| Abstract|| |
The aim of the present study is to report our experience with laparoscopic pyeloplasty via trans-mesocolic approach in children with left pelvi-ureteric junction (PUJ) obstruction. Between May 2007 and May 2008, 12 children aged between five and 16 years, with documented PUJ obstruction on the left side, underwent laparoscopic pyeloplasty via trans-mesocolic approach. The outcome was assessed by post-operative isotope renal scan. The mean age of the study patients was eight years, ranging between five and 16 years. There were five males and seven females in the study. All children underwent Anderson Hynes Pyeloplasty by a single surgeon. All cases were stented with a JJ stent for a period of six weeks post-operatively. The procedures were completed successfully in all patients without need for conversion to open pyeloplasty in any patient. The mean operative time was 95 min, with a range of 80-140 min. The average blood loss was 57 mL. The mean hospital stay was 3.5 days with a range of 2.5 to six days. All children returned back to school within nine days following surgery. The mean follow-up period was 12 months (range, nine to 14 months). Eleven of the patients were completely asymptomatic, while one reported mild flank pain. All children underwent renal scans and renal ultrasound three months after stent removal. Ten had improved function on the scan while in one patient, the function remained the same and, in another, it showed obstructed response to diuretic, although the symptoms had improved. In all the cases, renal ultrasound showed a decrease in the severity of hydronephrosis by at least one degree. These results confirm that laparoscopic pyeloplasty by trans-mesocolic approach in children for left-sided PUJ obstruction is safe and feasible.
|How to cite this article:|
Khan M, Ahangar S, Nazir SS, Qadri SF, Salroo NA. Laparoscopic trans-mesocolic pyeloplasty in children: Initial experience from a center in India. Saudi J Kidney Dis Transpl 2011;22:841-6
|How to cite this URL:|
Khan M, Ahangar S, Nazir SS, Qadri SF, Salroo NA. Laparoscopic trans-mesocolic pyeloplasty in children: Initial experience from a center in India. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Sep 21];22:841-6. Available from: http://www.sjkdt.org/text.asp?2011/22/4/841/82742
| Introduction|| |
Laparoscopic urology has rapidly evolved since mid-1990s through advances made in video technology and instrument design. The optimal correction of pelvi-ureteric junction (PUJ) obstruction has been a urological challenge ever since the entity is known. Open pyeloplasty, originally described by Anderson and Hynes, remains the standard against which many new techniques must be compared. The overall success rate of open pyeloplasty, even over longterm, is over 90%.  In 1983, Wickham and Kellet described percutaneous pyelolysis, which subsequently gained some popularity. The overall success rates of these minimally invasive options have consistently been less than open pyeloplasty, by 10-30%.  Laparoscopic pyeloplasty was introduced in 1993 by Schurssler et al, and has developed worldwide as a minimally invasive option that matches the success rates of open pyeloplasty, while achieving the added goals of low morbidity, short hospital stay and convalescence.  Laparoscopic pyeloplasty can be done via either trans-peritoneal or a retroperitoneal approach. Herein, we report our experience with trans-peritoneal laparoscopic pyeloplasty with a little modification in the approach to the renal pelvis. Our approach was via a window created in the mesocolon for left-sided PUJ obstruction. The trans-mesocolic approach to a dilated left pelvis enables a shorter operative time without increasing morbidity. 
| Patients and Methods|| |
This prospective study was conducted in the Department of Surgery, Government Medical College, Srinagar, India, from May 2007 to May 2008. Twelve children aged between five and 16 years with documented PUJ obstruction on the left side underwent laparoscopic pyeloplasty via trans-mesocolic approach. The indications for surgery were flank pain in ten children, while two patients had incidentally detected gross hydronephrosis on ultrasound, done for recurrent urinary tract infections. The pre-operative evaluation included routine blood examinations, urine culture, renal ultrasound, intravenous urography, diuretic renal isotope (Tc99 DTPA) scan, voiding cysto-urethrography and retrograde pyelography (when indicated). Nine patients showed obstructed response on diuretic injection during Tc99 DTPA scan; two showed an equivocal response and one patient did not respond to diuretic due to severe impairment of renal function. Among the patients with equivocal diuretic response, one had a concomitant renal calculus (laparoscopic trans-mesocolic pyelolithotomy with pyeloplasty was done in him) and, in another, trial with conservative treatment failed to resolve symptomatology.
Informed consent was obtained from parents and/or guardians before proceeding with the procedure. All the procedures were performed by a single surgeon having expertise in the field of advanced laparoscopy. All children underwent Anderson Hynes Pyeloplasty. The outcome was assessed by post-operative isotope renal scan. The mean age was eight years (range, five to 16 years); there were five males and seven females in the study. All cases were stented with a JJ stent for a period of six-weeks post-operatively.
The patient was initially positioned supine for intravenous access, induction of general anesthesia, endotracheal intubation, bladder catheterization and nasogastric tube placement. Following this, the patient was positioned in a modified lateral decubitus position. Approximately 30 degrees of rotation of the chest and abdomen was used. Pneumo-peritoneum was established by closed technique using veress needle peri-umbilically and insufflation was done to achieve an intra-abdominal pressure of 12 mmHg. The first trocar (10 mm) for the introduction of endo-camera was placed peri-umbilically through a horizontal skin incision. After inspection of the abdominal cavity, additional trocars were placed under direct vision. Two 5-mm trocars were placed lateral to the rectus at the level of the umbilicus and in the midline between the umbilicus and the xiphoid process. Additional trocar was used when necessary [Figure 1]. Identification of the kidney through the mesocolon is easy in children as the mesentery is thin and transparent owing to the less amount of fat [Figure 2]. A window was created in the mesocolon directly over the pelvis using Maryland dissectors/harmonic ace [Figure 3]. The renal pelvis and upper ureter were dissected clear [Figure 4] and the redundant pelvis was divided with endo-scissors starting from the inferior pole of the pelvis [Figure 5]. We did not divide the pelvis completely at this point as it would serve the purpose of traction and would keep the orientation of the ureter intact. The ureter was then spatulated laterally for up to 1 cm below the obstruction. A new PUJ was made by anastomosing ureteric spatula with the inferior part of the pelvis. The anastomosis was done using a 4-0 polyglactin suture in an interrupted fashion, starting by anastomosing the heel of the ureteric spatula to the inferior pole of the pelvis [Figure 6]. A JJ stent was put into the bladder through the pyelotomy and the upper J of the stent was positioned into the pelvis [Figure 7]. The remaining part of the pyelotomy was closed in a continuous fashion with the same suture type [Figure 8]. A drain was kept at the anastomotic site followed by the closure of the mesocolon window [Figure 9].
Post-operatively, the patients were ambulated as soon as they were painfree. Oral sips were started on the first post-operative day. Intramuscular analgesics were given on the first postoperative day and oral analgesics from the second post-operative day. The Foleys catheter was usually removed on the second post-operative day followed by the removal of drain on the third post-operative day, provided it did not increase following catheter removal. The patients were discharged home the same day.
| Results|| |
All the study children had primary PUJ obstruction, and none of them had had any intervention previously. All cases were successfully completed laparoscopically without any need for conversion to open surgery. The mean operative time decreased with increase in experience. The average blood loss was 57 mL, and none of our patients required any transfusion. Crossing vessels were identified in four of the patients (33.3%): they were found to be obstructing in only one case, in which laparoscopic transposition of the vessel was done. There were no major intra-operative complications [Table 1]. The mean hospital stay was 3.5 days (range, 2.5 to six days). All children returned back to school within nine days of surgery. Post-operative complications included prolonged urinary leak (Clavein grade 2) in one patient and port-site infection (Clavein grade 2) in another patient. Both were managed conservatively by keeping the drain and indwelling catheter in situ till the leak ceased in the first case, and twice-daily dressings in the second one [Table 2]. The JJ stent was removed after a period of six weeks post-operatively. The mean follow-up was 12 months (range, 9 to 14 months). Eleven of the patients were completely asymptomatic while one reported mild flank pain. All children underwent renal scans and renal ultrasound three months after stent removal. Ten children had improved function on the scan with non-obstructed response on diuretic injection, while in one, function remained the same with equivocal diuretic response and in another, the scan showed deterioration with obstructed response (this child had a pre-operative concomitant renal calculus), although the symptoms improved [Figure 10]. Hence, in our study of 12 procedures, there was only one failure. The patient was subsequently managed by endopyelotomy.
|Table 1: Intra-operative parameters and complications seen in the study patients.|
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|Table 2: Post-operative parameters and complications noted in the study patients.|
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In all the cases, renal ultrasound showed a decrease in the severity of hydronephrosis by at least one degree.
| Discussion|| |
As with any technology-driven field, laparoscopic surgery has made tremendous progress in the recent years. Since Clayman et al performed the first laparoscopic nephrectomy in 1991, it is being increasingly performed as a viable alternative to open surgery. Laparoscopic pyeloplasty was introduced in 1993 by Schurssler et al. At present, a number of options are available with a surgeon for the correction of PUJ obstruction. These range from minimally invasive endo-urologic procedures to open pyeloplasty. The success rates have been reported to be highest with open pyeloplasty and least with endo-urologic procedures. Laparoscopy comes in handy by combining the positives of both the procedures, i.e. the success rates of open procedure while keeping the invasion to a minimum. Laparoscopic pyeloplasty can be done either via a trans-peritoneal or retroperitoneal approach. Trans-mesocolic pyeloplasty is a minor modification of the classical trans-peritoneal approach for the left-sided PUJ obstruction. As is evident from the results above, trans-mesocolic pyeloplasty is a viable alternative to the classical trans-peritoneal pyeloplasty, with the added advantages of being faster and avoiding colonic mobilization and iatrogenic injury. 
The results of our study confirm that laparoscopic pyeloplasty by the trans-mesocolic approach is a safe and feasible procedure for children for left-sided PUJ obstruction. Also, the risk of bowel injury is less as the gut is hardly handled. 
| References|| |
|1.||Anderson JC, Hynes W. Retrocaval ureter. A case diagnosed preoperatively and treated successfully by a plastic operation. Br J Urol 1949;21:209. |
|2.||Wickham JE, Kellet MJ. Percutaneous pyelolysis. Eur Urol 1983;9:122-4. |
|3.||Castillo OA, Vitagliano G, Alvarez JM, Pinto I, Toblli J. Transmesocolic pyeloplasty: Experience of a single center. J Endourol 2007;21 (4):415-8. |
|4.||Singh H, Ganpule A, Malhotra V, Manohar T, Muthu V, Desai M. Transperitoneal laparoscopic pyeloplasty in children. J Endourol 2007; 21(12):1461-6. |
|5.||Ramalingam M, Selvarajan K, Senthil K, Pai MG. Transmesocolic approach to laparoscopic pyeloplasty: our 8-year experience. J Laparoendosc Adv Surg Tech A 2008;18(2):194-8. |
|6.||Porpiglia F, Billia M, Volpe A, Morra I, Scarpa RM. Transperitoneal left laparoscopic pyeloplasty with transmesocolic access to the pelvi-ureteric junction: technique description and results with a minimum follow-up of 1 year. BJU Int 2008;101(8):1024-8. |
Department of Surgery, Government Medical College, Srinagar, Kashmir
[Figure 1], [Figure 2], [Figure 3], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Figure 4]