Pediatric Laparoscopic and Robotic Pyeloplasty

Pediatric Laparoscopic and Robotic Pyeloplasty



Historically, open pyeloplasty has been the standard treatment for congenital or acquired ureteropelvic junction (UPJ) obstruction in adults and children, with overall success rates of 90% to 100% (1,2,3). Although endopyelotomy (4) and retrograde dilation (5) are alternative methods of managing UPJ obstruction in children (6), the success of these two procedures is inferior to that reported for conventional dismembered pyeloplasty (7). Advances in technology have played a significant role in the therapeutic management of UPJ obstruction and have enabled the introduction of laparoscopic and robot-assisted laparoscopic pyeloplasty over the last few years. Continued interest in minimally invasive treatment for UPJ obstruction has inspired new questions about the optimal laparoscopic approach for treating this disease.

Laparoscopic pyeloplasty was introduced in adults in 1993 (8,9). In the initial reports, the operative time ranged from 3 to 7 hours, but the procedure has gradually gained in popularity and acceptance with a reported success rate of over 95% (10,11,12,13,14,15,16). Yeung et al. (15) reported their initial experience with retroperitoneal laparoscopic pyeloplasty in 13 children, one of who required open conversion. The mean operative time was 143 minutes (range 103 to 235 minutes). El-Ghoneimi et al. (16) reported their experience with 50 retroperitoneal laparoscopic pyeloplasties in children aged between 22 months and 15 years. Conversion to open surgery was necessary in four cases due to technical difficulties during suturing. Mean hospital stay was 2 days, and return to full activities occurred within 5 days of surgery. The longer time needed for the retroperitoneal approach is almost certainly related to the limited working space that renders suturing more difficult.


Open pyeloplasty still remains the gold standard for correcting UPJ obstruction with a high success rate done either through a flank, dorsal lumbotomy, or anterior muscle-splitting incision. Proponents of open pyeloplasty have shown that this procedure can be done without placement of an indwelling ureteral stent along with simple percutaneous drainage either by a nephrostomy tube or single Penrose drain (1,2).

Endopyelotomy and retrograde dilation are also alternative methods of managing UPJ obstruction in children. Endopyelotomies are performed in the same fashion as in adults either by a percutaneous approach or ureteroscopically in a retrograde manner (4). The long-term success rate of endopyelotomy is less than the standard open or laparoscopic approaches (4,12,13,14). Retrograde dilation has virtually no role in pediatrics due to its high failure rate requiring a subsequent procedure (5).


Initial cystoscopy and ureteric stenting is left to the discretion of the surgeon and may not be necessary (20,21). An indwelling Foley catheter is placed to gravity drainage.

Positioning of the patient is crucial as it facilitates optimal ergonomics for the surgeon and increased access to the operative space. For both a transperitoneal and retroperitoneal approach, the patient is placed in a lateral or semilateral decubitus position in close proximity to the posterior edge of the table, the table is flexed, the kidney rest is elevated, appropriate padding is applied, and the patient is secured with 2-inch tape and a safety belt. An option for the retroperitoneal approach described by Yeung et al. (15) is a modified semiprone position with the left flank up or a 45-degree right lateral decubitus position (for right-sided obstruction) to allow the subsequent ureteropelvic anastomosis using the right hand (for a right-handed surgeon). Another option utilized for the transperitoneal approach is to place the patient supine with a slight 30-degree rotation of the ipsilateral side. The patient is then secured to the table with 2-inch silk tape (Fig. 102.1). The table can then be rotated as needed after visualization of the intraperitoneal field. This approach can be utilized on the left side allowing the colon to stay lateral to the left kidney so a transmesenteric window is unobstructed. As far as trocar placement, a fundamental concept that is important to implement is that conventional laparoscopy is ergonomically favored by triangulation of ports, whereas the robotic platform will function better with the ports arranged in as straight a line as possible with at least 4 cm between all ports.

FIGURE 102.1 Supine positioning for transperitoneal approach in left-sided and bilateral cases.

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Pediatric Laparoscopic and Robotic Pyeloplasty

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