Abstract
Introduction:
Hidden incision endoscopic surgery (HIdES) has gained increasing acceptance in pediatric robotic pyeloplasty, nephrectomy, and ureteral extravesical reimplantation cases. 1,2 In addition to the benefits of laparoscopy (smaller incisions, shorter hospital stays, and decreased pain or narcotic use), HIdES adds significant improvement in cosmetic outcomes while maintaining similar operative times as compared with traditional port placement techniques. 3 In this report, we describe another application of HIdES to perform multiquadrant robotic ureteroureterostomy (UU) and distal ureterectomy using only three hidden incisions.
Materials and Methods:
The index patient was a 15-month-old boy with an antenatal diagnosis of right hydronephrosis, and was found to have a duplex kidney on postnatal imaging. Specifically, the upper pole moiety was dilated with associated hydroureter. Voiding cystourethrogram showed a normal urethra, smooth bladder wall, and reflux into a dilated right ureter when voiding. This was suggestive of an ectopic insertion. Nuclear imaging demonstrated an upper pole function of 28% and poor drainage with a t½ of 40 minutes. Cystoscopy with retrograde stenting of the lower pole ureter was performed. A HIdES approach was utilized for laparoscopy, with one 8.5 mm multipurpose port placed at the umbilicus, and two working ports hidden at the level of a Pfannenstiel incision. The upper pole ureter was mobilized, ligated, and then spatulated. An end-to-side anastomosis was performed to the stented lower pole ureter. The robot was then rotated, reoriented, and retargeted toward the pelvis using the same three ports for the distal ureterectomy to the level of ectopic insertion. Two additional patients, both 7-month-old girls, had severe upper pole hydronephrosis in unilateral duplex kidneys (one left and one right) because of ectopic ureteral insertion. Parenchymal function was retained on nuclear imaging. Both girls underwent three port HIdES approach for UU with distal ureterectomy in a similar manner.
Results:
An effective UU and excision of distal ureter was performed on all three children. Operative times ranged from 176 to 199 minutes (mean 189), with 108–152 minutes of console time (mean 125). Two patients were discharged on postoperative day (POD) 1. One 7-month-old patient had a postoperative ileus, and was discharged on POD 7. There were no postoperative readmissions or unexpected visits to the emergency room. Patients required between one and six doses of narcotics postoperatively. All patients had their stents removed between 4 and 6 weeks postreconstruction; renal ultrasonography 1 month later showed improvement in upper pole hydronephrosis.
Conclusions:
HIdES is a feasible approach for multiquadrant pediatric UU and distal ureterectomy in a duplex kidney, with improved cosmetic outcomes compared with traditional port placement or open surgery.
No competing financial interest exist.
Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Runtime of video: 5 mins 5 secs
Presented April 1, 2018 at AUA meeting in San Francisco, California.
