V7-08: Robot-Assisted Laparoscopic Lower to Upper Pyeloureterostomy in the Pediatric Patient
VideoIntroductions and Objectives
Urinary duplication is commonly associated with ureteropelvic junction (UPJ) obstruction of the lower pole moiety. Lower pole UPJ obstruction may resolve spontaneously similar to a single-system obstruction, but if persistent and symptomatic, it may require surgical correction. Traditional dismembered pyeloplasty is usually feasible with complete duplication. However, partial duplication can be technically challenging especially if the ureteral junction is proximally located resulting in insufficient lower ureteral length. This challenge is overcome by performing a lower to upper pyeloureterostomy. Although current data focuses on open surgical repair, we present a video of robot-assisted laparoscopic pyeloureterostomy to demonstrate the feasibility of this minimally invasive approach in the pediatric population.
A 6 year old male with a history of left-sided prenatal hydronephrosis presented with an episode of renal colic. An ultrasound during the episode revealed severe hydronephrosis of the left lower pole. Three months later, follow-up ultrasound imaging and MAG3 renal scan revealed improved hydronephrosis of the left lower pole and a differential renal function of 59% on the left with a lower pole diuretic half-time of 3 minutes. The patient was diagnosed with intermittent UPJ obstruction of the left lower pole and surgical treatment was pursued using a robotic approach.
Transmesenteric dissection revealed a high partial duplication. After sharply transecting the lower pole ureter, the intrinsic obstruction was noted to extend the length of the lower pole ureter to the lower pole renal pelvis. The short lower pole ureter was excised and a lower to upper pyeloureterostomy was performed. The wide opening of the lower pole pelvis was anastomosed to the upper pole ureter using 5-0 vicryl in a running fashion. A 4.8-French x 16-cm double-J ureteral stent was placed antegrade before completion of the anastomosis. There were no intraoperative complications and the patient was discharged the following day.
Surgical correction of UPJ obstruction in a partial duplex system varies depending on the location of the obstruction and the duplication junction. It requires a full appreciation for the individualized anatomy. Robotic surgery has become integral in urinary reconstruction in the pediatric population because it allows for excellent visualization and dissection of complex anatomy in a confined space. The robotic approach is both feasible and successful in performing a lower to upper pole pyeloureterostomy.