Vol.

46 (2): 253-259, March - April, 2020

ORIGINAL ARTICLE
doi: 10.1590/S1677-5538.IBJU.2019.0381

The outcomes of mini-laparoscopic pyeloplasty in children

- brazilian experience
_______________________________________________
Cristiane Reis Leonardo 1, Alexandra Muzzi 2, José Eduardo Távora 3, Rodrigo Q. Soares 3
1
Departamento de Urologia Pediátrica, Neocentro - Hospital Vila da Serra, Nova Lima, MG, Brasil;
2
Departamento de Cirurgia Pediátrica, Neocentro - Hospital Vila da Serra, Nova Lima, MG, Brasil;
3
Departamento de Urologia, Neocentro - Hospital Vila da Serra, Nova Lima, MG, Brasil

ABSTRACT ARTICLE INFO

Objetive: Pelvicureteric junction (PUJ) obstruction is the main cause of hydronephrosis Cristiane Reis Leonardo
in childhood. Open pyeloplasty has been the gold standard treatment of this condition http://orcid.org/0000-0003-3461-3465
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 out- Keywords:
comes of our initial experience with LP in 38 children from 2 months of age. Child; Laparoscopy; Kidney
Materials and Methods: From June 2015 to December 2017 38 children aged 2-60 Pelvis
months (mean age 1.7 years) underwent LP for correction of PUJ obstruction. The
Int Braz J Urol. 2020; 46: 253-9
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 di-
Submitted for publication:
uretic renogram. Anderson-Hynes pyeloplasty was the performed technique. Results June 10, 2019
are reported. _____________________
Results: Mean operative time was 107 minutes (70-180) with no conversion to open Accepted after revision:
procedure. Pain control was needed mainly in the first 12hs. Mean hospitalization was August 30, 2019
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 Published as Ahead of Print:
mean follow up was 18 months (13-36). The mean reduction on the postoperative APD October 30, 2019
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.

INTRODUCTION Open pyeloplasty has long been the gold

standard treatment of PUJ obstruction in children.
Pelvic-ureteric junction (PUJ) obstruc- The open approach was described by Anderson-
tion is a common problem and the main cause of -Hynes in 1949 with success rates over 90% (1).
hydronephrosis in childhood. The advent of pre- Laparoscopic pyeloplasty (LP) was first performed
natal ultrasound (US) has brought the diagnosis in adults in 1993 (2). The approach results are al-
even earlier, before symptoms occur. Thus, treat- ready well established, and it has been the first
ment has been proposed at younger ages. choice where such technology is available, with

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advantages of a minimally invasive procedure. Warmed pneumoperitoneum is maintained at a

The proposed benefits are shorter hospitalization, mean pressure of 8mmHG. Most of the time, the
reduced postoperative pain, early return to dai- renal pelvis is easily seen. When necessary, the
ly activities and improved cosmetic appearance, colon is reflected medially or it is approached
while providing good functional results in a rea- trans-mesocolon on the left side. A hitch stitch
sonable operative time (3, 4). is placed through the abdominal wall to stabilize
The first LP in children was performed in the renal pelvis. The PUJ is dismembered and the
1995 (5). It has gained popularity for older chil- healthy ureter is spatulated on its lateral aspect.
dren. The role of LP in youngers and mainly in 6.0 (until 2 years old) or 5.0 polyglactin threads
infants is less well defined. It has just slowly (>2 years old) are used in a running suture fashion
emerged as safe and an alternative to the open for pelvi-ureteric anastomosis. Except in a very
procedure (6). large APD (>50mm), no attempt is made to trim
From the end of 2014 on we started a mul- the dilated pelvis. The anastomosis is performed
tidisciplinary program to develop minimally inva- anterior to anomalous lower pole vessel, when it
sive pediatric urology. Since June 2015, all chil- is present. The DJ stent is placed toward the blad-
dren with PUJ obstruction have been submitted to der in an antegrade fashion. A drain is introduced
LP in our institution. through the lower port. Local bupivacaine is used
The results of our initial experience with in all trocar ports. A bladder catheter is left in pla-
LP in children from 2 months to 5 years old are ce during hospitalization (Figures 1 and 2).
reported here, addressing pre and postoperative Oral intake is started as soon as the patient
data. is recovered from anesthesia.
Pain control is available on patient and or
MATERIALS AND METHODS parents demand. Intravenous dipyrone and oral
paracetamol are available to usual pain. Morphine
From June 2015 to December 2017 38 chil- is available to non-regular pain.
dren undergoing LP due to PUJ obstruction and All patients have been followed by US at
aged 5 years old or younger were enrolled to this 1, 3 and 6 month after DJ removal and thereafter
study. at every 6 months. DR was repeated when renal
Inclusion criteria were: follow-up of at le- dilatation persisted on US.
ast 6 months after double J (DJ) stent removal and Statistical analysis was performed by sta-
US after this period of time. tistical software. Data were expressed in mean
Indications for surgery were worsening and range for continuous variables. Students t-
hydronephrosis and anteroposterior diameter of -test was used to compare pre and postoperative
the renal pelvis (APD) above 20mm on US, plus parameters. A p value of <0.05 was considered
obstructed pattern on diuretic renogram (DR)-Tc significant.
99m diethylenetriamine penta-acetic acid (DTPA).
The surgical technique performed was An- RESULTS
derson-Hynes dismembered pyeloplasty.
LP is performed positioning the child in From June 2015 to December 2017 thirty
a 60-degree lateral decubitus with the side to be eight children aged 2-60 months (mean 1, 7 years
treated up. Four ports are used: 3 to 3mm ins- old) underwent LP and were included in this study.
truments (20cm long) and 15mm to the telescope. All patients were operated on by the same team-2
The telescope is positioned lateral to the umbili- surgeons (CRL and RSQS).
cus on the side of the affected kidney. The next There were 28 boys and 10 girls. Twenty
2-3mm ports are placed mid clavicular and an- patients were younger than 1 year old, 6 were
terior axillary lines in a triangular fashion to the between 13 and 24 months and 12 between 25
telescope port. The last 3mm port is placed in the months to 5 years old. The mean weight was
lower abdomen, also in the mid clavicular line. 8.2Kg (4 to 22Kg).

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Figure 1 - Trocars position - lateral decubitus. The mean pre-operative APD was
43.5mm (21.4 to 76mm) on US. Loss of renal
cortex was found in 17 patients (68%).
All patients had an obstructed pattern
on DR and post furosemide T1/2>20min. Of
them, 9 presented split renal function <40% on
the affected side Table-1 shows details of the
procedure.

Mean surgical time was 107 minutes

(70-180min) from port insertion to port closu-
re. There was no conversion to open procedure.
Eleven patients had a lower pole vessel obstruc-
ting the PUJ (29%).
Child postioned to left pyeloplasty in a 60-degree lateral decubitus. One 5mm trocar Oral intake was started from 40 to 240 min
to the telescope placed lateral to the umbilicus on the side of the affected kidney and
two 3mm ports placed in a triangular fashion to the telescope port. The last 3mm
(mean 120min) after the end of the procedure.
port is placed in the lower abdomen on the mid clavicular line. Mean time of analgesia requirement was
12hs (0-24hs). Dipyrone was used. No opioid
Figure 2 - Trocars position - postoperative period. was necessary.
Mean hospitalization was 2 days (1-5 days).
DJ stent was removed in mean after 45
days after the procedure (15-62 days). There were
complications in 6 children (15.7%) with no effect
on the final outcome. Three children had UTI, one
of them needing hospitalization. Two had dislod-
gement of the DJ stent. One had omental fat ex-
teriorization during drain removal.
Two patients had worsening hydrone-
phrosis and re-obstruction after DJ removal,
requiring a second intervention. The second
procedure was performed by laparoscopic ap-
proach with very good results. The first one
had chromosomal disease and abnormal renal
vessels. The second one had previous infective
stones which were removed at the LP.
Position of the trocars - right pyeloplasty, one 5mm port to the telescope placed Median follow-up was 18 months (from
above and lateral to the umbilicus on the side of the affected kidney and three 3mm 13 to 36 months).
trocars to the instruments.
Mean reduction on the postoperative
APD was 41.8% (end APD 5 to 41mm) p <0.001.
PUJ obstruction was diagnosed by antenatal Three patients had improved, but maintai-
hydronephrosis in 27 patients, urinary tract infec- ned postoperative hydronephrosis. All of them
tion (ITU) in 6 and abdominal pain in 5 patients. showed a good washout curve on DTPA. All
Comorbidities were present in 6 children: 1 children are symptoms free. All children had
vesicoureteric reflux, 1 horse shoe kidney, 2 chro- good cosmetic results. Overall success rate was
mosome disease, 1 multicystic dysplastic kidney, 1 94.7%, Table-2 shows results according to age.
renal stones. Two patients had previous pyelostomy.
Obstruction was on the left renal pelvis in All parents of the children signed the in-
20 children (52%). formed consent for LP.

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Table 1 - Laparoscopic Pyeloplasty - surgical details.

Pelvis approach
Colon mobilization 27 (71%)
Transmesocolon 11 (29%)
Anastomotic thread
Vicryl 5.0 12 (32%)
Vicryl 6.0 (<2 years old) 26 (68%)
Drain
Penrose 4
Suction 33
No one 1
Bladder catheter + Double J 38
Surgical time (min.)
Mean 107 min.
Range 70-180 min.
Conversion to open procedure 0

Table 2 - Laparoscopic Pyeloplasty - results by age.

N (38) Age APD reduction Surgical time min Success Rate

20 < 1 year 44,6% 82-180 20/20

6 1-2 years 43% 70-160 6/6

12 3-5 years 38% 98-170 10/12

N = number of patients; APD = anteroposterior pelvic diameter

DISCUSSION obstruction have been submitted to LP in our ins-

titution. We report here the outcomes and details
PUJ obstruction is a common problem of 38 LP in children aged 2 months to 5 years old.
in children. The open dismembered pyeloplasty Minimally invasive surgery has gained
described by Anderson-­‐Hynes has long been the the world and its benefits are well known: image
gold standard treatment with success rate above magnification, decreased blood loss, lower anal-
90%. Although LP has been widely performed in gesia requirement, faster recovery, better cosme-
adults, its benefits in infants have been less cle- tic outcome. LP also has another reported benefit.
ar. The minimally invasive approach has slowly Through laparoscopic view, the PUJ is seen in
emerged as safe and effective alternative to treat its real position, in contrast to the open or video
PUJ obstruction in children. assisted procedure which brings the PUJ outside,
By the end of 2014 we started a multi- disrupting its normal anatomy. LP is thought to
disciplinary program in pediatric urology which provide better identification to anomalous ves-
comprised adult videourology and pediatric uro- sels and avoid twisting or bad positioning of the
logy teams. Adult experience was already establi- ureter (3, 7).
shed and after experience was obtained with older The dismembered LP for treatment of
children we were able to start operating the youn- PUJ obstruction in children was first described
ger ones. Since June 2015 all children with PUJ in 1995 (5). Since then, a few pediatric large se-

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ries are available in the literature. Many reference 16) we had spent a mean of 107min., which
centers do not have programs to perform LP in may be near the open procedures time. Previous
young children-less than 2-3 years old (8). Ho- adult experience, same team, routine and focu-
wever, while early series had reported anastomo- sing on simplifying every step certainly play a
tic stenosis in babies (9, 10), subsequent studies role in the operative time.
demonstrated feasibility irrespective of patient DJ stent is inserted by laparoscopic view.
age and weight (6, 7, 11-13). A guide wire is placed through a 3mm aspirating
LP has been thought to be a technically tube in an antegrade fashion, saving the cystos-
challenging procedure in children. In fact it re- copy time. Those who favor cystoscopy inser-
quires suture training and an experienced lapa- tion affirm that retrograde DJ insertion avoids
roscopist (3, 8). There is a learning curve to LP stent dislodgement and related complications
with is far more difficult to pediatric surgeons. (8). However, a study of 15 academic European
Since the beginning of training, pediatric sur- institutions showed that the antegrade fashion
geons have smaller and more delicate structures provided the lowest complication rate compared
to work with, compared to adult surgeons who with retrograde stent insertion (17).
find larger structures in their patients. There- We had one child whose DJ didn’t rea-
fore, limited laparoscopic working space and ch the bladder. Since then, we focus on urine
small ureteral caliber make anastomosis chal- drops reflowing from the stent as it reaches the
lenging. Also, even in reference centers, the bladder. The bladder catheter is inserted at the
number of pediatric cases in general suitable end of the procedure or otherwise kept closed in
for laparoscopic procedures in the same pe- the bladder until there.
riod of time is lower to pediatric urology when Surgical site drainage may be a matter
compared to the adult urology, slowing the le- of discussion since the postoperative leakage is
arning curve further. Despite this, virtual labs usually little. Perinephric drain offers the ad-
and multidisciplinary practice may be useful to vantage of warning about complications. Pos-
speed the learning curve. toperative ileus is described by series where
In our institution after having establi- drains are avoided (3, 6). We started using a
shed a per and postoperative protocol, all pa- Penrose drain, but moved on to suction drain.
tients were operated by the same team (2 sur- Although we had a small omental prolapse, it
geons CRL and RSQS). Therefore, the surgical wasn’t necessary any surgical procedure to deal
steps were redrawn as needed. with. Adequate size Blake® drains may reduce
Robotic surgery certainly will add tech- the reported risk (8).
nical facilities in pyeloplasty (14, 15). However, Our children had oral intake soon after
the need of larger incisions for larger port pla- anesthetic recovery with very good tolerance. Af-
cement and no availability of 3mm instruments ter local bupivacaine injection at the end of the
makes its role in younger children questionable procedure, pain control was on patient and parents
at moment. demand. It was used in mean during the first 12hs
Concerning technical details, we use which is a short time when compared with open
three ports. The third port helps on exposure. procedures. No opioids were necessary. Two pa-
Not placing the telescope into umbilical scar tients didn’t require any postoperative analgesia.
brings all the instruments near the target PUJ. Hospitalization was in average 2 days.
This may avoid organs injuries in small spaces Although a subjective data, patients were no-
as reported even by expert laparoscopists (3, 6). ticed to be with more mobility when compa-
While operating on babies it is impor- red to our experience in open procedures. In a
tant a full integration of the anesthetic team to comparative prospective study of open versus
laparoscopic procedures at younger ages. laparoscopic pyeloplasty in children, Piaggio
Although most series report longer ope- et al. observed fewer narcotic need and shorter
rative time in LP, (mean 155-240min) (3, 8, 11, hospitalization for LP as others (16, 18).

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Our study showed very good functional This study demonstrated functional results
results in 33 children with significant reduction as reported to open surgery and benefits of a mi-
of the hydronephrosis - mean reduction on the nimally invasive procedure as described by other
postoperative APD was 41.8% (preoperative APD- series in literature (12, 13 17, 22, 27, 28).
21 to 76mm and final APD-5 to 41mm) p<0.001.
We don’t regularly trim the renal pelvis and the CONCLUSIONS
APD reduction found is associated with success
rate according to the literature (19). Our study is limited by short follow-up
Four patients underwent DR as they had and small number of patients, however its data
maintained postoperative hydronephrosis. Des- suggests that LP has acceptable percentage of
pite persistent dilatation, all of them showed complications, good functional and cosmetic re-
a good washout curve on DTPA with no obs- sults, not compromising the success of the open
tructed pattern, ensuring a good result after LP. procedure, regardless patient age.
Two children needed reoperation due to worse-
ning hydronephrosis post operatively. One pa-
tient had abnormal chromosomes and disrupted CONFLICT OF INTEREST
anatomy with intra-­‐renal pelvis and anoma-
lous vessels to the kidney. The fail was due to None declared.
the fact that the pelvic-ureteric anastomosis
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19. Rickard M, Braga LH, Oliveria JP, Romao R, Demaria J, _______________________
Lorenzo AJ. Percent improvement in renal pelvis antero- Correspondence address:
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afterpediatric pyeloplasty supporting safe monitoring Belo Horizonte, MG, Brasil, 30210-370
with ultrasound alone. J Pediatr Urol. 2016;12:228.e1-6. E-mail: cris.leonardo@gmail.com

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