Pediatric Laparoscopic Pyeloplasty: Lessons Learned from the First 52 Cases

Background and Purpose: The use of laparoscopy for pediatric pyeloplasty is increasing. We review our experience with our first 50 cases and describe the main technical points learned during this experience. Patients and Methods: We retrospectively reviewed the charts of all patients who underwent laparoscopic pyeloplasties ( LP) over a 4-year period ( January 2004 to January 2008) at our institution. Patient demographics, operative details, hospital stay, outcomes, and complications were examined. Results: Fifty-two patients underwent LP from for primary repair of ureteropelvic junction obstruction ( UPJO). Thirty-six male and 16 female were operated on at an average age and weight ( range) of 51.8 months ( 3 weeks to 216 months) and 20 kg ( 3.9-74.2 kg), respectively. Intraoperatively, 47/52 ( 90%) underwent retrograde ureteropyelography ( RUPG), and 51/52 ( 98%) had a ureteral stent placed during surgery. Nine crossing vessels ( 17%) were identified at the time of surgery. The anastomoses were performed with a running absorbable suture. Operative time was 248 min ( range 120-693 min). The average hospital stay was 3 days ( range 1-7). A bladder catheter usually remained indwelling for 2 days and a perirenal drain for 3 days; they were removed before hospital discharge. The stent remained in place on average 39 days ( range 11-127 d) and was removed with the patient under a brief general anesthetic. Anastomotic patency was seen in 51/52 ( 98%) patients determined by improvement on postoperative renal ultrasonography and/or resolution of symptoms. Mean follow-up was 20 months ( range 3-50 mos). Complications included recurrence of UPJO necessitating redo LP ( 1), dislodgement of a nephrostomy ( 1), stent replacement ( 1), ileus ( 2), and vascular injuries treated laparoscopically ( 2). No patients needed conversion to open surgery. Conclusion: LP has supplanted open pyeloplasty at our institution. We have noted improved success by performing RUPG to define the anatomy and stent placement at the beginning of the case, using purple 5-0 or 6-0 poliglecaprone suture for the anastomosis and a 5-mm wide-angle lens for visualization. We found no disadvantages for the transperitoneal approach, although we find it necessary to leave a drain. With the increased use of LP in pediatric urology, we hope these observations from our experience will help improve the learning curve for others making this transition.