© 2007 THE AUTHORS JOURNAL COMPILATION © 2 0 0 7 B J U I N T E R N A T I O N A L | 1 0 1 , 2 2 7 – 2 3 0 | doi:10.1111/j.1464-410X.2007.07106.x 227 Paediatric Urology LAPAROSCOPIC RECONSTRUCTION FOR OBSTRUCTION IN CHILDREN WITH DUPLEX RENAL ANOMALIES LOWE et al. Laparoscopic reconstructive options for obstruction in children with duplex renal anomalies Gregory J. Lowe, Stephen J. Canon and Venkata R. Jayanthi Section of Urology, Columbus Children’s Hospital, The Ohio State University, Columbus, OH, USA Accepted for publication 17 May 2007 our institution. The port placement and surgical exposure were analogous to that for transperitoneal laparoscopic pyeloplasty. A JJ stent was placed retrogradely into the ureter immediately before each procedure. The procedures performed were pyelo- ureterostomy for incomplete duplication and lower pole pelvi-ureteric junction (PUJ) obstruction, lower pole pyeloplasty for lower pole PUJ obstruction and complete duplication, and ipsilateral uretero- ureterostomy and distal ureterectomy for an obstructed, ectopic upper pole. Foley catheters were left indwelling for 36–48 h and stents were removed at 4–6 weeks. Postoperative imaging included either ultrasonography or intravenous urography. RESULTS Three children presented with intermittent flank pain due to lower pole PUJ obstruction. The other child presented with pyonephrosis and purulent drainage from her vagina due to an ectopic ureter associated with a functioning upper pole segment. All procedures were successfully completed. The only complication was in the first patient (pyelo-ureterostomy) who had transient urinary extravasation that resolved with bladder decompression for 10 days. With a follow-up of 6–18 months, all had resolution of symptoms with improvement in radiographic variables. CONCLUSIONS This series shows that children with duplex anomalies and obstruction can undergo successful reconstruction using techniques learned with laparoscopic pyeloplasty. KEYWORDS hydronephrosis, PUJ obstruction, laparoscopy, duplex kidney Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To present our initial experience of laparoscopic reconstructive surgery in children with upper urinary tract obstruction associated with duplex anomalies, as although there is much information on ablative procedures such as laparoscopic heminephrectomy, there is little available about minimally invasive reconstructive options for duplex renal anomalies in children. PATIENTS AND METHODS We retrospectively reviewed four consecutive patients (aged 6–11 years) with duplex anomalies and laparoscopic reconstruction for obstructed, dilated segments treated at INTRODUCTION There is ever-increasing experience with laparoscopic repair of PUJ obstruction. There are many reports on its efficacy and usefulness in the paediatric population [1–10]. Obstructive duplex anomalies are less common and there is scant published information regarding laparoscopic reconstructive options [11–18]. We present our initial experience with this approach in children with upper urinary tract obstruction associated with duplex anomalies. PATIENTS AND METHODS We retrospectively reviewed four consecutive patients (aged 6–11 years) with duplex anomalies and laparoscopic reconstruction for obstructed, dilated segments treated at our institution. Diagnosis of obstruction was based on standard imaging protocols (IVU, ultrasonography, CT and/or nuclear renography) in conjunction with classic symptoms. In all cases, cystoscopy with retrograde pyelography was used to define the patient’s anatomy. In patients with planned anastomosis between the obstructed segment and the normal ipsilateral ureter, a JJ stent was placed retrogradely into the normal ureter. Standard transperitoneal laparoscopy was performed with a 5-mm umbilical camera port. Two working ports (3–5 mm) were placed in the epigastrium and ipsilateral lower quadrant, thus three ports in each case. The surgical approach was identical to that for laparoscopic pyeloplasty. For right-sided repairs, the hepatic flexure was mobilized just enough that the renal pelvis is visualized. Left-sided repairs were performed in a trans- mesocolic fashion. Once the dilated segment was identified, percutaneous holding sutures were used to lift it out of the renal fossa to assist with mobilization, dissection, spatulation, and suturing. For lower pole PUJ obstruction in conjunction with incomplete duplication, once the lower pole pelvis was transected, a lateral ureterotomy was made in the normal ureter. An end-to-side anastomosis was created using 5/0 polydiaxonone suture. For an obstructed upper pole due to an ectopic ureter, a medial ureterotomy was made in the normal, ipsilateral lower pole ureter and an end-to-side anastomosis was created. For lower pole PUJ obstruction, associated with complete ureteric duplication, a standard dismembered pyeloplasty was performed between the lower pole renal pelvis and ureter. After completion of the repair, the posterior peritoneum or sigmoid mesentery was re-approximated, and the port-sites closed. Drains were not placed.