Laparoscopic Pyeloplasty via Transmesenteric Approach for Pediatric Ureteropelvic Junction Obstruction

Summary

Transmesenteric laparoscopic pyeloplasty for left-sided UPJO in children accesses the dilated pelvis through a mesenteric window, avoiding colon mobilization. The technique reduces operative time, minimises blood loss, and accelerates postoperative bowel function recovery while providing a focused surgical field.

Abstract

With ongoing advances in minimally invasive surgical techniques, laparoscopic pyeloplasty (LP) has become the standard of care for the treatment of pediatric ureteropelvic junction obstruction (UPJO). Numerous studies have demonstrated that, compared with traditional open surgery, laparoscopic surgery offers significant advantages, including reduced postoperative pain, diminished surgical trauma, accelerated recovery, and superior cosmetic outcomes, while achieving success rates comparable to those of open surgery. Among various surgical approaches, the transmesenteric approach represents an innovative route that directly accesses the renal pelvis through the mesenteric window, effectively circumventing the complex step of extensive colonic mobilization required in conventional transperitoneal laparoscopic pyeloplasty. This approach is particularly advantageous for the treatment of left-sided UPJO in children, enabling rapid and precise localization of the hydronephrotic renal pelvis while avoiding excessive colonic mobilization, thereby shortening operative time and reducing intraoperative blood loss. However, laparoscopic suturing and knot-tying techniques remain technically demanding and challenging, with a prolonged learning curve, particularly in pediatric patients with limited intra-abdominal working space, which imposes stringent requirements on the surgeon's laparoscopic proficiency. With the progressive standardization of surgical techniques and the widespread adoption of robotic-assisted surgical systems, robotic-assisted laparoscopic surgery—leveraging three-dimensional visualization and articulating robotic arms with up to seven degrees of freedom—has substantially reduced the difficulty of fine maneuvers such as intracorporeal dissection and suturing. Combining this approach with advanced laparoscopic technology may further improve surgical outcomes for pediatric UPJO and propel the field toward greater precision and minimal invasiveness.

Introduction

Hydronephrosis ranks among the most prevalent congenital anomalies in pediatric urology, with UPJO constituting its primary etiology^1,2,3. Progressive disease may precipitate urinary tract infections, flank pain, and, in severe cases, irreversible renal impairment or end-stage kidney disease⁴, necessitating timely surgical intervention. Historically, open pyeloplasty served as the gold standard for UPJO management⁵. However, the substantial incisions and tissue trauma associated with open surgery prompted the pursuit of minimall....

Protocol

This protocol adhered to the ethical standards of the Medical Ethics Committees at Peking University First Hospital and Ningxia Women and Children's Hospital, and informed consent was obtained from the patient's guardians.

1. Pre-surgical steps

1. Following endotracheal intubation under general anesthesia, the patient was positioned in the right lateral decubitus position (healthy side down).
2. The lumbar region was elevated using a cushion, and the affected (left) side was raised to approximately 45 ° to optimize exposure of the renal hilum.
3. A standard three-port configuration was em....

Results

The operative time was 120 min, with an estimated intraoperative blood loss of approximately 10 mL. No blood transfusion was required. The patient experienced an uneventful postoperative recovery, with no complications, including urinary leakage, intestinal obstruction, wound infection, or fever. Postoperative ultrasonography was performed at 1, 5, and 9 months to evaluate surgical outcomes (Figure 4A–D)¹¹. The patient remained under continuous follow.......

Discussion

UPJO constitutes the predominant cause of pediatric hydronephrosis, with an incidence of approximately 1/2000 to 1/1000¹². Surgical indications include pelvic separation ≥3 cm, or ≥2 cm with calyceal dilation accompanied by symptoms or recurrent infections¹³. Dismembered pyeloplasty yields efficacy rates exceeding 95%^14,15,16. Traditional LP employs a transcolonic parac.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Electrocoagulation hook	Karl Storz	26050D	Used for dissection separation
Laparoscope--4K3D-laparoscope	Karl Storz	L-EX2721	The surgical field shows
Inflatable needle	Karl Storz	26120J	Used as a channel for percutaneous ureteral stent insertion
One-time use laparoscopic puncture device	Shide (Xiamen) Medical Equipment Co., Ltd.	IIA-3F-35X100	The disposable abdominal puncture device is used to create an abdominal operation hole.
Suture	Johnson medical	5-0 Absorbable Suture	Anastomosis of renal pelvis and ureter
Ureteral stent	BARD	4.7F	Used for supporting the anastomosis site
Da-Vinci surgical system	Da-Vinci		robotic-assisted surgical systems