Endourology / Laparoscopy (2) - Part 2

146

LAPAROSCOPIC TRANSPOSITION OF LOWER POLE VESSELS- THE 'VASCULAR HITCH': AN ALTERNATIVE FOR PELVIURETERIC JUNCTION OBSTRUCTION IN CHILDREN

Prasad GODBOLE, Duncan WILCOX*, Imran MUSHTAQ* and Patrick DUFFY*
Great Ormond Street Hospi, Paediatric Urology, London, UNITED KINGDOM - * Great Ormond Street Hospital, Paediatric Urology, London, UNITED KINGDOM

PURPOSE: Dismembered pyeloplasty has been the traditional technique in the management of ureterovascular pelviureteric junction obstruction (PUJO) in children. Endopyelotomy and concomitant laparoscopic transposition of lower pole vessels for PUJO has been described in adults. We describe our experience and technique of laparoscopic transposition of lower pole vessels in children with PUJO.


MATERIAL AND METHODS: The technique of laparoscopic transposition of lower pole vessels involved transperitoneal mobilisation of the lower pole vessels of the renal pelvis therebying freeing the PUJ and transposing them superiorly where they were anchored by approximating the pelvis around the vessels by 2-3 absorbable sutures through the adventia of the pelvis, well clear of the PUJ. The main outcome measures were relief of symptoms,improvement in U/S appearances and/or drainage parameters on a postoperative MAG3 renogram performed within 4-6 weeks following surgery.

RESULTS: The mean operating time was 90 minutes. All patients were discharged within 36 hours following surgery. 9 patients remain symptom free at a mean of 5.2 m(4-9)and showed improved appearances on U/S and good drainage on the postoperative MAG3 renogram.One patient had recurrent symptoms needing a JJ stent insertion.

CONCLUSIONS: Our early experience of laparoscopic transposition of lower pole vessels suggests it to be a useful minimally invasive alternative to standard open or laparoscopic pyeloplasty in older children with symptoms of intermittent PUJO and a high index of suspicion of lower pole vessels as the underlying aetiology.

147

LAPAROSCOPIC TRANSPOSITION OF LOWER POLE VESSELS- THE "VASCULAR HITCH": AN ALTERNATIVE FOR PELVIURETERIC JUNCTION OBSTRUCTION IN CHILDREN

Prasad GODBOLE, Duncan WILCOX*, Imran MUSHTAQ* and Patrick DUFFY*
Great Ormond Street Hospi, Paediatric Urology, London, UNITED KINGDOM - * Great Ormond Street Hospital, Paediatric Urology, London, UNITED KINGDOM

PURPOSE: Dismembered pyeloplasty has been the traditional technique in the management of ureterovascular pelviureteric junction obstruction (PUJO) in children. Endopyelotomy and concomitant laparoscopic transposition of lower pole vessels for PUJO has been described in adults. We describe our experience and technique of laparoscopic transposition of lower pole vessels in children with PUJO.

MATERIAL AND METHODS: Ten patients with a mean age of 15.4 years (14-16) underwent laparoscopic transposition of lower pole vessels. Surgery was indicated on the basis of recurrent symptoms of intermittent PUJO and ultrasound and MAG3 confirmation of obstruction with or without reduced function. The technique of laparoscopic transposition of lower pole vessels involved transperitoneal mobilisation of the lower pole vessels of the renal pelvis therebying freeing the PUJ and transposing them superiorly where they were anchored by approximating the pelvis around the vessels by 2-3 absorbable sutures through the adventia of the pelvis, well clear of the PUJ. The main outcome measures were relief of symptoms, and improvement in the ultrasound appearances and/or drainage parameters on a postoperative MAG3 renogram performed within 4-6 weeks following surgery.

RESULTS: The mean operating time was 90 minutes. All patients were discharged within 36 hours following surgery. 9 patients remain symptom free at a mean of 5.2 m(4-9). All patients showed improved appearances on u/s or good drainage on the postoperative MAG3 renogram.One had recurrent symptoms needing JJ stent insertion.

CONCLUSIONS: Our early experience of laparoscopic transposition of lower pole vessels suggests it to be a useful minimally invasive alternative to standard open or laparoscopic pyeloplasty in older children with symptoms of intermittent PUJO and a high index of suspicion of lower pole vessels as the underlying aetiology.

148

HORSESHOE KIDNEY AND ENDOSCOPIC SURGERY /RETRO OR TRANSPERITONEAL APPROACH?

Jean-stephane VALLA, Xavier CARPENTIER, Andrei ZAVATE and Henri STEYAERT
fondation Lenval, pediatric surgery, Nice, FRANCE

PURPOSE: Horseshoe kidneys pose unique challenge due to variable vascular anatomy and the presence of isthmus passing medialy and inferiorly; as in open surgery , the approach for endoscopic surgery could be choosen according to the position of the target organ. How to approach a horseshoe kidney for performing pyeloplasty or nephrectomy is debatable: trans or retroperitoneal.

MATERIAL AND METHODS: 4 childrens (6 months to 12 years old) underwent laparoscopic procedure: the first case (nephrectomy) by using a retroperitoneoscopic approqach, the three following cases(1 nephrectomy + 2 pyeloplasties) using a transperitoneal approach with the scope located through the ombilicus (2 cases) or in the iliac fossa (1 case).

RESULTS: All cases were completed laparoscopically. No difference was found compâring operating time, postoperative recovery, analgesia, duration of hospital stay; however the choice of intraperitoneal access allowed an easier procedure because of a better view and a larger space for instruments movements.

CONCLUSION: Although the both access, trans or retroperitoneal, are feasable, the transperitoneal one seems better adapted for minimally invasive approach of horseshoe kidney. Technical details are illustrated by a video
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