ultrasound-guided antegrade access during laparoscopic pyeloplasty in infants less than one year of age: a point of technique

Background: Access to urethras and ureters of infants may be hazardous and injurious through an endoscopic route. Placement and removal of stents in infants requires anaesthesia and access through these small caliber urethras. We describe our technique of placing antegrade splint during a laparoscopic pyeloplasty in these infants. Materials and Methods: An ultrasound-guided percutaneous renal access is obtained. Telescopic metal two part needle is passed into the kidney over a guide wire. A second guide wire is passed through the telescopic metal two part needle. The tract is dilated with 14 Fr screw dilator. Over one guide wire, a 5 Fr ureteric catheter is passed and coiled in the renal pelvis. Over the other wire, a 14 Fr malecot catheter is placed as nephrostomy. Laparoscopic pyeloplasty is then done. During pyelotomy, the ureteric catheter is pulled and advanced through the ureter before the pyeloplasty is completed. The ureteric catheter thus acts as a splint across the anastomosis. Ureteric catheter is removed on the 3 rd post operative day and nephrostomy is clamped. Nephrostomy is removed on 4 th post operative day if child is asymptomatic. The modified technique was successfully done in five patients aged less than one year old. All patients tolerated the procedure well. Post operative period was uneventful in all. Conclusion: Ultrasound-guided ante grade nephroureteral ureteral splint for infant laparoscopic pyeloplasty is safe. It avoids the need for urethral instrumentation for insertion and removal of stents in these small patients.