Which is better--retroperitoneoscopic or laparoscopic dismembered pyeloplasty in children?

Groups at multiple institutions have documented the efficacy of minimally invasive repair of ureteropelvic junction obstruction with a retroperitoneoscopic or laparoscopic approach. To our knowledge no group has compared the 2 operative procedures directly at a single institution.

The records of 49 consecutive patients with a history of retroperitoneoscopic pyeloplasty or transperitoneal laparoscopic pyeloplasty for ureteropelvic junction obstruction were reviewed retrospectively, of whom 29 underwent attempted retroperitoneoscopic pyeloplasty and 20 underwent laparoscopic pyeloplasty. Retroperitoneoscopic pyeloplasty cases were performed first in the series before changing to the laparoscopic pyeloplasty approach. Retroperitoneoscopic pyeloplasty was performed using an anterolateral approach with retroperitoneal balloon distention. Laparoscopic pyeloplasty repair was performed using a transmesenteric approach for left ureteropelvic junction obstruction or after right colon mobilization for right repairs. Dismembered pyeloplasty was performed over a stent using 5-zero polydioxanone suture. Stents were placed antegrade or retrograde based on anatomy and presenting symptoms. Parameters studied were patient age, operative time, postoperative analgesic requirement during hospitalization, hospital stay and success rate.

No difference was observed between the 2 groups in patient age, success rate, hospital stay or analgesic narcotic requirement. Average operative time for retroperitoneoscopic pyeloplasty was significantly longer than for laparoscopic pyeloplasty (239.1 vs 184.8 minutes). Overall success rates were also statistically equivalent (25 of 27 retroperitoneoscopic and 19 of 19 laparoscopic pyeloplasties) with incomplete followup in 1 patient in the retroperitoneoscopic pyeloplasty group and 1 in the laparoscopic pyeloplasty group. Three children, including 2 with retroperitoneoscopic and 1 with laparoscopic pyeloplasty, had transient urinary extravasation postoperatively, which was related to poorly positioned stents. Five patients in the retroperitoneoscopic group and 1 in the laparoscopic group underwent balloon dilation for indistinct but persistent postoperative flank pain with equivocal radiological findings. There were no major complications following either technique.

In our experience no major difference exists between the retroperitoneoscopic and laparoscopic approaches for correcting ureteropelvic junction obstruction. The difference in operative time likely reflects the learning curve for laparoscopic suturing and dissection. Currently we prefer the laparoscopic approach because of the larger working space for suturing, the perceived ease of antegrade stent placement and the subjective improvement in cosmetic outcome. The 2 techniques should be considered equal with regard to the successful correction of ureteropelvic junction obstruction.