V7-09: Robot-Assisted Laparoscopic Ureterocalicostomy in the Pediatric Patient
VideoIntroductions and Objectives
Ureterocalicostomy is a versatile alternative to the traditional Anderson-Hynes pyeloplasty in the treatment of recurrent ureteropelvic junction (UPJ) obstruction, UPJ obstruction associated with anatomic anomalies, such as horseshoe kidney and intrarenal pelvis, and trauma of the UPJ or proximal ureter. Although the robotic approach has become increasingly popular for urologic reconstructive procedures in the adult and pediatric populations, little data has been published on robot-assisted laparoscopic ureterocalicostomy especially in the pediatric population. To illustrate the feasibility of this minimally invasive approach in pediatrics, we present a case series with one representative video of robotic ureterocalicostomy.
Four patients with an age range of 11 to 22 years (average age 15 years) with equal gender distribution underwent robot-assisted laparoscopic ureterocalicostomy for left UPJ obstruction between 2011 and 2014. In all patients, preoperative ultrasound revealed severe hydronephrosis with diffuse cortical thinning. Preoperative renal scans (MAG3 or DMSA) demonstrated decreased differential renal function on the affected left side in a range of 29-40% (average 31%), and obstructive parameters with a diuretic half-time in the range of 19 to greater than 100 minutes (average time 51 minutes). Half of the patients underwent planned, salvage ureterocalicostomy reconstruction due to recurrent UPJ obstruction following traditional pyeloplasties. Utererocalicostomy was indicated as a primary procedure for the other two patients due to anatomic abnormalities, an intrarenal pelvis and complex ureteral anatomy.
There were no intraoperative complications. Double-J ureteral stents were placed intraoperatively in each patient. Mean hospital stay was 1.5 days. Stents were removed less than 7 weeks postoperatively. Postoperative ultrasound demonstrated persistent, but stable hydronephrosis, an unsurprising result given their history of long-standing obstruction and severe hydronephrosis. Two patients experienced recurrent flank pain, but renography revealed a widely patent anastomosis.
Robotic ureterocalicostomy is a feasible and successful procedure for recurrent and severe UPJ obstruction in pediatric patients. Its versatility allows for its application for both pyeloplasty failure and as an alternative procedure for cases of challenging renal and ureteral anatomy. More data is necessary to quantify the advantages and disadvantages of the robotic approach as compared to open and laparoscopic approaches.