|Year : 2021 | Volume
| Issue : 1 | Page : 146-149
Laparoscopic primary ureterocalicostomy in children with ureteropelvic junction obstruction
RB Nerli1, Pathade Amey2, Shridhar C Ghagane3, Sushant Deole1, Murigendra B Hiremath4
1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed to be University), Belagavi, Karnataka, India
2 Department of Urology, KLES Centenary Hospital, Belagavi, Karnataka, India
3 Department of Urology, Urinary Biomarkers Research Centre, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
4 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Submission||30-Jan-2020|
|Date of Acceptance||10-Aug-2020|
|Date of Web Publication||09-Feb-2021|
Dr. R B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi-590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Ureterocalicostomy (UC) involves excision of the hydronephrotic lower renal pole parenchyma and anastomosis of the dismembered ureter directly to the lower pole calyx. UC offers distinct advantages, notably for obstruction secondary to complicating anatomical anomalies of the kidney, such as horseshoe kidney. The present study was aimed to assess our experience and evaluate the outcome of primary laparoscopic UC in children with ureteropelvic junction obstruction (UPJO).
Materials and Methods: We retrospectively reviewed the clinical notes, imaging records, and laboratory investigations of all the children who had undergone laparoscopic UC as a primary procedure in our center during a 12-year period (January 2006–December 2017).
Results: Ten children (six males and four females) underwent laparoscopic primary UC for UPJO during the study period. The mean age of the children was 10.8 ± 2.78 years. The mean operating time was 175 min (range 140–210 min). No major intraoperative complications were noted.
Conclusions: Primary laparoscopic UC for UPJO with complicated renal anatomy is feasible, safe, and associated with minimal morbidity. The outcomes show adequate drainage of the pelvicalyceal system.
Keywords: Anastomosis, kidney, laparoscopy, surgical, ureter, ureteral obstruction
|How to cite this article:|
Nerli R B, Amey P, Ghagane SC, Deole S, Hiremath MB. Laparoscopic primary ureterocalicostomy in children with ureteropelvic junction obstruction. Indian J Health Sci Biomed Res 2021;14:146-9
|How to cite this URL:|
Nerli R B, Amey P, Ghagane SC, Deole S, Hiremath MB. Laparoscopic primary ureterocalicostomy in children with ureteropelvic junction obstruction. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Apr 16];14:146-9. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/146/308965
| Introduction|| |
The Anderson-Hynes dismembered pyeloplasty technique is the preferred procedure for the treatment of congenital ureteropelvic junction obstruction (UPJO). This procedure has gained widespread acceptance as the standard UPJO repair, with a success rate of approximately 95%., However, there are occasions when it may be necessary to consider alternative techniques to achieve reliable drainage, such as recurrent UPJO, UPJO associated with anatomical anomalies, notably horseshoe kidney, and traumatic damage to the ureteropelvic junction (UPJ) or proximal ureter.,, One such procedure is an ureterocalicostomy (UC) which was first reported by Neuwirt in 1948.
Mesrobian and Kelalis were instrumental in popularizing UC and highlighting the key technical aspects of success, namely extensive excision of lower pole tissue to expose the calyx and a stented noncircumferential anastomosis, with care being taken to ensure continuity between the urothelial lining of the ureteric lumen and the luminal surface of the opened calyx. Mesrobian and Kelalis reported the use of UC for a range of indications in a series of 21 children ranging in age from 6 months to 17 years. Nineteen of these patients had a decrease or elimination of hydronephrosis. Few reports regarding laparoscopic UC in the pediatric population have been published to date. Gill et al. reported on their initial experience with laparoscopic UC in two adult patients, of whom one had UPJO and multiple secondary calculi in a dilated, dependent lower pole calyx, and one had surgically failed UPJO with a scarred pelvis and significant hydronephrosis. There are several issues in performing laparoscopic UC, one of them being excessive bleeding from the anastomotic site and the other issue being the creation of a tension-free ureterocaliceal anastomosis. A reliable and meticulous intracorporeal suturing technique is essential. We report our experience with laparoscopic primary UC for UPJO in children.
| Materials and Methods|| |
We retrospectively reviewed the clinical notes, imaging records [Figure 1],[Figure 2],[Figure 3], and laboratory investigations of all the children who had undergone laparoscopic UC as a primary procedure in our center during a 12-year period (January 2006–December 2017). The study was performed following permission obtained from the University/Institutional Ethical Committee. Detailed attention was paid to the surgical indications, technical aspects of the procedure [Figure 4] and [Figure 5], and clinical outcomes.
|Figure 1: Sonography shows left.sided gross dilatation of the pelvicalyceal system|
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|Figure 2: (a and b) Computed tomography shows gross dilatation of the left kidney with a small dilated pelvis|
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|Figure 3: Preoperative radioisotopic renogram shows poorly functioning obstructed left kidney|
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|Figure 4: (a) The left kidney, ureter, and renal pelvis are being dissected out. (b) The dilated lower pole is identified, and a part of the dependent lower pole is excised. (c) The lower calyx is opened wide. (d) Spatulation of the upper ureter|
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|Figure 5: (a) Ureterocalyceal anastomosis in process. (b) Insertion of double J. (c) Completed ureterocalyceal anastomosis|
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Ethical Clearance was obtained from KLES Kidney Foundation Institutional Ethics Committee with Ref no KLESKF/IEC/2016/22 dated 14.02.2016.
The procedure of laparoscopic UC was performed under general anesthesia. A 3 or 4 Fr ureteric catheter is introduced into the affected side under cystoscopic guidance. The child is positioned in the 45°–60° flank position. A three-port transperitoneal approach was used. The colon was reflected medially and the ureter was dissected free from its surrounding tissues up to the renal pelvis. The renal hilar vessels were similarly mobilized so as to apply the Satinsky clamps if necessary. The kidney was mobilized within Gerota's fascia and the thinned lower pole parenchyma exposed. As the parenchyma over the lower pole appeared to be thin, clamping of the renal hilar vessels was not done. An approximately 2 cm circular rim of the tip of the lower pole renal parenchyma was excised using both cold and hot scissors. Bleeders were cauterized and hemostasis achieved. The dilated lower pole calyx was entered and the interior of the collecting system was inspected.
The UPJ was transected and the opening in the ureter/pelvis was sutured. The upper ureter was spatulated laterally. The ureteric catheter was withdrawn partially and the end-to-end ureterocaliceal anastomosis was performed in mucosa to mucosa fashion using 5-0 absorbable sutures. The double J stent was inserted midway between the anastomosis. Freehand intracorporeal suturing and knot tying technique was used.
| Results|| |
Ten children (six males and four females) underwent laparoscopic primary UC for UPJO during the study period. The mean age of the children was 10.8 ± 2.78 years (range 6–15 years). The presenting symptoms included pain in the abdomen, fever with chills, and vomiting. The diagnosis of UPJO was based on ultrasonography imaging, intravenous urogram, radioisotope imaging, and whenever necessary computed tomography urogram. All children were taken up for laparoscopic pyeloplasty under general anesthesia with the children positioned in a modified semilateral position. The indications for conversion to laparoscopic UC are as shown in [Table 1].
The mean operating time was 175 min (range 140–210 min). No major intraoperative complications were noted. A 3 or 4 Fr double J stent was left in all. Postoperatively, the children were started on oral liquids within 24 h, the retroperitoneal drain was removed after 48 h, and the urethral catheter was removed after 72 h. No major postoperative complications were noted in any child. The double J stent was removed after 6 weeks, and a radioisotope renal scan was done 3 months later to note the drainage. All children showed improvement in drainage and were symptom free.
| Discussion|| |
Pyeloplasty is usually a very successful procedure, but unusual renal anatomy or complications require alternative techniques. It is ureterocalicostomy is an excellent operation in properly selected patients for restoring upper urinary tract continuity. It gives good results, especially in reconstructive efforts for renal salvage. Because of its particular indications, this procedure is rarely used, and usually, surgeons have limited experience. Open UC is a well-established procedure, and excellent outcomes have been reported.,,, The advantage of UC is that it provides dependent urinary drainage from the lower calyx into the ureter. Matlaga et al. reported successful open UC in 11 patients with no patients experiencing significant perioperative complications, and the renal function on the affected side improved from a mean of 54.6% preoperatively to 60.1% postoperatively. Similarly, Osman et al. reported a success rate of 73% in 22 open UCs after a mean follow-up of 26.7 months.
There have been a few reports of laparoscopic UC in the pediatric population that have been published till date. Radford et al. reported on the outcome of 13 children who had undergone UC. An open approach was employed in 12 patients, whereas in one patient, it was performed by a laparoscopically assisted technique. Arap et al. reported on a series of six laparoscopic UCs done for complicated upper urinary obstruction. Patients underwent laparoscopic UC due to previous failed procedures (three patients), anatomic abnormalities (two patients), and a severe upper ureteral stenosis (one patient). The median operative time was 215 (180–270) min. There were no major complications. There were no conversions to open surgery. In a median follow-up of 30 (8–56) months, all patients presented with clinical and radiological improvement with no signs of obstruction. In all cases, the postoperative renal scintigraphy revealed a T1/2 lower than 10 min.
Recently, Nishimura et al. reported the case of a 10-year-old female patient who presented with a high-grade hydronephrosis and a renal stone. Laparoscopic pyelolithotomy with UC was performed as the renal pelvis was completely intrarenal and the renal cortex was thinned out, especially at the lower calyx. A transperitoneal approach was used in a lateral flank position with four trocars. The renal stone was extracted with a small longitudinal incision made at the UPJ. Ureterocaliceal anastomosis was completed in a running fashion using 5-0 absorbable sutures. The postoperative course was uneventful. Postoperative imaging studies showed marked improvement of the right hydronephrosis.
The technique of open UC has been well established, and so has been the technique of laparoscopic UC. The technique of UC involves the disconnection of the ureter from the renal pelvis and identification of the most dependent portion of the lower pole calyx. The risk of fibrotic stenosis should be minimized by ensuring that the renal parenchyma is generously excised to expose a sizeable area of the lower pole calyx. A tension-free anastomosis between the spatulated proximal ureter and the opened calyx is created, with care being taken to ensure continuity between the two urothelial surfaces.
There has been a widespread increase in the use of the robotic surgical platform for almost every urological procedure that can be performed by open or laparoscopic means. The EndoWrist® technology, with its seven degrees of freedom, as well as the motion scaling feature, makes this an ideal platform for fine dissection and suturing, the very basis of reconstructive surgery. These features, in particular, seem to render UC ideally suited for robot-assisted reconstruction. The robot-assisted laparoscopic UC was first described in 2007 by Korets et al., in a patient with refractory proximal ureteric stricture, secondary to multiple interventions for stones. The authors used laparoscopy for the initial dissection and exposure and robotic techniques for lower pole amputation and the ureterocalyceal anastomosis. Wietsma et al. presented a case series of four patients with an age range of 11–22 years (average age 15 years) with equal gender distribution who underwent robot-assisted laparoscopic UC for left UPJO between 2011 and 2014. There were no intraoperative complications. The authors concluded that robotic UC was a feasible and successful procedure for recurrent as well as severe UPJO in pediatric patients. Similarly, Casale et al. reported successful robotic-assisted laparoscopic UC in nine pediatric patients. The mean operative time was 168 min, and the feasibility of the use of the robot was well demonstrated. All patients were found to have no evidence of obstruction on diuretic radionuclide imaging at 12 months postoperatively.
| Conclusions|| |
Ureterocalyceal anastomosis is still indicated in some difficult anatomical situations or anomalies in children. Laparoscopic UC is feasible, safe, and effective as a primary procedure whenever standard laparoscopic pyeloplasty is difficult to perform. The outcomes of this procedure are good as reflected on renograms.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]