Laparoscopic appendiceal interposition pyeloplasty for long ureteric strictures in children.

INTRODUCTION: The management of long ureteric strictures is very challenging, and ureteral substitution is necessary when end-to-end anastomosis can not be accomplished.

OBJECTIVE: To evaluate the mid-term results of laparoscopic appendiceal interposition pyeloplasty in children with long ureteric strictures.

METHODS: Between March 2010 and September 2016 four patients (median age 24 months, male/female 3/1) underwent laparoscopic appendiceal interposition pyeloplasty at the current hospital. Two patients had previously failed pyeloplasty, one had a traffic injury, and one had iatrogenic ureteral injury (Summary Table). The intraoperative, postoperative and follow-up results were analyzed. Success was defined as clinical (subjective) and radiologic (objective) resolution of the stricture.

RESULTS: All surgeries were successfully completed without conversion. The mean stricture length was 4.5 cm. Two cases were right-sided strictures, and two were left-sided. The mean operative time and estimated blood loss were 238.5 min and 25.0 ml, respectively. No intraoperative complication was encountered. No Grade 3 or Grade 4 complication was observed after surgery. One was anastomosed in the antiperistaltic manner and three were in the isoperistaltic fashion. The mean postoperative hospital stay was 7.3 days. The success rate was 100% at a mean follow-up duration of 33.8 months.

DISCUSSION: There is no consensus on the best surgical approach for long ureteric strictures. Ureteric replacement with intestinal segments or kidney autotransplantation is a viable alternative treatment to long ureteric strictures. However, both methods are technically challenging with significant complications. Appendiceal interposition to restore ureteral continuity has been described in adult patients. The current results demonstrated that laparoscopic appendiceal interposition pyeloplasty is a safe and feasible minimally invasive approach for the treatment of long ureteral strictures in children.

CONCLUSIONS: Laparoscopic appendiceal interposition pyeloplasty was a viable minimally invasive alternative for children with long ureteric strictures on both left and right sides. Both isoperistaltic or antiperistaltic anastomosis were feasible.