Elsevier

Journal of Pediatric Urology

Volume 5, Issue 6, December 2009, Pages 475-479
Journal of Pediatric Urology

Robot-assisted laparoscopic ureteroureterostomy for proximal ureteral obstructions in children

https://doi.org/10.1016/j.jpurol.2009.03.004Get rights and content

Abstract

Objective

Ureteropelvic junction obstruction is a common presentation in the pediatric population, but proximal ureteral obstructions are rare. In this setting, robot-assisted laparoscopy (RAL) offers a minimally invasive option to open or traditional laparoscopic repair. The present study demonstrates successful RAL in two children with proximal ureteral obstructions: one with a right retrocaval ureter and one with a left ureter entrapped between two lower-pole crossing vessels.

Method

After retrograde placement of a double-J ureteral stent, the child was secured in a lateral decubitus position exposing the affected side. A three-port RAL system was used to dissect free the obstructed ureter. A spatulated watertight ureteroureterostomy was then fashioned after transposition of the ureter into an anatomic position. Sutures and free instruments were passed into the peritoneal cavity via the 5-mm instrument ports, thus obviating the need for a separate assistant port.

Results

RAL provided for crisp visualization, meticulous dissection, and precise approximation of the reconstructed ureter. In both patients, blood loss was negligible, narcotic use was minimal, and length of stay was roughly 30 h. Follow-up imaging at 1 month showed excellent hydronephrosis resolution for both reconstructions.

Conclusion

These two cases demonstrate the feasibility of RAL for proximal ureteral anomalies in the pediatric population.

Introduction

In the pediatric population, ureteral obstructions are most commonly identified at the ureteropelvic or ureterovesical junction, and are repaired using various pyeloplasty or reimplantation techniques, respectively. Proximal ureteral obstructions not involving the ureteropelvic junction are comparatively rare, representing less than 5% of all congenital ureteral obstructions [1], [2]. The etiologies of proximal ureteral obstructions are numerous, including external compression (e.g. crossing vessels, neoplasia, trauma, aberrant ureteral position), intrinsic mural anomaly (e.g. aperistalsis, inflammation, strictures, radiation injury), and luminal defects (e.g. urolithiasis, neoplasia, valves, iatrogenic injuries). Surgical reconstruction in these cases is predicated on relieving the external compression, removing the diseased ureteral segment, and repositioning the ureter in a tension-free manner.

Surgical approaches for proximal ureteroureterostomy have steadily evolved over the last 50 years closely paralleling the introduction of new technologies: traditional open surgery [3] has been largely supplanted by endoscopic [4] and laparoscopic techniques [5]. Most recently, the advent of robot-assisted laparoscopy (RAL) has expanded the potential for minimally invasive proximal ureteroureterostomy, primarily due to its facilitation of intracorporeal suturing [6], [7]. However, this nascent technique remains poorly characterized, especially in the pediatric population. This article describes our experience with RAL for complex proximal ureteroureterostomy in children. First, our standard patient preparation and surgical technique are presented. Next, two pediatric cases from our center are discussed that demonstrate the feasibility and efficacy of this technique for proximal ureteral reconstructions.

Section snippets

Patient preparation and surgical technique

All children complete a routine outpatient bowel preparation with oral polyethylene glycol the night before RAL. Immediately after a broad spectrum intravenous antibiotic is administered, general anesthesia is induced and the child is placed in a low dorsal lithotomy position. Cystoscopy and retrograde ureterography are performed to characterize the ureteral defect. A double-J stent is then placed with its tether secured to the glans penis in boys or the ipsalateral groin in girls. After a

Case reports

The following case reports demonstrate the application of our RAL surgical technique in two challenging proximal ureteroureterostomies.

Discussion

RAL continues to gain momentum in the pediatric urology community for treating common upper tract defects, such as UPJOs [9], [10] and VUR [11], largely due to its enhancements over traditional laparoscopy: three-dimensional visualization, 10× magnification, wrested articulation, tremor filtering, and surgeon ergonomics. The safety and efficacy of RAL versus traditional open surgery for such repairs have recently been demonstrated [9].

Despite the rapidly growing popularity of RAL for pediatric

Conclusion

Our experience demonstrates that RAL is feasible for repair of proximal ureteral anomalies in children.

Conflict of interest

The authors have no conflict of interest.

Funding

None declared.

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