+

MODEL

Journal of Pediatric Urology (2015) xx, 1.e1e1.e5

Laparoscopic pyeloplasty in infants: Single-surgeon experience V.V.S. Chandrasekharam Summary Pediatric Surgery, Pediatric Urology & MAS, Rainbow Children’s Hospitals, Hyderabad, Telangana, India Correspondence to: V.V.S. Chandrasekharam, Pediatric Surgery, Pediatric Urology & MAS, Rainbow Children’s Hospitals, Hyderabad, Telangana, India, Tel.: þ91 40 44665555, þ91 9849010175 (mobile) [email protected] (V.V.S. Chandrasekharam) Keywords Hydronephrosis; Infant; Laparoscopy; Obstruction; Pyeloplasty Received 19 April 2015 Accepted 25 May 2015 Available online xxx

Introduction Although laparoscopic pyeloplasty (LP) is popular in children, its role in infants is less well defined. It is presumed that infant LP is technically challenging, with a higher failure rate. Objective To consider the hypothesis that LP can be safely and successfully performed in infants. Methods The records of 111 infants that underwent LP from March 2009 to December 2013 with at least 1 year of follow-up, were retrospectively reviewed. The results of pre- and postoperative imaging studies (ultrasound (US) and diuretic renogram (DR)), operative details and complications were noted. Pre- and postoperative parameters were compared using statistical software. Results The details are given in the Table. Laparoscopic pyleoplasty was successfully completed using three ports in all children without any open conversions. There were complications in 14 children (12%); 13 did not require a second intervention and the final outcome was not affected. One child (1%) had a re-

obstruction with worsening hydronephrosis (HDN) 2 months after stent removal; she underwent successful redo LP. Median follow-up was 2 years; LP was successful in relieving the obstruction in 115 kidneys (99%); all had follow-up US, while 76 children had follow-up DR. The tests showed significant reduction in HDN (mean pre-operative anteroposterior diameter (APD) of renal pelvis, 34.4 mm (SD 13.4) versus mean post-operative APD 10.6 mm (SD 5.7), p < 0.001) and improved drainage in all kidneys. In unilateral cases, there was significant improvement in mean split renal function (SRF) of the operated kidneys (pre-operative 22.1% (SD 8.6) versus post-operative 35.6% (SD 11.4), p < 0.001). Discussion Over the past 6 years, all pyeloplasties at our unit have been performed by laparoscopy, irrespective of the age or weight of the child. In this large retrospective series, it is demonstrated that infant LP is a safe and successful operation; pyeloplasty in this age group not only resulted in significant reduction of hydronephrosis, but also in significant functional improvement. The results are comparable to published series comparing open pyeloplasty to laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70 to 96%, and complication rates ranging from 0 to 24% for open pyeloplasty.

Table Summary of data from 111 patients who underwent laparoscopic pyeloplasty (116 kidneys) Data given as n (%), or mean/median (range). Sex (male) Prenatal diagnosis Left side Bilateral Surgical age (months) Surgical weight (kg) Surgical time (minutes) Double J stent Length of stay, median (days) Intra-operative complications Postoperative complications Success of pyeloplasty Failure requiring reoperation

92 96 71 5 3.8 5.3 106 109 2 2 12 115 1

(83) (86) (63) (4.5) (1e12) (3e10.5) (65e145) (94) (2e8) (1.7) (10.3) (99) (1)

http://dx.doi.org/10.1016/j.jpurol.2015.05.013 1477-5131/ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.

Please cite this article in press as: Chandrasekharam VVS, Laparoscopic pyeloplasty in infants: Single-surgeon experience, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.013

+

MODEL

1.e2

Introduction Pyeloplasty is a common operation in paediatric urology. With the increasing use of antenatal ultrasound, many babies are being diagnosed with severe hydronephrosis requiring surgery at an early age, even before they become symptomatic. The first use of laparoscopic dismembered pyeloplasty (LP) for pelviureteric junction (PUJ) obstruction in children was reported in 1995 by Peters et al. [1]. This minimally invasive approach, as well as robot-assisted LP has slowly emerged as a safe, effective alternative to the gold standard, open pyeloplasty [2e6]. However, the situation is different in infants; limited working space and small ureteral calibre make LP in infants challenging. Additional concerns are the increased technical difficulty and a higher susceptibility to bowel injury, given the limited space of the infant abdominal cavity [7]. In an early series of laparoscopic pyeloplasty in 16 paediatric patients Tan observed two failures due to anastomotic stenosis in patients who were 3 months old at surgery [8]. While subsequent reports demonstrated feasibility irrespective of patient age and weight, reports of laparoscopic pyeloplasty in the infant population are limited to rather small series [7,9e12]. In our unit, infant LPs have been carried out since 2009, after experience had been gained with LP in older children for over 2 years. The results of a 4.9-year experience with LP in a large group of children younger than 12 months, with a minimum postoperative follow-up of 1 year, are reported.

Patients and methods One hundred and eleven infants (116 kidneys) that underwent LP by a single surgeon from March 2009 to December 2013 and completed at least 1 year of postoperative followup are included in this retrospective review. Nine infants that underwent LP during the same period but were lost to follow-up are excluded. Data regarding patient details, preoperative and postoperative imaging studies, details of surgery and postoperative hospital course were noted and analysed. Pre-operatively, all children underwent ultrasound (US) and a diuretic renogram (DR). Micturating cystourethrography was only performed in children with bilateral hydronephrosis (HDN) and in those children who presented with urinary infection. The parameters studied were: grade of HDN (according to Society of Fetal Urology (SFU)), anteroposterior diameter (APD) of the affected renal pelvis on US and split renal function (SRF) on DR using Tc99m diethylenetriamine pentaacetic acid (DTPA). Indications for surgery included loss of renal function in the context of obstruction on diuretic renography, worsening hydronephrosis with loss of renal cortex on serial US, and febrile urinary tract infection with evidence of obstruction on DR. In general, for unilateral hydronephrosis (HDN), an SRF 20 mm or SFU grade 4 HDN was considered an indication for pyeloplasty. In bilateral obstruction, the more severely affected kidney was operated first. The contralateral kidney was operated later if the HDN worsened during follow-up.

V.V.S. Chandrasekharam The technique used for transperitoneal LP is as follows; some of the technical details have already been published by us previously [13]. The baby is placed in a 60-degree modified lateral decubitus position with the affected side up. All pressure points are padded, and the table remains flat, without flexion. Three ports are used; a 3 or 5 mm umbilical telescopic port and two 3 mm ports in the epigastrium and hypogastrium. It has been our observation that in most babies with gross hydronephrosis, the PUJ is close to the midline; hence the ports are placed close to the midline. The PUJ is usually approached by reflecting the hepatic flexure of the colon on the right side; a transmesocolic approach is preferred on the left side. The PUJ is dissected; a hitch stitch is placed to stabilize the renal pelvis and the PUJ is dismantled along with a cuff of renal pelvis which is used to handle the ureter during the rest of the procedure; the normal ureter itself is never grasped with any instrument. Except in a very large pelvis (APD >50 mm), no attempt is made to trim the dilated pelvis. The ureter is spatulated with straight scissors on its lateral aspect. Pelviureteric anastomosis is then performed with two running 6/0 or 5/0 polyglycolic acid sutures for the anterior and posterior walls. A round-bodied needle is preferred for suturing. After the completion of the posterior wall suturing, a 3F double J stent is placed in an antegrade fashion; the stent is removed by cystoscopy after 4e6 weeks. In some small babies, even a 3F stent may not go across the VUJ; in such a situation, a nephrostomy (10F Foley catheter) and a transanastomotic external stent (3F ureteric catheter) are used; these remain in place for 5e7 days before they are removed in the clinic. The same technique of dismembered pyeloplasty is followed even in the presence of a lower pole crossing vessel; the pelviureteric anastomosis is performed anterior to the vessel. A transurethral catheter is placed at the end of surgery; it is left in place for 48 h, after which it is removed and the child is sent home. Low-dose antibiotic prophylaxis (cephalexin) is continued for 2e3 months after the surgery. During follow-up, renal US is done 3e6 months after the surgery, and DR 3e6 months later, especially if the preoperative function was compromised. After this, a yearly follow-up with US is advised. Outcome measures included operative time, hospital stay and resolution on follow-up US and/or DR. Treatment failure was defined as inability to complete the intended procedure, persistent radiographic evidence of obstruction and/or the need for definitive adjunctive procedures. Statistical analysis was done using statistical software; pre- and postoperative parameters were compared using Student’s t-test and p 20 mm; all kidneys had unequivocal obstruction (post-lasix t1/2

Please cite this article in press as: Chandrasekharam VVS, Laparoscopic pyeloplasty in infants: Single-surgeon experience, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.05.013

+

MODEL

Infant laparoscopic pyeloplasty Table 1

1.e3

Patient demographics.

Characteristic Patients, n Kidneys involved, n Sex, n (%) Male Female Mean age, months (range) Mean weight, kg (range) Left-sided, n (%) Initial presentation, n (%) Prenatal HDN Febrile UTI

111 116 92 (83) 19 (17) 3.8 (1e12) 5.3 (3e10.5) 71 (63) 96 (86) 15 (14)

HDN: hydronephrosis.

>20 min) on DR. The LP was successfully completed using three ports in all children without any open conversions or additional port placement. No intraperitoneal drains were routinely used. Antegrade placement of a JJ stent was successful in 109 kidneys (94%); seven had a nephrostomy and external stent placement. Two children underwent simultaneous laparoscopic repair of inguinal hernias (one bilateral). Three children had associated vesicoureteric reflux (grade 2e3, one bilateral) which spontaneously resolved during follow-up. The details of pre-, post- and intra-operative parameters are summarized in Table 2. The mean operating time (first port insertion to port removal) was 106 min (range 65e145). Six kidneys (6%) had a lower pole crossing vessel obstructing the PUJ. The median hospital stay was 2 days (2e8). There were 14 complications (12%), two intraoperative and ten postoperative. One child with a large liver had a minor liver injury during instrument insertion in a right sided pyeloplasty; there was no significant bleeding and it was inconsequential. In another child, there was a suspicion of an electrocautery injury to the vermiform appendix during right sided pyeloplasty; the appendix was removed after parental consent. Postoperatively, five children had ileus lasting 24 h, while two children had port-site infections which responded to conservative management. A Table 2

45-day old child had a urinary leak after right-sided pyeloplasty. This child had a tear in the renal pelvis at the time of surgery. The tear was recognized and repaired; although a DJ stent was in position, a perinephric drain was also placed at the end of surgery as a safety measure. As anticipated, there was a urinary leak from the drain which stopped spontaneously after 5 days. On follow-up, the child did well with a successful pyeloplasty result. Three children (two boys and one girl) had premature expulsion of the JJ stent into the urethra at 3, 15 and 20 days after the surgery; the stents were removed with no adverse consequences. Thus, 13 of 14 complications did not require a second intervention and did not affect the final outcome. One child (1%) had a re-obstruction that showed up as worsening HDN with infection 2 months after DJ stent removal. This child underwent redo LP; 6 months after the redo operation, the child is doing well, with significant reduction of HDN on follow-up US. Median follow-up was 2 years (range 1e5). In 115 kidneys, LP was successful in relieving the obstruction; all had follow-up US, while 76 children had follow-up DR. The tests showed significant reduction in hydronephrosis and improved drainage in all kidneys, with significant improvement in the mean SRF (Table 2, Fig. 1).

Discussion This is a report of one of the largest series of infant LP to date. The results indicate that LP can be safely performed, even in small infants, with good success. Although LP is well established in children, many earlier series contain older children with small numbers of infants only. Most of the children in this series were small (Table 1), and LP was performed safely and successfully in these babies. There are a few reports in the literature specifically addressing the role of LP in infants. Tan initially cautioned against the use of LP in children younger than 6 months but later reported good success with LP even in small children [8,14]. Kutikov et al. [9] reported 100% success with LP in eight children

Laparoscopic pyeloplasty in infants: single-surgeon experience.

Although laparoscopic pyeloplasty (LP) is popular in children, its role in infants is less well defined. It is presumed that infant LP is technically ...
266KB Sizes 0 Downloads 39 Views