Double J or transrenal transanastomotic stent in laparoscopic pyeloplasty in infants and children: a comparative study and our technique

Laparoscopic pyeloplasty in neonates and infants is safe and efficient

Introduction

Dismembered laparoscopic pyeloplasty (LP) is a well-accepted treatment modality for ureteropelvic junction obstruction (UPJO) in children. However, its efficacy and safety in infants, particularly neonates, remain uncertain. To address this significant knowledge gap, we aimed to compare outcomes between a cohort of neonates and infants undergoing LP vs. open pyeloplasty (OP) at less than 6 months and 6 weeks of age.

Material and methods

We conducted a retrospective analysis of data from patients who underwent primary pyeloplasty at our institution between 2000 and 2022. Only patients aged 6 months or less at the time of surgery were included, excluding redo-procedures or conversions. Ethical approval was obtained, and data were assessed for redo-pyeloplasty and postoperative complications, classified according to the Clavien-Madadi classification. A standard postoperative assessment was performed 6 weeks postoperatively. This included an isotope scan and a routine ultrasound up to the year 2020.

Results

A total of 91 eligible patients were identified, of which 49 underwent LP and 42 underwent OP. Patients receiving LP had a median age of 11.4 (1-25.4) weeks, compared to 13.8 (0.5-25.9) weeks for those receiving OP (p > 0.31). Both groups in our main cohort had an age range of 0-6 months at the time of surgery. Nineteen patients were younger than 6 weeks at the time of surgery. The mean operating time was longer for LP (161 ± 43 min) than that for OP (109 ± 32 min, p < 0.001). However, the mean operating time was not longer in the patient group receiving LP at ≤6 weeks (145 ± 21.6) compared to that in our main cohort receiving LP. There was no significant difference in the length of stay between the groups. Four patients after LP required emergency nephrostomy compared to one patient after OP. The rate of revision pyeloplasty in our main cohort aged 0-6 months at surgery was 8% in the patient group receiving LP and 14% in the patient group receiving OP (not significant). Three revisions after LP were due to persistent UPJO, and one was due to stent migration. Only one patient requiring revision pyeloplasty was less than 6 weeks old.

Conclusion

To our knowledge, this is one of the largest collectives of laparoscopic pyeloplasty performed in infants, and it is the youngest cohort published to date. Based on our experience, LP in neonates and infants under 6 months appears to be as effective as open surgery.

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).

Comparison of external stents and DJ stents techniques for pediatric pyeloplasty: A systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the efficacy and safety between an external stent and a Double J stent for pediatric Pyeloplasty.

METHODS

Through a systematical search of multiple scientific databases in July 2022, we performed a systematic review and meta-analysis of the primary outcomes of interest according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), whose protocol was registered with PROSPERO(CRD42021274087).

RESULTS

Eleven studies involving 1,758 patients were included. No significant differences were observed in operative time (MD: 2.26; 95% CI -9.62 to 14.14; P = 0.79), operative success rate (OR: 1.10; 95% CI 0.57 to 2.10; P = 0.780), length of hospital stay (MD: 0.65; 95% CI -0.04 to 1.34; P = 0.063), or complications (OR: 0.87; 95%CI 0.48 to 1.56; P = 0.630) between external stents and DJ stents in pediatric pyeloplasty. According to the subgroup analysis, we found the external stent group had a shorter operative time than the DJ stent group in terms of robot-assisted laparoscopic pyeloplasty (MD: -17.13; 95% CI -32.8 to -1.45; P = 0.032).

CONCLUSIONS

There were no significant differences in operative time, operative success rate, length of hospital stay, or complications between external stents and DJ stents in pediatric pyeloplasty. The external stented procedure seemed to have less operative time when using robot-assisted laparoscopic pyeloplasty. However, due to the limitations of our analysis, more studies are still required to support our conclusion.

SYSTEMATIC REVIEW REGISTRATION

This systematic review has been registered on PROSPERO, the registration ID is CRD42021274087.

Trans-uretero-cystic external urethral stent for urinary diversion in pediatric laparoscopic pyeloplasty: A novel approach

PURPOSE

We present a new approach for urine drainage in pediatric patients following laparoscopic pyeloplasty, the trans-uretero-cystic external urethral stent (TEUS).

METHODS

We retrospectively identified 85 children who underwent laparoscopic pyeloplasty from July 2015 to June 2017. The included children were assigned to group A (double-J stent) or group B (TEUS). In group A, the double-J stent was removed by a cystoscopy under anesthesia after 1 month, while in group B, the external stent was removed after 5 to 7 days. We examined the durations of operation, hospital stay and the frequency of stent-related complications including urinary leakage, stent dislocation, stent occlusion, and urinary tract infection.

RESULTS

The operation time was significantly longer for patients in group B than for those in group A. No significant difference was observed between the groups regarding stent-related complications. In group A, 4 patients need auxiliary stent re-insertion for the management of complications, 2 developed urinary tract infection, and 2 had stent occlusion. In group B, none needed auxiliary stent re-insertion for complications and avoided re-operation.

CONCLUSIONS

In children, the outcome of external stent implantation was similar to that using double-J stent, and the use of the former approach may be beneficial for younger children.

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.

Laparoscopically Guided External Transanastomotic Stenting in Dismembered Pyeloplasty: A Safe Technique

OBJECTIVE

To describe a technique for insertion of external transanastomotic stents during laparoscopic dismembered pyeloplasty in children of all age-groups. To analyze stent-associated complications and changes in differential renal function (DRF).

PATIENTS AND METHODS

A retrospective study was performed of all patients up to 18 years of age undergoing laparoscopic pyeloplasty at our institution between March 2004 and December 2013. We analyzed patients in whom an external transanastomotic stent was placed using a specially constructed semicircular spear. Medical records were reviewed for stent-associated complications such as bleeding, stent dislocation, stent obstruction, and urinary tract infection. Additionally required secondary surgical procedures and changes in DRF were assessed.

RESULTS

A total of 150 patients (155 renal units [RU]) were included in the study, with a median patient age of 22 months (range, 1-214). Stents were removed after a median time of 7 days (range, 3-21). Stent-associated complications were observed in a total of 11 patients (12 RU), consisting of stent dislocations (6 RU), stent obstructions (3 RU), and persistent percutaneous leakage along the stent (1 RU) or after stent removal (2 RU). Stent-associated complications required a secondary surgical procedure in 4 RU. Neither significant blood loss nor urinary tract infection was associated with external transanastomotic stent placement. DRF did not change significantly after the procedure.

CONCLUSION

External transanastomotic stenting during laparoscopic dismembered pyeloplasty using a specially constructed semicircular spear is a safe technique associated with a low complication rate and only rarely requires secondary surgical procedures for stent-related complications. This technique makes an additional anesthesia for stent removal unnecessary, as it is required for internal urinary diversion.