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Laparoscopic pyeloplasty in posteriorly malrotated renal pelvis: Preoperative clues, laparoscopic challenges, and
Ramesh Babu1, Sneha Angadi1, Rajkumar Ashwin1
1Department of Paediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai - 600106, India.
Introduction:
Posterior malrotation of the renal pelvis is an under-recognised anatomical variant that can make laparoscopic pyeloplasty technically demanding because of difficult hilar exposure and an unfavourable orientation of the pelviureteric junction (PUJ). We describe characteristic preoperative imaging findings and simple operative modifications that facilitate successful reconstruction.
Patients And Methods:
Between 2018 and 2024, 24 (10.9%) of 220 children undergoing laparoscopic surgery for PUJ obstruction had a posteriorly malrotated renal pelvis. Preoperative suspicion was based on a box-shaped intrarenal pelvis with disproportionate calyceal dilatation despite a relatively small extrarenal pelvis. Twenty-four children underwent laparoscopic pyeloplasty using upfront nephropexy, a liver hammock for right-sided exposure, and early apex anchoring sutures; 12 additionally required nephropexy after reconstruction.
Results:
All procedures were completed laparoscopically without conversion or intraoperative complications. At a median follow-up of 24 months, split renal function improved from 38.4% to 42.6% (p = 0.004) and drainage half-time from 36.8 to 11.4 min (p < 0.001). Significant improvement occurred in anteroposterior pelvic diameter, cortical thickness and pelvis/cortex ratio (all p < 0.001). No patient required redo pyeloplasty or secondary intervention.
Conclusions:
Anticipating posterior malrotation (box shaped pelvis/right side/female) avoids unexpected intraoperative difficulty. Additional stay sutures aid laparoscopic reconstruction while adding a nephropexy prevents recurrence.