Laparoscopic dismembered pyeloplasty in children younger than 2 years

Laparoscopy has been implemented in the pediatric urologic population for many different operative interventions.

Recently, laparoscopic pyeloplasty has been shown to be feasible in the pediatric population with few reports also branching out into the infant and toddler population. This study by Cascio, et al. reviewed their experience with laparoscopic dismembered pyeloplasty in kids under the age of 2 years. It was a retrospective review of patients who underwent a laparoscopic Anderson-Hynes dismembered pyeloplasty. The diagnosis of UPJ obstruction was confirmed on renal sonography and diuretic renogram. All the procedures were done transperitoneal. All patients underwent postoperative diuretic renograms and renal ultrasonography.

They had 38 children with UPJ obstructions that underwent a laparoscopic pyeloplasty. Of these patients, 11 of them were younger than 2 years of age. One had bilateral ureteral pelvic junction obstructions. Two of these patients (17%) required a redo laparoscopic pyeloplasty as well. The operative time ranged from 70-140 minutes and the mean hospital stay was 2 days. Follow-up studies showed normal drainage in all patients except one who after the redo pyeloplasty exhibited significantly improved but still prolonged drainage. They comment that their study suggests that laparoscopic pyeloplasty can now be performed on young children with good results.

I agree that the laparoscopic approach is feasible in this patient population. However, I also feel that it is a very challenging operating. With the use of 3 mm instrumentations and 6-0 and 7-0 sutures, the amount of skill required for this intracorporeal suturing is quite high. Nonetheless, for those who are comfortable with laparoscopy, this approach may even be better than an open approach because the surgery is performed in situ with minimal tissue manipulation. I perform these procedures with stay sutures to avoid traumatizing the ureter. We typically utilize 7-0 and 6-0 suture material for our anastomosis. At first, we place stents in all these children but now we are moving more towards a percutaneous 5 or 4 French open ended catheter, traversing the anastomosis down into the mid ureter. I have been happy with this approach and feel more comfortable doing a dismembered pyeloplasty laparoscopically then open. The key thing to remember is the patient. Laparoscopy should just be considered another alternative approach. I firmly believe that your operative approach whether laparoscopic or open if it is successful and comparable to the gold standards, you should offer that approach as your primary mode of intervention.

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