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Upper urinary tract reconstruction using minimally invasive surgery

Authors

Abstract

The objective of this video is to present some pediatric examples of upper urinary tract reconstruction using minimally invasive surgery.

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contribution

Keywords

Upper urinary tract reconstruction, minimally invasive surgery

Media type

Duration

11'14''

Publication

2011-04

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E-publication

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3236.htm

Upper urinary tract reconstruction using minimally invasive surgery

1. Introduction 00'10''

The goal of this video is to present some pediatric examples of upper urinary tract reconstruction using minimally invasive surgery. The first technical question is: which approach to use, retroperitoneal or transperitoneal? As there is no clear answer, the choice could vary according to each case and to each surgeon.

2. Congenital pyeloureteral obstruction 00'35''

The most frequent indication —more than 100 cases in our experience— is the congenital pyeloureteral obstruction. The gold standard by open surgery is Anderson-Hynes’s technique, which could be reproduced by videosurgery. For the usual cases, we favour the retroperitoneal approach in the lateral position. Three trocars are needed: one 5mm trocar for the telescope, and two 3mm for operative devices.

3. Gerota’s fascia incision 01'05''

The Gerota’s fascia is incised.

4. Ureter exposure and spatulation 01'07''

The ureter and the pelvis are exposed using blunt and sharp dissection. The junction is attached to the psoas muscle. To present and stabilize the tissues, the ureter is spatulated below the narrow segment using fine scissors. The pelvis is incised. For suturing, a camera holder is useful to get a stable image.

5. Anastomosis 01'32''

The first suture approximating the lower margin of the spatulated ureter to the lower margin of the renal pelvis is of critical importance. The anterior part of the anastomosis is completed by running or separated sutures. Only at that time, the junction is completely divided.

6. Transanastomotic drainage 02'05''

We usually use a transanastomotic drainage, which is introduced through the pelvis wall with an angiocath. This kind of drainage could be removed without requiring new anesthesia. The posterior part of the anastomosis is then completed. The excess renal pelvis is resected and closed with running sutures. The specimen is extracted through the 5mm hole and a small drainage is placed through a 3mm port site.

7. Pyeloureteral junction obstruction 03'13''

A pyeloureteral junction (PUJ) obstruction is sometimes associated with the presence of aberrant lower pole vessels. If the obstruction seems only related to extrinsic compression from the vasculature, as in this example on the right side transperitoneal access, the transposition of the artery away from the UPJ and fixation to the anterior pelvis is sufficient to relieve the obstruction. If an intrinsic compression or obstruction seems associated with aberrant vessels, as in this example on the left side retroperitoneal approach, it is then necessary to completely divide the UPJ to uncross it.

8. Pyeloplasty 04'07''

After having anchored the pelvis on the psoas muscle close to the ureter, a typical dismembered pyeloplasty is performed, leaving the artery posterior to the anastomosis.

9. Lithiasis 04'23''

If the ureteropelvic junction (UPJ) is associated with lithiasis, as in that case of a 1-year-old girl, an intrarenal endoscopic exploration is possible with a 5mm telescope.

10. Posterior pyelotomy 04'51''

In that case, a large posterior pyelotomy allowed to aspirate all small calculi, but other devices could be used to extract lithiasis. A dismembered pyeloplasty was then completed as usual.

11. Horseshoe kidney 05'17''

In case of horseshoe kidney, a transperitoneal approach is recommended. It allows to get a good exposure, whatever the UPJ position is. In this first example of a huge dilatation in an infant, the junction was located in the lower part of the abdomen. The view on the malformation was good. The ergonomic position for the surgeon was favorable for suturing. In this second example in an 11-year-old boy, the UPJ was approached through a transmesocolic route. The UPJ was highly inserted on the pelvis without any external compression by the parenchymal bridge or one aberrant vessel.

12. Ureterocalicostomy 06'53''

A ureterocalicostomy is rarely indicated after failed pyeloplasty. This boy was operated at 6 weeks of age by open surgery without success. After two unsuccessful attempts of endoscopic dilatation, a redo surgery was indicated. A transperitoneal approach allowed to expose the lower pole of the left kidney, the pelvis, the ureter. Cutting the ureter confirmed the persistent obstruction. After incision of the lower pole parenchyma, a ureterocalicostomy was performed using separate stitches. A double-J stent was passed through the parenchyma. The entire pelvis was then resected and closed. Our two cases have had a good result in the long-term follow-up.

13. Ureterostomy 08'34''

Ureteroureterostomy is another rare indication for selected cases of total duplication, dilated but still functioning upper pole, no associated reflux. The end-to-side anastomosis between the two ureters could be performed at the level of the iliac vessels by a transperitoneal approach, like in this first example. In this second example, the anastomosis was performed at the level of the kidney through a retroperitoneal approach. A probe was introduced on each side of the anastomosis to check its patency. This high-located anastomosis allows to resect the major part of the dilated ureter. We have performed five cases of ureteroureterostomy with good results.

14. Symptomatic retrocaval ureter 10'07''

Finally, we have managed two cases of symptomatic retrocaval ureter by retroperitoneoscopy. After dissection, the vena cava was exposed and the ureter was divided on its right side. Its retrocaval portion was uncrossed, and re-anastomosed to the right pelvis. In conclusion, the application of minimally invasive surgery to reconstructive urological procedures in children has lagged behind its use in adults, particularly because of the steep learning curve of intracorporeal suturing in a small space with fine threads. Consequently, operative times are significantly longer. Moreover, the classical benefits of minimally invasive surgery —less scars, less pain, less hospital stay— are more obvious in teenagers than in infants. However, with training patients and times, the success rate is equivalent to traditional open surgery even in infants, even without the robot, which is an expensive tool not well-adapted to small patients.

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