There are different techniques for surgical repair of UPJO. Open pyeloplasty (OP), laparoscopic pyeloplasty (LP), and robotic pyeloplasty are the main techniques used nowadays. The prevalence of minimally invasive pyeloplasties has increased in the last decade . Nonetheless, OP remains the most prevalent procedure for children with UPJO, and MIS appears to be available mainly in institutions where surgeons have a high level of skill in laparoscopic surgery, such as large paediatric hospitals and teaching hospitals . Many reported series and meta-analysis studies comparing different techniques for managing UPJO revealed that LP has an aesthetic advantage, less pain, fewer overall complications, and shorter hospital stay than OP. And despite the fact that the LP had a longer operative time, the success rate of LP is comparable to that of OP [7, 13, 14].
Laparoscopic pyeloplasty can be done via a transperitoneal approach or retroperitoneal approach. The retroperitoneal approach is characterized by being extraperitoneal with minimal complications for the GIT but, unfortunately, a small working space with longer operative time . We preferred the transperitoneal approach for wider working space and easier anastomosis.
In this study, we presented our early experience. Our mean operative time was 175 min which is similar to other reported LP studies that ranged from 155 to 275 min [8, 9, 14, 16, 17]. Intraoperatively, there were no major complications like organ injury or haemorrhage. No need for conversion to open pyeloplasty. Most of the operative time was consumed by the intracorporeal suturing. LP needs a high level of experience in laparoscopic surgery with good training on intracorporeal suturing.
At the beginning of our work, we encountered some difficulties while inserting the double J catheter in some cases. Silay et al. found that the most common intraoperative complication in LP was due to complicated double J stent insertion . Many techniques have been used to place the double J stent, either antegrade or retrograde. In the antegrade technique, the main problem is the passage of the stent through the vesicoureteric junction, especially in patients under the age of 1 year. We first used a percutaneous wide bore cannula to introduce the stent and Rodriguez technique using methylene blue to ensure entry into the bladder . It is difficult to determine the exact positioning of the distal end as it is a blind approach. Then, we shifted to retrograde approach using cystoscopy, which has an additional advantage of diagnosing the associated distal obstructive ureterovesical junction. Some studies recommended using transrenal stenting than double J stents [19, 20].
At the beginning of LP in paediatrics, many surgeons found it hazardous in infants , but over time, the studies have proven that it is safe and feasible to perform in infants [5, 22]. We had 7 cases under the age of 1 year in our study with no intra or post-operative complications.
The definition of successful surgery is not standardized. Accepted one is that successful surgery will meet the following criteria: resolution of symptoms, no reoperation, decreased hydronephrosis and/or improved renographic drainage . Passoni and Peters found that the success rate of LP is 92–99% . Also, Chandrasekharam and Ramesh found a similar success rate of 97.5% . John Gatti has similar success rate as well (94%) . In our study, only one case needed further intervention for associated distal vesicoureteric obstruction.
The main issue in LP is the learning curve; it takes time to become an expert in LP. We noticed improvement in the operative time with progress in cases in our study. Our study is limited by the small cohort size and the absence of comparison with open pyeloplasty series. Another limitation is a relatively short follow-up period which can potentially affect the assessment of late surgery failure. Long-term follow-up with greater number of patients is justified to demonstrate the safety and efficacy of LP.