Journal of Robotic Surgery

, 3:161

Robotic ureteroureterostomy in children with a duplex collecting system

Authors

    • Children’s Hospital of Philadelphia University of Pennsylvania
  • Sarah Lambert
    • Children’s Hospital of Philadelphia University of Pennsylvania
Original Article

DOI: 10.1007/s11701-009-0153-7

Cite this article as:
Casale, P. & Lambert, S. J Robotic Surg (2009) 3: 161. doi:10.1007/s11701-009-0153-7
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Abstract

Duplex collecting system pathology can be handled using an ablative procedure or reconstructive procedure even in the light of a poorly functioning moiety. We propose that, when a reconstructive procedure is an option, a robotic ureteroureterostomy is safe and feasible. Fifteen children between the ages of 6 months and 10 years (mean 31.26 months) underwent transperitoneal robotic ureteroureterostomy for duplex collecting system pathology. The surgical procedure included transperitoneal robotic approach. Outcome measures included operative time, length of hospital stay, and resolution of symptoms. Mean operative time was 1.2 h (range 0.75–2.2 h) for the entire procedure, including the cystoscopic evaluation. Length of stay averaged 20.8 h (range 15–26 h). All postoperative imaging demonstrated intact, well-draining collecting systems. The presenting symptomatology resolved in all the patients in whom symptoms were present. Robotic ureteroureterostomy is feasible and safe in the pediatric population and should be considered part of the surgical armamentarium when upper tract preservation seems warranted.

Keywords

KidneyLaparoscopyRobotic surgeryUreterChild

Introduction

Several investigators have reported on laparoscopic upper tract techniques when treating a child with a duplicated collecting system [16]. In 1997 Janetschek et al. reported a series of laparoscopic pediatric heminephroureterectomy with excellent clinical outcomes. These investigators noted that laparoscopic interventions in duplex collecting systems can pose a challenge and should be performed at specialized centers [1]. El-Ghoneimi et al. [2] described their retroperitoneal approach to laparoscopic surgery on duplex systems. Recently, Ramalingam [3] reported their experience with three cases of transperitoneal laparoscopic approaches to reconstruction of duplex systems with pathology. Two were adults and one was a 4-month-old infant. All authors to date agree that laparoscopic reconstruction of the upper tracts is quite challenging in the pediatric population.

Robotics has been implemented in duplicated systems [4, 5]. Passerotti et al. described their robotic technique, concluding that robotic-assisted laparoscopic ureteroureterostomy appears to be a safe and feasible approach in pediatric patients as well as effective in their experience. An earlier manuscript on both laparoscopic and robotic complex upper tract reconstruction in children with duplicated systems found the approach to be easier to perform in a robotic fashion, at both the renal and bladder level, as compared with a laparoscopic secondary to the three-dimensional visualization and dexterity that is added with the robotic platform [5].

Duplex collecting system pathology can be handled using one of two different strategies. The debate over whether to perform an ablative procedure or reconstructive procedure has not been settled, even in the light of a poorly functioning moiety. Our experience lends us to preserve the moiety with good function either by reimplantation, ureteropyelostomy or ureteroureterostomy, which varies according to surgeon preference at our institution. We propose that, when a reconstructive procedure is an option, a robotic ureteroureterostomy is safe and feasible.

Materials and methods

Fifteen children between the ages of 6 months and 10 years (mean 31.26 months) underwent transperitoneal robotic ureteroureterostomy for duplex collecting system pathology (Table 1). The da Vinci® surgical system was used during the surgical procedures for all patients. Work-up included a magnetic resonance urogram (MRU) or diuretic radionuclide imaging (DRI) that showed an upper pole ectopic ureter with function in that moiety in all the female patients. The 10-year-old boy with a history of left flank pain and pyelonephritis had a computed tomography (CAT) scan urogram performed, revealing a left upper pole ectopia to the prostate with preserved function and contrast seen to the level of the prostate.
Table 1

Summary of patient characteristics described in the current series

Patient age

Gender

Pathology

Symptoms

6 Months

F

Left upper pole ectopia to urethra

Febrile UTIs

6 Months

F

Right upper pole ectopia to Gartner’s duct cyst

Antenatal hydronephrosis and vaginal mass; febrile UTI

7 Months

F

Right upper pole ectopia to urethra

Antenatal hydronephrosis; febrile UTI

8 Months

F

Left upper pole ectopia to Gartner’s duct cyst

Antenatal hydronephrosis, febrile UTIs, and vaginal mass

10 Months

F

Left upper pole ectopia to vagina

Antenatal hydronephrosis; febrile UTI

12 Months

F

Right upper pole ectopia to vagina

Antenatal hydronephrosis; febrile UTI

12 Months

M

Left upper pole ectopia to seminal vesicle

Antenatal hydronephrosis

13 Months

F

Left upper pole ectopia to vagina

Antenatal hydronephrosis; febrile UTI

15 Months

F

Right upper pole ectopia to vagina

Antenatal hydronephrosis

15 Months

F

Left upper pole ectopia to urethra

Antenatal hydronephrosis

17 Months

F

Right upper pole ectopia to vagina

Antenatal hydronephrosis, febrile UTI

5 Years

F

Left upper pole ectopia to vagina

Incontinence

6 Years

F

Right upper pole ectopia to vagina

Incontinence

8 Years

M

Right upper pole ectopia to seminal vesicle

Flank pain/epididymitis

10 Years

M

Left upper pole ectopia to prostate

Flank pain/pyelonephritis

The surgical procedure included transperitoneal robotic approach similar to that previously described in the literature for robotic extravesical reimplantation [6]. All patients underwent cystoscopic evaluation with retrograde ureteropyelogram (RGP) with open-ended ureteral catheter placement into the lower pole ureter prior to robotic intervention. After RGP a double pigtail stent was placed on a string. Delineation of the two ureters was facilitated by the preplaced ureteral stent (Fig. 1).
https://static-content.springer.com/image/art%3A10.1007%2Fs11701-009-0153-7/MediaObjects/11701_2009_153_Fig1_HTML.jpg
Fig. 1

Dissection of the upper pole ureter from the lower pole ureter in a 6-month-old girl

All reapproximations were performed with 6-0 polyglactic acid sutures in running fashion (Fig. 2). All ureteral segments distal to the vagina were removed at the level of the vagina. The ureter to the prostate in the boy was removed at the level of the prostate via the same transperitoneal approach. We do not leave ureteral stumps when performing these procedures laparoscopically due to the relative easy access via transperitoneal approach. If there is any concern for the anastomosis, the string is removed from the stent prior to losing robotic access.
https://static-content.springer.com/image/art%3A10.1007%2Fs11701-009-0153-7/MediaObjects/11701_2009_153_Fig2_HTML.jpg
Fig. 2

Upper pole to lower pole end to side anterior anastomosis with stent in lower pole moiety

Outcome measures included operative time, length of hospital stay, and resolution of symptoms. The patients were also evaluated by ultrasonography along with either MRU or intravenous pyelogram (IVP) to evaluate the reconstruction.

Results

Mean operative time was 1.2 h (range 0.75–2.2 h) for the entire procedure, including the cystoscopic evaluation. Length of stay averaged 20.8 h (range 15–26 h). Stents were removed 1–2 weeks postoperatively if on a string, or 4–6 weeks postoperatively without a string. The patients then had repeat ultrasounds and either an IVP or MRU 6 months postoperatively to evaluate the reconstruction. All postoperative ultrasound, MRU, and/or IVP imaging demonstrated intact, well-draining collecting systems. The presenting symptomatology resolved in all the patients in whom symptoms were present.

Discussion

The debate will always continue as to whether the moiety should be saved or removed, with recent publications showing that the decision on the affected moiety depends upon function and pathology, especially with an incomplete duplication [35]. Typically a common sheath reimplantation or heminephroureterectomy seems to be the treatment of choice for ectopia. We preserve the affected moiety if it shows function on preoperative studies, typically by a common sheath reimplantation or upper tract reconstruction depending on concomitant entities, i.e., lower pole reflux or the necessity of bladder neck reconstruction with ectopia. Since our experience with upper tract reconstruction for pyeloplasty is extremely positive, we previously chose to perform a reconstruction at the renal level in a similar minimally invasive manner when the renal moiety has well-preserved function [5]. However, with our robotic experience for extravesical reimplantation [6], we now apply those techniques to a duplex system at the level of the pelvis with a low ureteroureterostomy. The argument that the upper pole adds little overall renal function is fair. We believe that, if the lower pole moiety parenchyma is kept from harm during an upper pole heminephrectomy, we can avoid further loss of renal parenchyma. It has been our experience to preserve the moiety with good function by reimplantation, ureteropyelostomy or ureteroureterostomy, which varies according to surgeon preference at our institution.

One caveat that we feel is important pertains to the stent. The theory behind this concept stems from the fact that the lower pole moiety produces the majority of the urine from that side. If the stent is small in diameter to accommodate infants, the stents are typically not perforated throughout their entire length. The possibility of urinary leakage might be increased. We feel that it is not imperative to stent across the anastomosis since the urine passage from the functioning upper pole moiety is sufficient for patency as in the same manner one sees patency in stentless pyeloplasties. The diversion of urine from a potentially leaking site is important. We realize this can be achieved with a Penrose-type drain to be removed in the immediate postoperative period, but the stents on a string can be left in for a similar amount of time with no added surgical morbidity. If there is concern for the anastomosis prior to completion due to a teaching environment, the string is removed intraoperatively prior to robotic disengagement and under robotic visualization and direct manipulation to ensure the stent does not migrate.

Our postoperative management included an ultrasound at 4 weeks because this would show whether the system drained completely by artificial means with the stent in place. It provided a baseline to compare the subsequent ultrasound because, if the systems were completely decompressed at the 4-week ultrasound, then any development of hydronephrosis would warrant more aggressive imaging. Since our patient population is small, we wanted to ensure that there was sufficient information available to allow a complete evaluation not only of feasibility but also of safety, especially since our previous experience was only six children done in a minimally invasive fashion [5].

We feel that this procedure is a feasible option for this patient population. The aspect that is most appealing in our opinion is that the reconstruction is done in situ with no chance of distortion from retractors. By implementing the da Vinci® surgical system, one can perform the complicated maneuvers of intracorporeal suturing with minimal fatigue and optimal visualization. It goes without saying that a case series is a good start, but prospective, randomized data is needed to make a meaningful comparison between the techniques described in this manuscript and the gold-standard approach of open surgery. However, we believe that robotic ureteral reconstruction in children is an alternative approach that may be added to the surgical armamentarium, although requiring further investigation.

Conclusions

Robotic ureteroureterostomy is feasible and safe in the pediatric population and should be considered part of the surgical armamentarium when upper tract preservation seems warranted.

Copyright information

© Springer-Verlag London Ltd 2009