Original Article

A comparative study on the Efficacy of Retroperitoneoscopic

Pyeloplasty and Open Surgery for Ureteropelvic
Junction Obstruction in Children
Jianghua Jia1, Qingsong Meng2, Ming Zhang3, Jinchun Qi4, Dongbin Wang5
ABSTRACT
Objectives: To compare the therapeutic effect of retroperitoneoscopic dismembered pyeloplasty and
open ureteropelvic junction plasty on the ureteropelvic junction obstruction (UPJO) in children.
Methods: After the retrospective analysis of clinical data, 78 children with ureteropelvic junction stenosis
treated from January, 2012 to June, 2018 were divided into two groups: OP (open pyeloplasty) group (38
cases) and LP (laparoscopic dismembered pyeloplasty) group (40 cases) according to the surgical methods.
The operation time, intraoperative bleeding volume, postoperative length of stay (LOS), postoperative
complication rate, postoperative hydronephrosis improvement and other indicators were compared
between the two groups.
Results: All patients underwent surgery successfully, without conversion to open surgery in LP group. The
incidence of postoperative urine leakage and the recovery of hydronephrosis between LP group and OP
group 12 months after operation showed no statistically significant difference (P>0.05). The intraoperative
bleeding volume, the incidence of postoperative retroperitoneal hematoma, and the postoperative LOS
in LP group were lower than those in OP group, while the operation time was longer than that in the OP
group, with statistically significant difference (P<0.05).
Conclusion: Retroperitoneoscopic dismembered pyeloplasty had similar effect with open dismembered
pyeloplasty, but faster recovery and fewer complications, so it has become the preferred treatment
method for UPJO in children.
KEYWORDS: Retroperitoneoscopic pyeloplasty, Open pyeloplasty, Ureteropelvic junction obstruction,
Children.
doi: https://doi.org/10.12669/pjms.37.7.4205
How to cite this:
Jia J, Meng Q, Zhang M, Qi J, Wang D. A comparative study on the Efficacy of Retroperitoneoscopic Pyeloplasty and Open Surgery
for Ureteropelvic Junction Obstruction in Children. Pak J Med Sci. 2021;37(7):1768-1774.
doi: https://doi.org/10.12669/pjms.37.7.4205
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Jianghua Jia,
2. Qingsong Meng, INTRODUCTION
3. Ming Zhang,
4. Jinchun Qi, Ureteropelvic junction obstruction (UPJO) is the
5. Dongbin Wang, main cause of hydronephrosis in children, and
1-5: Department of Urology,
The Second Hospital of Hebei Medical University, early diagnosis and timely treatment are of great
NO. 215 Heping Xi road, Shijiazhuang, Hebei, 050000, China. significance to the protection of renal function of
Correspondence: children. If children’s hydronephrosis is not treated
Dongbin Wang, or treated incorrectly, renal function will be further
Department of Urology, impaired. There are a variety of surgical methods
The Second Hospital of Hebei Medical University,
NO. 215 Heping Xi road, Shijiazhuang, Hebei, 050000, China. for the treatment of UPJO, of which dismembered
E-mail: [email protected] pyeloplasty is considered to be the gold standard
* Received for Publication: January 21, 2021
for the treatment of UPJO with the success rate
* Revision Received: June 7, 2021 of over 90% and good long-term efficacy1,2 after
* Revision Accepted: * June 28, 2021 long-term follow-up. After more than 20 years of

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 Jianghua Jia et al.

development, laparoscopic pyeloplasty has been device after routine disinfection and surgical
widely used for its advantages of less pain, less drape spreading. An incision of about 2.0cm was
trauma, faster recovery, better cosmetic effect and made below the costal margin of posterior axillary
higher success rate than open surgery. The technique line, which was opened to the lumbar dorsal fascia
improvement has made retroperitoneoscopic layer by layer, and then broken through into
pyeloplasty feasible and effective, even for the the retroperitoneal space. A visual balloon was
infants with UPJ obstruction, and our preliminary inserted, inflated with about 300ml-360ml air, and
experience report is as follows. then removed after five minutes. Suture fixation
was performed after 10 mm Trocar cannula was
METHODS
embedded, and then the laparoscope was inserted
The procedures followed in this study and the pneumoperitoneum was connected, with
comply with the ethics standards established the pressure maintained at 8-10 mmHG, and the
and approved by the ethics committee, and all incision was made at the anterior axillary line
subjects and their parents have given informed below costal margin, midaxillary line, and two
consent. The UPJO children hospitalized from transverse fingers above ilium; 5 mm and 10 mm
January, 2012 to June, 2018 were selected as Trocars were inserted under laparoscope, with
the study subjects, and divided into OP group the core withdrawn, and the laparoscope moved
(open pyeloplasty) and LP group (laparoscopic to Trocar cannula above axillary midline and
dismembered pyeloplasty) according to surgical ilium. The elastic separating plier and ultrasonic
methods. Among the 38 children in OP group, knife were inserted into the remaining two Trocar
there were 25 males and 13 females, aged from cannulas respectively. The perirenal fascia was
12.3 to 73.2 months, with an average age of opened, ranging from subphrenic space to iliac
(35.6±23.8) months, and there were 26 cases of fossa. The perirenal fat was opened to separate the
moderate hydronephrosis and 12 cases of severe space between anterior psoas major and posterior
hydronephrosis. Among the 40 children in LP kidney, so that the free upper ureteral segment
group, there were 25 males and 15 females, and dilated renal pelvis was under direct vision.
aged 10.5-80.9 months, with an average age of The renal pelvis was cut in an arc, so that the renal
37.4±22.5 months, and there were 25 cases of pelvis was bell-opened, and the ureter of stenotic
moderate hydronephrosis and 15 cases of severe segment was cut off about 0.5cm from the distal
hydronephrosis. The two groups of children end of stenotic segment. The lateral proximal
were compared in terms of age, sex, severity of ureteral wall was cut longitudinally by about
hydronephrosis and other basic conditions, and 1.0cm. The lowest point of flared opening of renal
all the P values were >0.05, which was comparable pelvis and the lowest point of the cut of ureter was
(see Table-I). Both groups received preoperative sutured with 4-0 absorbable needle suture for one
intravenous urography (IVU), urinary ultrasound stitch, while the highest point of flared opening of
and CT. IVU showed delayed development time renal pelvis and the highest point of the broken
of renal pelvis and calyx on the affected side, end of ureter was sutured with 4-0 absorbable
dilatation of renal sinus, and abrupt termination needle suture for one stitch. Continuous suture of
of contrast agent at the ureteropelvic junction, the posterior wall was performed with 4-0 absorbable
ultrasonography showed hydronephrosis signs suture, one locking stitch every two stitches,
but no ureteral dilatation, and the preoperative the distal end of double J tube was inserted into
blood and renal function examination remained urinary bladder at anastomotic stoma guided by
within the normal range. the thread, which was drawn later, ensuring the
The retrospective analysis study was approved urine could flow out from the side hole when the
by the Institutional Ethics Committee of The Second abdomen was squeezed, while the proximal end
Hospital of Hebei Medical University treated from was inserted into renal pelvis, and 4-0 absorbable
January, 2012 to June, 2018, and written informed suture with needle was used to suture the anterior
consent was obtained from all participants. closed anastomotic stoma, and then the closed
Retroperitoneal laparoscopic surgery: After general urethral catheter was opened. After no bleeding,
anesthesia, a catheter was indwelled and clamped, errhysis and urine leakage could be observed at
and then the patient was aligned waist and raised the anastomotic stoma, and peristaltic ureteral
waist bridge in the unaffected side-lying position, waves could pass through the anastomotic stoma,
and connected to the corresponding laparoscopic the retroperitoneal drainage tube was placed, and

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 Treatment of Ureteropelvic Junction Obstruction in Children

Fig.1: Dissociate UPJ. Fig.3: Anastomose UPJ.

then the incision was sutured layer by layer (Fig.1- inside and outside the renal pelvis and ureter
5). The drainage tube was removed 2~5 days after respectively, and then the renal pelvis was cut
the operation, the urinary tube was removed 7~10 open above the stenosis segment, which was cut
days after the operation, and the ureteral double J arc-shaped to make the renal pelvis outlet flared,
tube was removed by ureteroscopy under general then the stenosis segment was removed, and the
anesthesia 6~8 weeks later. normal ureter was incised longitudinally about
Open Surgery: The urinary catheter was placed 1.0 cm under the stenosis segment; afterwards,
in the urinary bladder after successful general the anastomosis was performed between pelvis
anesthesia. The patient was placed in the healthy outlet and proximal ureter with 4-0 absorbable
side-lying position with the waist slightly surgical suture: anastomosed the anterior wall
elevated, and then an oblique incision was made firstly, placed the ureteral stent (with the distal
at the waist in the affected side after routine end passing through anastomotic stoma and the
disinfection and surgical drape spreading, and the proximal end led in vitro via pelvis incision), led
skin was incised layer by layer to subcutaneous in the pyelostomy catheter through skin incision,
tissue, obliquus externus abdominis, obliquus and then place it in the renal pelvis through
internus abdominis and musculus trasversus another pelvis incision, and then anastomosed the
abdominis. The peritoneum was opened and posterior wall. One retroperitoneal drainage tube
the perinephric fascia was cut open to make the was indwelling and the incision was sutured layer
pelviureteric junction and upper ureteral segment by layer. The drainage tube and urinary catheter
fully exposed, and the indication lines was drawn were removed two to five days after the operation,

Fig.2: Cut UPJ. Fig.4: Place Double J tube.

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 Jianghua Jia et al.

Table-I: Comparison of the general information

of Children in OP group and LP Group.

OP group LP group
Index p
(n=38) (n=40)

Age (month) 35.6±23.8 37.4±22.5 0.956

Sex
Male 25 25
0.873
Female 13 15
Affected side
Left 26 24
0.438
Right 12 16
Hydronephrosis degree
Moderate 26 25
0.583
Fig.5: Finish anastomosis J. Severe 12 15

the ureteral stent was removed 10~14d after the the two groups at the 12th month as the statistical
operation, and the nephrostomy tube was removed indicators. The degree of hydronephrosis was
after methylene blue was injected one to two days determined by the urinary tract dilation(UTD)
after the operation to confirm the ureteral patency. classification system3: (1) mild: 1.0~2.0cm separation
Observation indexes: The operation time, of collecting system, and normal renal parenchyma
intraoperative bleeding volume, postoperative LOS, and kidney shape; (2) moderate: 2.1~3.5cm
and postoperative complication rate (incidence of separation of collecting system, slightly thinner
urine leakage and retroperitoneal hematoma) of renal parenchyma, and enlarged kidney shape; (3)
the children in the LP group and OP group were severe: more than 3.6cm separation of collecting
compared and observed. Intraoperative blood system, significantly thinner renal parenchyma,
loss was calculated by the total amount of fluid and enlarged and deformed kidney shape.
aspirated minus the amount of intraoperative rinse Statistical Method: SPSS16.0 statistical
fluid. The follow-up visits were made to the two software was used for statistical analysis, with
groups of children at the 3rd, 6th and 12th months the measurement data expressed as X ±S, two
after the operation respectively, and the recovery independent samples were used for t-test, and
was observed through B-ultrasound examination the counting data were tested by chi-square
of urinary system, with the number of severe, test, P <0.05 indicating statistically significant
moderate, mild and no hydronephrosis cases in difference.

Table-II: Comparison of the intraoperative and postoperative

follow-up data of the children in LP group and OP group.

Item OP group (n=38) LP group (n=40) p

Time of operation/min 114.4±13.1 122.7±13.4 0.007

Intraoperative bleeding volume/ml 29.4±9.7 21.9±7.4 <0.001
Postoperative LOS 8.9±1.3 7.1±1.2 <0.001
Incidence rate of leakage of urine/% (cases) 5.6 (2/36) 11.1 (4/36) 0.433
Incidence rate ofretroperitoneal hematoma/% (cases) 15.2 (5/33) 0 0.018
Postoperative follow-up recovery after 12 months
No hydronephrosis 33 34
0.815
Mild hydronephrosis 3 4
0.745
Moderate hydronephrosis 2 2
0.958
Severe hydronephrosis 0 0

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 Treatment of Ureteropelvic Junction Obstruction in Children

RESULTS field is clear, but it is easy to cause intra-

abdominal viscera injury, and postoperative
All patients received surgery successfully, complications, such as abdominal distension,
without conversion to open surgery in the LP
intestinal obstruction, and intestinal adhesion, etc.;
group. The incidence of postoperative urine
moreover, because the renal pedicle vessels make
leakage and the hydronephrosis recovery
the ureteropelvic junction difficult to be exposed,
between LP group and OP group 12 months
thereby largely increasing the operation difficulty,
after surgery showed no statistically significant
while it is well exposed via retroperitoneal
difference (P>0.05). The intraoperative bleeding
approach, which is convenient for operation,
volume, the incidence of postoperative
with small abdominal injury, and no significant
retroperitoneal hematoma, and the postoperative
complication. Retroperitoneal laparoscopic
LOS in LP group were lower than those in OP
pyeloplasty is difficult, and skilled surgeons are
group, while the operation time was longer than
required to reconstruct the renal pelvis and ureter
that in the OP group, with statistically significant
under the endoscope; in addition, due to limited
difference (P<0.05). The duration of indwelling
operating space, it is difficult to complete suture
drainage tube and LOS were prolonged for the
and knotting in vivo, and a certain learning curve
children with postoperative leakage of urine and
is required. In this study, all the patients in the LP
retroperitoneal hematoma.
group were successfully operated without being
DISCUSSION converted to open surgery. The intraoperative
bleeding volume, the incidence of postoperative
It has been reported in most studies that the retroperitoneal hematoma, and the postoperative
success rate of open Anderson–Hynes pyeloplasty LOS in LP group were lower than those in OP
is greater than 90%, so it is the preferred group, while the operation time was longer than
method for surgical treatment of pediatric UPJ that in the OP group. Rasool S et al also reported that
obstruction4. Minimally invasive surgery has intraoperative blood loss was significantly lower
become a growing trend over the past decade. The in the LP group than in the OP group.11 Another
small retroperitoneal space in pediatric patients study also found that there are shorter operative
is not conducive to the operation of laparoscopic times in the laparoscopic-assisted pyeloplasty
instrument, so the application of retroperitoneal and shorter overall hospitalization.12 There was
laparoscopic technology in pediatric urological no significant difference in the incidence of urine
surgery is limited. leakage and recovery of hydronephrosis between
In 1999, Tan et al.5 reported that 18 children the two groups 12 months after operation. Our
underwent laparoscopic pyeloplasty via peritoneal surgical experience is summarized as follows:
approach and two underwent secondary surgery (1) The lumbar and dorsal fascia of children is
for the first time. Yeung et al.6 also reported that immature, and the peritoneum is relatively
13 infants underwent laparoscopic pyeloplasty thin, so the surgical operation should be gentle,
via retroperitoneal approach in 2001, one of and when the expansion balloon is used to
which was converted to open surgery. Zhou prepare retroperitoneal space, the peritoneum
huixia et al.7 Summarized and reported 36 cases should not be overinflated and torn. Generally,
of children undergoing laparoscopic pyeloplasty it should be inflated about 300-360ml, and
via retroperitoneal approach, and believed that the pneumoperitoneum pressure is set as
it is prone to dissociate after pneumoperitoneum 8-10mmHg.
formation and the anatomical hierarchy is clear (2) It is generally not dissociated in the kidney of
for the children with little retroperitoneal fat ventral side, but only dissociated in the lower
and loose tissue; therefore, retroperitoneal middle part of the dorsal side of kidney, and
laparoscopic pyeloplasty is a safe, effective and it will seek and follow the non-vascular plane
minimally invasive method for the treatment of for dissociation, so it is necessary to avoid
pediatric UPJ stenosis. injury and bleeding, especially in children, who
The laparoscopic pyeloplasty can be performed have small blood volume, and it is essential to
via abdominal approach and retroperitoneal actively stop bleeding, so as to ensure a clear
approach, each of which has its advantages operating field;
and disadvantages.8-10 The operation space via (3) When placing the cannula, it is necessary
abdominal approach is larger, and the surgical to first place and fix the cannula at the

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 Jianghua Jia et al.

incision of posterior axillary line, connect and stent displacement should be considered.
the pneumoperitoneum, place the If necessary, stent replacement or nephrostomy
laparoscope, and place another two cannulas should be performed, and nutrition should be
under the laparoscope to avoid injury to strengthened to promote wound healing, so that
retroperitoneum. the condition can be improved 1-2 weeks later
(4) The ureteral lumen in children is small and generally.16,17
fine, so the posterior wall can be sutured with Secondary obstruction after UPJO surgery is
intermittent locking stitch during anastomosis. one of the major complications after pyeloplasty.
After the ureteral DJ tube is placed, the anterior Studies have shown that reoperation after
wall can be sutured with intermittent 2~3 primary pyeloplasty is required for about 11% of
stitches, and the suture should not be too close, patients, indicating that the actual achievement
so as to reduce the incidence of postoperative rate of pyeloplasty is lower than that reported
anastomotic stenosis. in the literature. The author believes that
(5) Laparoscopic double “J” intra-tube drainage the key to the success of the operation is to
is performed with double drainage of luminal determine the lowest point of renal pelvis and
drainage and peri-tube drainage, which can anastomose it with the ureter.18 Zhou Huixia19
effectively reduce the incidence of infection at et al. determined the direction of renal axis and
the anastomotic stoma, reduce the incidence of the lowest point suture technique by using the
recent incision infection and urine leakage, and direction of the upper, middle and lower calyx
effectively promote the recovery of patients.13 zaxis, so as to reduce the risk of postoperative
re-obstruction, and improve the achievement
During laparoscopic surgery, it should be
ratio of operation; meanwhile, the non-clamp
converted to laparotomy in time if the following
anastomotic technique can reduce the injury
conditions appear14,15: (1) severe adhesion
of anastomotic tissue and blood vessels, and
between renal pelvis and surrounding tissues,
improve the achievement ratio of operation.
unclear anatomical structure, and difficulty
in laparoscopic separation and resection; CONCLUSION
(2) intraoperative calculus, and difficulty in
thorough removal under the laparoscope; (3) Retroperitoneal laparoscopic dismembered
intraoperative bleeding, and ineffective control pyeloplasty share the similar effects with open
under the laparoscope; (4) intraoperative injury dismembered pyeloplasty, but the faster recovery
of duodenum or colon, and difficult to make and fewer complications have made it the
accurate repair under the laparoscope; (5) during preferred treatment for UPJO in children.
the operation, the length of lesion to be removed Limitations of this study: The number of subjects
is found to be longer, the tension of anastomotic included in this study was limited, so the
site is high, it is difficult to perform accurate conclusions drawn may not be very convincing.
anastomosis, and there are few skilled surgeons In addition, we only analyzed and discussed the
for laparoscopic surgery. cases included in our hospital, which may not
Urethrovesical anastomotic leakage is the be representative enough. We look forward to a
most common complication after pyeloplasty, multi-center study in the future to reach more
which is usually due to inadequate laparoscopic
comprehensive conclusions.
anastomosis, postoperative regression of
anastomotic edema, urinary extravasation, Source of funding: None.
or stent blockage and displacement. Good
Conflicts of interest: None.
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