Preliminary experience with laparoscopic Foley's YV plasty for ureteropelvic junction obstruction in children.

INTRODUCTION: Laparoscopic dismembered pyeloplasty is an acceptable option for ureteropelvic junction (UPJ) obstruction in the paediatric population. We compared our results of laparoscopic dismembered and non-dismembered Foley's YV pyeloplasty.
MATERIALS AND METHODS: Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. Foley's YV plasty was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres. Children were followed up for urinary infection, and renogram was repeated after 3 months.
RESULTS: During the study period, 108 children (63 male and 45 female) with a mean age of 4.94 ± 2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children (5 male and 6 female) with a mean age of 4.00 ± 1.776 years underwent laparoscopic Foley's YV plasty. There were no major peri-operative complications noted and conversion to open was not necessary in any child. Renogram done at 3 months post-operatively showed good drainage and improvement of renal function.
CONCLUSIONS: Laparoscopic Foley's YV pyeloplasty is a safe and effective technique in appropriately selected cases of primary UPJ obstruction in children.

INTRODUCTION

A ureteropelvic junction (UPJ) obstruction can be thought of as a restriction to flow of urine, from the renal pelvis to the ureter, which, if left uncorrected, leads to progressive renal deterioration.[123] UPJ obstruction occurs in all paediatric age groups, but there tends to be a clustering in the neonatal period because of the detection of antenatal hydronephrosis and again later in life because of symptomatic occurrence.[4] The surgical correction of UPJ obstruction has evolved on a number of fronts, with open surgical techniques yielding way to endoscopic, laparoscopic and robot-assisted approaches. Whatever be the approach, dismembered pyeloplasty has been universally accepted because of its (1) broad applicability, including preservation of lower pole or crossing vessels, (2) excision of the pathologic UPJ and (3) successful reduction pyeloplasty.[4] At times, dismembered pyeloplasty may be problematic whenever the renal pelvis is small and the ureteral length is inadequate. In such instances, a non-dismembered pyeloplasty can be performed to overcome this problem.

In non-dismembered pyeloplasty, a spiral flap is created from the renal pelvis to repair the defect at the UPJ.[5] Such a flap is able to bridge the gap between the pelvis and healthy ureter over a distance of several centimetres. Scardino and Prince described a vertical flap that can be used in the situation of a dependent UPJ with a large, square-shaped extrarenal pelvis.[6] The Foley YV plasty was originally described for the correction of UPJ with a high ureteral insertion. We report our experience with laparoscopic Foley's YV pyeloplasty.

MATERIALS AND METHODS

Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. The diagnosis of UPJ obstruction was firmly established based on history, physical examination, renal sonography, intravenous urography and scintigraphy. Renal pelvic volume was determined on ultrasonography. Exclusion criteria included presence of active urinary tract infection and very poor renal function (split renal function < 10%). The risks of the laparoscopic operation were fully explained to the parents of the children, which included post-operative infection, bleeding, failure of pyeloplasty, the need to convert to open surgery, damage to other viscera and adhesion formation.

The first 5 mm endoscope port was inserted by open laparoscopy using a blunt Hasson cannula through the umbilical crease. The abdomen was inspected in detail so as to plan to insert the remaining two 3/5 mm instrument ports. Correct placement of these ports was critical to the ease of performing the anastomosis. Occasionally an extra 5 mm port was placed for retraction purposes. The peritoneum overlying the exposed kidney was incised just lateral to and above the colonic flexure. The loose adventitia around the kidney was detached from the renal capsule. Once the correct plane was identified, the renal capsule was traced into the renal sinus until the renal pelvis was identified. The renal pelvis was dissected free from the medial side. The UPJ and the proximal ureter were identified. The adventitia around the proximal ureter and UPJ was cleared.

Whenever it was observed that dismembered pyeloplasty could not be easily performed, the kidney was completely mobilised so as to pull the kidney downwards. Such a manoeuvre can provide an additional 5 cm of length. Foley's YV plasty [Figure 1] was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres. The V flap was outlined. The base of the V was positioned on the dependent, medial aspect of the renal pelvis and the apex at the UPJ. The incision from the apex of the flap, which represents the stem of the Y, was then carried along the lateral aspect of the proximal ureter well into an area of normal calibre. The flap was developed with fine Pott's scissors. The apex of the pelvic flap was brought to the inferior most aspect of the ureterotomy incision. The posterior walls were approximated utilising interrupted or running fine absorbable sutures with an 18 cm, 6/0 vicryl suture on a 3/8 round body needle. A 0.025 inch guide wire was then passed through the proximal ureter into the bladder. A 3 Fr multi-length double pig-tail catheter was passed over the guide-wire into the bladder. The proximal end of the double pig-tail stent was then placed within the renal pelvis. The anastomosis was completed with approximation of the anterior walls of the pelvic flap and urethrotomy [Figure 2].

Figure 1

IVU showing Rt. dilated pelvic calyceal system with small renal pelvis (<30cc)

Figure 2

Operative steps of Laparoscopic Foly's YV plasty. (a) Rt UPJ showing Dilated Pelvis (b) Apex of V being planned at UPJunction (c) From the apex of V, the inferior limb of Y being extended on the lateral margin of upper ureter (d) Y-V Plasty in progress (e) Completion of Y-V Plasty

Post-operatively the drain was removed once the drainage was less than 5 cc/24 h. The catheter was removed the next day. Oral fluids and feeds were started on the appearance of peristaltic sounds. Children were followed up for urinary infection, and renogram was repeated after 3 months.

RESULTS

During the study period January 2004 to December 2010, 119 children prospectively underwent laparoscopic pyeloplasty for UPJ obstruction. Seven of these children were antenatally diagnosed with hydronephrosis. Of these, 108 children (63 male and 45 female) with a mean age of 4.94 ± 2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children (5 male and 6 female) [Table 1] with a mean age of 4.00 ± 1.776 years underwent laparoscopic Foley's YV plasty.

Table 1

Comparison of operative and post-operative parameters

The surgical indication for Foley's YV plasty was a small sized renal pelvis (mean renal pelvic volume 31.8 ml) in five children, long narrow ureteric segment with a small renal pelvis (mean renal pelvic volume 34.6 ml) in three children and a high insertion of ureter with a small sized renal pelvis (mean renal pelvic volume 30.4 ml) in the remaining three children. In none of these 11 children crossing renal vessels were observed at the UPJ. In all these 11 children, the kidney was dissected from the surrounding fibro-fatty tissue to release the kidney and pull it downwards. The mean operating time for laparoscopic dismembered pyeloplasty was 87.22 ± 7.69 min and the mean post-operative hospital stay was 106.29 ± 22.76 h. In comparison, the mean operating time for laparoscopic Foley’YV plasty was 77.27 ± 5.18 min and mean post-operative hospital stay was 82.91 ± 12.53 h. There were no major peri-operative complications noted and conversion to open was not necessary in any child. The drain was removed after 24 h in all the children and the per-urethral catheter removed after 48 h.

The mean follow-up of these 11 children was 20.82 ± 1.83 months. Renogram done at 3 months post-operatively showed good drainage and improvement of renal function. The mean post-operative differential renal function was 41.64 ± 2.38%.

DISCUSSION

Open pyeloplasty (OPN) has been the standard treatment for congenital or acquired UPJ obstruction in adults and children, with overall success rates of 90-100%.[7] Laparoscopic surgery has increasingly assumed a central role in the management of both benign and malignant urologic diseases. Numerous studies have implicated that minimally invasive procedures can provide equivalent surgical outcomes with reduced morbidity when compared with their open counterparts. As a consequence, laparoscopy has become more integrated into mainstream practice and in some cases has evolved into the standard of care for certain procedures.[89] A prime example of this latter point is the pyeloplasty procedure for the treatment of UPJ obstruction, which in present day is commonly performed via a minimally invasive (laparoscopic or robotic) approach.

Feasibility, safety and effectiveness of laparoscopic pyeloplasty in children was described with similar success rates as open procedure.[101112] Ravish et al.,[11] compared the results of laparoscopic and OPN in children with primary UPJ obstruction. The mean operative time was significantly shorter in the open surgery group. Post-operative discomfort/pain was significantly less in the laparoscopic group and similarly the mean hospital stay was significantly shorter in the laparoscopic group. The surgical outcome in both the groups was similar in both the groups.

Casale et al.,[13] reported on a series of 26 children aged between 8 months and 15 years (mean age 5 years) who underwent trans-peritoneal laparoscopic pyeloplasty for an obstruction not caused by a crossing vessel. Nineteen had an Anderson–Hynes dismembered pyeloplasty (AH), while the remaining seven had a non-dismembered pyeloplasty in a Heineke–Mikulicz fashion (HM). The mean operative time was 3.1 and 2.5 h for AH and HM, respectively. No difference in hospital stay was noted, with a mean of 3 days. The stent was removed 6 weeks later. Four of the seven patients having non-dismembered procedures presented with acute flank pain within 3 days of stent removal. The AH pyeloplasty produced a 94% rate of resolution of UPJ obstruction, while the HM patients did poorly, with a success rate of only 43% (P = 0.002; Fisher's exact test).

Singh et al.,[14] evaluated the role of non-dismembered laparoscopic pyeloplasty and percutaneous endopyelotomy for UPJ obstruction with low volume renal pelvis. A total of 34 patients of laparoscopic non-dismembered pyeloplasty were compared with 26 patients of UPJ obstruction with pelvic volume less than 50 ml undergoing antegrade endopyelotomy. Only operative time was significantly less in patients undergoing endopyelotomy (P < 0.05). They concluded that in patients with UPJ obstruction with low volume pelvis and good renal function, laparoscopic non-dismembered pyeloplasty was effective with significantly longer operative time compared with endopyelotomy.

Szydełko et al.,[15] performed a retrospective study to compare the results of dismembered and non-dismembered Y-V laparoscopic pyeloplasties and the complications observed after the two types of surgery. Eighty-eight patients with UPJ obstruction underwent a laparoscopic operation. In two cases, an open conversion was made. A laparoscopic Hynes–Anderson pyeloplasty (LHAP) was performed on 50 patients, whereas a laparoscopic Y-V pyeloplasty (LY-VP) was performed in 36 cases. The mean operative time for LHAP was 219 min and for LY-VP 185 min. The mean hospital stay after LHAP was 5.9 days and for LY-VP 5.3 days. The overall success rate was 91.5% (91.8% for LHAP patients and 91.2% for LY-VP patients).

In our study, the mean operating time for laparoscopic Foley's YV plasty was 77.27 ± 5.18 min, which was significantly less when compared with the laparoscopic dismembered pyeloplasty group. This was probably due to the need for extensive intra-corporeal suturing needed for dismembered pyeloplasty and also trimming of the hugely dilated renal pelvis. Post-operative recovery of renal function was similar to those undergoing dismembered pyeloplasty.

Robotic-assisted surgery may be ideally suited for a pyeloplasty, allowing one to overcome the difficulties encountered with laparoscopic suturing. Lee et al.,[16] presented the first preliminary results of robotic-assisted laparoscopic trans-peritoneal pyeloplasty in children. They performed a retrospective case control study of 33 patients undergoing robot-assisted laparoscopic pyeloplasty (RALP) and 33 undergoing OPN. Mean operative time was significantly less for OPN (181 vs 219 min for RALP, P = 0.031). Total narcotic requirements were significantly less in the RALP group. Olsen and Jorgensen[17] reported their unique experience of retroperitoneal robotic-assisted pyeloplasty in 13 children with a median age of 6.7 years. Median operative time was 173 min and there were no perioperative complications. This early experience has been corroborated by a number of centres, demonstrating that advanced laparoscopic re-constructive surgery is feasible even in children.

There has been an on-going effort to develop an even more ‘minimally invasive’ approach to surgery. A novel example of such advancement can be found in laparoendoscopic single-site (LESS) surgery. Performing surgery through a single site of access holds the promise of decreased morbidity, lower blood loss, shorter convalescence and improved cosmesis. Given the non-extirpative nature of the pyeloplasty procedure, this patient cohort has proven to be the ideal candidates for LESS surgery. There are now several studies in the published literature demonstrating the feasibility and efficacy of LESS pyeloplasty in both children and adults.[18] Although comparative studies have failed to demonstrate any objective advantage of the LESS pyeloplasty operation, it is important to realize that LESS surgery is still a fairly new technique. Further technological developments and additional studies will ultimately define its role in the field of urologic surgery, and subsequently, its application for the pyeloplasty procedure.

CONCLUSIONS

Laparoscopic Foley's YV pyeloplasty is a safe and effective technique in appropriately selected cases of primary UPJ obstruction in children. The operative time and post-operative hospitalization was significantly less when compared with laparoscopic dismembered pyeloplasty. Post-operative recovery of renal function was similar to those who underwent laparoscopic dismembered pyeloplasty.