Laparoscopic pyeloplasty for repair of pelvi-ureteric junction obstruction in children

To report our initial experience with laparoscopic pyeloplasty (LP) in children with pelvi-ureteric junction (PUJ) obstruction, and to describe the evolution and evaluate the results for these patients.

Between May 2005 and April 2008, we retrospectively reviewed the records of 28 consecutive infants and children (20 males, eight females; mean age 63 months, range 2-180 months) with unilateral PUJ obstruction, some with deterioration of renal function on isotope renography. They all underwent LP (18 on the right, 10 on the left). The patient was placed in a (3/4) lateral position with three ports. The PUJ was resected and the anastomosis made using absorbable sutures. A JJ stent was inserted by laparoscopy in the majority of patients. Follow-up included clinical and ultrasound assessment, and isotope renography at 6 months.

LP was feasible in 26 of 28 patients (93%). The procedure could not be completed by laparoscopy in two patients, the main reason being difficulty in completing the anastomosis. Stent insertion was successful in 25 of the remaining 26 cases. In the one unsuccessful case, a perianastomotic drain was placed without complication in the postoperative period. An aberrant crossing vessel was found in four patients. In two we held up the aberrant crossing vessel and PUJ by 2-3 non-absorbable sutures without tension, and without the need for pyeloplasty. In the other two cases we performed an LP-enabled ureteric transposition. There were three postoperative complications: pyelonephritis in two patients and one patient required operative intervention for PUJ leakage, and underwent a nephrostomy with a further uneventful course. The mean operative time was 145 min (range 70-270 min), and mean hospital stay was 4 (1-8) days. In one patient the JJ time of removal by cystoscopy, and ureteroscopy was used to retrieve it. Mean follow-up was 18 months (range 4-64 months). The 26 patients who underwent LP were asymptomatic after removal of the double JJ stent, showing reduction of the degree of hydronephrosis in all patients, and had also improved PUJ drainage on isotope renography or sonography.

LP is effective and safe in children with minimal morbidity and gives excellent short-term results. The feasibility is also excellent in patients younger than 1 year. The transabdominal approach revealed good exposition without disadvantage to the patient. However, the LP is more difficult and the operative time remains longer than open pyeloplasty.