it is possible that with experience RALP outcomes in infants also will catch up with LP. Miniaturization of robotic instruments might render RALP the future standard of care for pyeloplasty in infants.

Primary laparoscopic pyeloplasty in children: A single-center experience of 279 patients and analysis of possible factors affecting complications

INTRODUCTION

Laparoscopic pyeloplasty (LP) has been widely used in the treatment of pediatric ureteropelvic junction obstruction (UPJO). However, no prior reports with a large pediatric series have focused on the analysis of complications and impact factors of the outcomes. We hypothesized there were risk factors of higher Clavien grade postoperative complications.

OBJECTIVE

To analyze the characteristics of complications and risk factors of high Clavien grade postoperative complications.

PATIENTS AND METHODS

All children with UPJO treated with primary transperitoneal LP between July 2016 and July 2018 were retrospectively reviewed. The Clavien complication grades in groups with different weight, intraoperative complication (drainage methods), anteroposterior pelvic diameters (APPD), side, gender, title of surgeon, preoperative presentation and obstruction reason were compared.

RESULTS

Of the 279 children, intraoperative complications in which the placement of double-J stents was not accomplished and conversion to open surgery (Satava grade II) occurred in 17 (6.09%) and 2 (0.72%) patients, respectively. A total of 270 patients (277 kidneys) were included in the analysis of postoperative complications. Postoperative complications occurred in 51 (18.89%) patients. The most frequent postoperative incident was febrile UTI in 27 patients. Of the 13 patients who required reoperations, 6 patients had kidney restenosis and were considered as failure of surgery. All complications with an exact onset time occurred within 10 months after surgery. In the univariate and multivariate analysis, weight <10 kg and having intraoperative complication with nephrostomy tube were risk factors of higher Clavien postoperative complication grade (P＜0.05).

DISCUSSION

Patients who were <10 kg in weight and having intraoperative complication with nephrostomy tube had a greater risk of a higher Clavien grade postoperative complication. To reduce high Clavien grade postoperative complications, asymptomatic patients under 10 kg in weight and having intraoperative complication with nephrostomy tube need close monitoring. In the 26 patients who had an exact time of the postoperative complications, the longest time we found was 10 months. Thus, we recommend the follow-up time required to observe postoperative complications in patients should be at least 10 months after surgery.

CONCLUSIONS

LP has been proven to be safe and effective in children with a low rate of complications. Weight <10 kg and having intraoperative complications with nephrostomy tube were risk factors of higher Clavien grade postoperative complications. Children with low weight and intraoperative complications need more attention in terms of the occurrence of complications.

The outcomes of mini-laparoscopic pyeloplasty in children - brazilian experience

Objetive

Pelvicureteric junction (PUJ) obstruction is the main cause of hydronephrosis in childhood. Open pyeloplasty has been the gold standard treatment of this condition with success rate above 90%. The role of laparoscopic pyeloplasty (LP) in children is less well defined and has slowly emerged as an alternative procedure. We report outcomes of our initial experience with LP in 38 children from 2 months of age.

Materials and Methods

From June 2015 to December 2017 38 children aged 2-60 months (mean age 1.7 years) underwent LP for correction of PUJ obstruction. The mean pre operative anteroposterior diameter of the renal pelvis (APD) was 43,5mm and all patients had hydronephrosis (APD 21.4-76 mm) and obstructed curve on diuretic renogram. Anderson-Hynes pyeloplasty was the performed technique. Results are reported.

Results

Mean operative time was 107 minutes (70-180) with no conversion to open procedure. Pain control was needed mainly in the first 12hs. Mean hospitalization was 2 days (1-5). There were complications in 5 children not affecting the final outcome. Two patients had a re-obstruction requiring a second procedure with good result. The mean follow up was 18 months (13-36). The mean reduction on the postoperative APD was 41% - p<0,001 (end APD 5 to 41mm). Overall success rate was 94,7%. All children had good cosmetic results.

Conclusions

This is a small series limited by short follow up, however its data suggest that LP has good functional and cosmetic results, not compromising the success of the open procedure, regardless patient age.

Managing Ureteropelvic Junction Obstruction in the Young Infant

In the last decade, management of congenital UPJ obstruction has become progressively observational despite the lack of precise predictors of outcome. While it is clear that many children will have resolution of their hydronephrosis and healthy kidneys, it is equally clear that there are those in whom renal functional development is at risk. Surgical intervention for the young infant, under 6 months, has become relatively infrequent, yet can be necessary and poses unique challenges. This review will address the clinical evaluation of UPJO in the very young infant and approaches to determining in whom surgical intervention may be preferable, as well as surgical considerations for the small infant. There are some clinical scenarios where the need for intervention is readily apparent, such as the solitary kidney or in child with infection. In others, a careful evaluation and discussion with the family must be undertaken to identify the most appropriate course of care. Further, while minimally invasive pyeloplasty has become commonly performed, it is often withheld from those under 6 months. This review will discuss the key elements of that practice and offer a perspective of where minimally invasive pyeloplasty is of value in the small infant. The modern pediatric urologist must be aware of the various possible clinical situations that may be present with UPJO and feel comfortable in their decision-making and surgical care. Simply delaying an intervention until a child is bigger may not always be the best approach.

Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances. Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures. Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame. Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

Outcomes of infants undergoing laparoscopic pyeloplasty: A single-center experience

PURPOSE:

The aim of this study was to evaluate the outcomes of laparoscopic pyeloplasty in children less than 12 months of age.

MATERIALS AND METHODS:

The records of 20 infants, who had pelviureteric junction obstruction and subsequently underwent LP from January 2013 to November 2016 with at least 1 year of follow-up, were retrospectively reviewed. Patients demographics, the results of preoperative and postoperative imaging studies, perioperative details, complications, and results were noted.

RESULTS:

The mean age of 20 infants was 4.75 months. The gender of cases was 5 females (25%) and 15 males (75%). Of that, 13 (65%) laparoscopic pyeloplasties were in left side and 7 (35%) were in right side. No cases needed open conversation. Aberrant crossing vessel was observed in three patients (15%). The mean operation time was 79.35 min (45-128 min). The mean hospital stay was 2.9 ± 0.308 days (2-3 days). There were complications in three children (15%); two patients developed stent migration and one child had fever over 38°. Three children with complications did not require a second intervention. In one child, the kidney was non-functioning in follow-up and nephrectomy was performed. The anteroposterior diameter significantly reduced. Preoperative mean value was 24.305 ± 5.6157 and postoperative mean value was 15.40 ± 6.030 (p = 0.000, p < 0.05). There was a significant degree of improvement in renal split function for all patients. Preoperative mean values were 45.53 ± 11.512, while postoperative values were 47.850 ± 13.347 (p = 0.029, p < 0.05).

CONCLUSION:

Although there are doubts about the reliability and efficacy of results for pyeloplasty in children less 12 months, many studies including this study show that laparoscopic pyeloplasty is an effective and reliable method for infants.

Prospective evaluation of retroperitoneal laparoscopic pyeloplasty in children in the first 2 years of life: Is age a risk factor for conversion?

INTRODUCTION

Laparoscopic pyeloplasty in children has stood the test of time. A clear advantage of laparoscopic pyeloplasty over open pyeloplasty has been proven both by retrospective and prospective trials. The aim of the current study was to address, in a prospective design, the outcomes, safety, conversion rates and risk factors for conversion in children aged <2 years who underwent retroperitonoscopic pyeloplasty by a single surgeon.

PATIENTS AND METHODS

In the period April 2014 to May 2016, 15 children with a median age of 6 months (range 1-24) and ureteropelvic junction (UPJ) obstruction were operated by a single surgeon using retroperitonoscopic pyeloplasty with antegrade renal stenting. The position and sites of tracers are shown in the figure.

RESULTS

With a median follow-up of 6 months, there were no recurrent cases of UPJO; one child had postoperative complications and recovered conservatively; median hospital stay was 1 day (range 1-7); and conversion to open pyeloplasty was encountered in three children (20%) aged <3 months. A statistically significant difference between laparoscopic and converted cases was present concerning the age (P = 0.048); neither gender nor side was significantly different.

DISCUSSION

Laparoscopic pyeloplasty in young children has been reported in many retrospective trials. Retroperitonoscopic pyeloplasty in young children has not been reported in prospectively designed studies to address safety and outcome. The current study reported experience in young children, defining the age category <3 months as a high-risk group for conversion to open surgery, but not to higher incidence of complications.

CONCLUSION

Retroperitonoscopic pyeloplasty in children aged <2 years is feasible, safe and successful. High conversion rates to open pyeloplasty have to be expected in children aged <3 months.

The BULT Method for Pediatric Minilaparoscopic Pyeloplasty in Infants: Technique and Results

We reviewed retrospectively the results of transperitoneal minilaparoscopic pyeloplasty in children younger than 2 years. The surgical technique utilized as well as the retrograde placement of the stent is described in detail. Twenty-four consecutive children with a mean age of 7.9 months (range 1-23), a mean weight of 7.4 kg (range 4-12), and a mean follow-up of 18 months (range 3-59) are included. Preoperative grade of dilatation was 3.8 (SFU scale) and postoperatively improved to 1.5. The AP diameter of the pelvis decreased from a mean of 28-9 mm. In 83% of cases, there was complete resolution of hydronephrosis (grades 0-2) and the rest showed improvement. There was one conversion to open surgery in a child with a horseshoe kidney. There was one omental prolapse though a port site in a child in whom an inappropriate drain was used. There were no stent-related complications and no reinterventions for persistent or recurrent obstruction. Given these outcomes, low complication rate and excellent cosmetic results, we recommend transperitoneal minilaparoscopy with a double J stent and a perirenal drain for infants requiring pyeloplasty.