a ureteropelvic junction ( upj ) obstruction can be thought of as a restriction to flow of urine , from the renal pelvis to the ureter , which , if left uncorrected , leads to progressive renal deterioration .
upj obstruction occurs in all paediatric age groups , but there tends to be a clustering in the neonatal period because of the detection of antenatal hydronephrosis and again later in life because of symptomatic occurrence .
the surgical correction of upj obstruction has evolved on a number of fronts , with open surgical techniques yielding way to endoscopic , laparoscopic and robot - assisted approaches . whatever be the approach ,
dismembered pyeloplasty has been universally accepted because of its ( 1 ) broad applicability , including preservation of lower pole or crossing vessels , ( 2 ) excision of the pathologic upj and ( 3 ) successful reduction pyeloplasty . at times ,
dismembered pyeloplasty may be problematic whenever the renal pelvis is small and the ureteral length is inadequate . in such instances , a non - dismembered pyeloplasty can be performed to overcome this problem . in non - dismembered pyeloplasty , a spiral flap is created from the renal pelvis to repair the defect at the upj .
such a flap is able to bridge the gap between the pelvis and healthy ureter over a distance of several centimetres .
scardino and prince described a vertical flap that can be used in the situation of a dependent upj with a large , square - shaped extrarenal pelvis .
the foley yv plasty was originally described for the correction of upj with a high ureteral insertion .
the diagnosis of upj obstruction was firmly established based on history , physical examination , renal sonography , intravenous urography and scintigraphy .
exclusion criteria included presence of active urinary tract infection and very poor renal function ( split renal function < 10% ) .
the risks of the laparoscopic operation were fully explained to the parents of the children , which included post - operative infection , bleeding , failure of pyeloplasty , the need to convert to open surgery , damage to other viscera and adhesion formation .
the first 5 mm endoscope port was inserted by open laparoscopy using a blunt hasson cannula through the umbilical crease .
the abdomen was inspected in detail so as to plan to insert the remaining two 3/5 mm instrument ports .
the peritoneum overlying the exposed kidney was incised just lateral to and above the colonic flexure .
once the correct plane was identified , the renal capsule was traced into the renal sinus until the renal pelvis was identified .
the adventitia around the proximal ureter and upj was cleared . whenever it was observed that dismembered pyeloplasty could not be easily performed
foley 's yv plasty [ figure 1 ] was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres .
the base of the v was positioned on the dependent , medial aspect of the renal pelvis and the apex at the upj .
the incision from the apex of the flap , which represents the stem of the y , was then carried along the lateral aspect of the proximal ureter well into an area of normal calibre .
the apex of the pelvic flap was brought to the inferior most aspect of the ureterotomy incision .
the posterior walls were approximated utilising interrupted or running fine absorbable sutures with an 18 cm , 6/0 vicryl suture on a 3/8 round body needle .
a 0.025 inch guide wire was then passed through the proximal ureter into the bladder .
a 3 fr multi - length double pig - tail catheter was passed over the guide - wire into the bladder .
the proximal end of the double pig - tail stent was then placed within the renal pelvis .
the anastomosis was completed with approximation of the anterior walls of the pelvic flap and urethrotomy [ figure 2 ] .
dilated pelvic calyceal system with small renal pelvis ( < 30cc ) operative steps of laparoscopic foly 's yv plasty .
( a ) rt upj showing dilated pelvis ( b ) apex of v being planned at upjunction ( c ) from the apex of v , the inferior limb of y being extended on the lateral margin of upper ureter ( d ) y - v plasty in progress ( e ) completion of y - v plasty post - operatively the drain was removed once the drainage was less than 5 cc/24 h. the catheter was removed the next day .
children were followed up for urinary infection , and renogram was repeated after 3 months .
during the study period january 2004 to december 2010 , 119 children prospectively underwent laparoscopic pyeloplasty for upj obstruction .
seven of these children were antenatally diagnosed with hydronephrosis . of these , 108 children ( 63 male and 45 female ) with a mean age of 4.94  2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children ( 5 male and 6 female ) [ table 1 ] with a mean age of 4.00  1.776 years underwent laparoscopic foley 's yv plasty .
comparison of operative and post - operative parameters the surgical indication for foley 's yv plasty was a small sized renal pelvis ( mean renal pelvic volume 31.8 ml ) in five children , long narrow ureteric segment with a small renal pelvis ( mean renal pelvic volume 34.6 ml ) in three children and a high insertion of ureter with a small sized renal pelvis ( mean renal pelvic volume 30.4 ml ) in the remaining three children .
in none of these 11 children crossing renal vessels were observed at the upj . in all these 11 children ,
the kidney was dissected from the surrounding fibro - fatty tissue to release the kidney and pull it downwards .
the mean operating time for laparoscopic dismembered pyeloplasty was 87.22  7.69 min and the mean post - operative hospital stay was 106.29  22.76 h. in comparison , the mean operating time for laparoscopic foleyyv plasty was 77.27  5.18 min and mean post - operative hospital stay was 82.91  12.53 h. there were no major peri - operative complications noted and conversion to open was not necessary in any child .
the drain was removed after 24 h in all the children and the per - urethral catheter removed after 48 h. the mean follow - up of these 11 children was 20.82  1.83 months .
renogram done at 3 months post - operatively showed good drainage and improvement of renal function .
open pyeloplasty ( opn ) has been the standard treatment for congenital or acquired upj obstruction in adults and children , with overall success rates of 90 - 100% .
laparoscopic surgery has increasingly assumed a central role in the management of both benign and malignant urologic diseases .
numerous studies have implicated that minimally invasive procedures can provide equivalent surgical outcomes with reduced morbidity when compared with their open counterparts . as a consequence
, laparoscopy has become more integrated into mainstream practice and in some cases has evolved into the standard of care for certain procedures .
a prime example of this latter point is the pyeloplasty procedure for the treatment of upj obstruction , which in present day is commonly performed via a minimally invasive ( laparoscopic or robotic ) approach .
feasibility , safety and effectiveness of laparoscopic pyeloplasty in children was described with similar success rates as open procedure .
ravish et al . , compared the results of laparoscopic and opn in children with primary upj obstruction .
post - operative discomfort / pain was significantly less in the laparoscopic group and similarly the mean hospital stay was significantly shorter in the laparoscopic group .
casale et al . , reported on a series of 26 children aged between 8 months and 15 years ( mean age 5 years ) who underwent trans - peritoneal laparoscopic pyeloplasty for an obstruction not caused by a crossing vessel .
hynes dismembered pyeloplasty ( ah ) , while the remaining seven had a non - dismembered pyeloplasty in a heineke  mikulicz fashion ( hm ) .
the mean operative time was 3.1 and 2.5 h for ah and hm , respectively .
four of the seven patients having non - dismembered procedures presented with acute flank pain within 3 days of stent removal .
the ah pyeloplasty produced a 94% rate of resolution of upj obstruction , while the hm patients did poorly , with a success rate of only 43% ( p = 0.002 ; fisher 's exact test ) .
singh et al . , evaluated the role of non - dismembered laparoscopic pyeloplasty and percutaneous endopyelotomy for upj obstruction with low volume renal pelvis .
a total of 34 patients of laparoscopic non - dismembered pyeloplasty were compared with 26 patients of upj obstruction with pelvic volume less than 50 ml undergoing antegrade endopyelotomy .
only operative time was significantly less in patients undergoing endopyelotomy ( p < 0.05 ) .
they concluded that in patients with upj obstruction with low volume pelvis and good renal function , laparoscopic non - dismembered pyeloplasty was effective with significantly longer operative time compared with endopyelotomy .
szydeko et al . , performed a retrospective study to compare the results of dismembered and non - dismembered y - v laparoscopic pyeloplasties and the complications observed after the two types of surgery .
eighty - eight patients with upj obstruction underwent a laparoscopic operation . in two cases ,
anderson pyeloplasty ( lhap ) was performed on 50 patients , whereas a laparoscopic y - v pyeloplasty ( ly - vp ) was performed in 36 cases .
the mean operative time for lhap was 219 min and for ly - vp 185 min .
the mean hospital stay after lhap was 5.9 days and for ly - vp 5.3 days .
, the mean operating time for laparoscopic foley 's yv plasty was 77.27  5.18 min , which was significantly less when compared with the laparoscopic dismembered pyeloplasty group .
this was probably due to the need for extensive intra - corporeal suturing needed for dismembered pyeloplasty and also trimming of the hugely dilated renal pelvis .
robotic - assisted surgery may be ideally suited for a pyeloplasty , allowing one to overcome the difficulties encountered with laparoscopic suturing .
lee et al . , presented the first preliminary results of robotic - assisted laparoscopic trans - peritoneal pyeloplasty in children .
they performed a retrospective case control study of 33 patients undergoing robot - assisted laparoscopic pyeloplasty ( ralp ) and 33 undergoing opn .
mean operative time was significantly less for opn ( 181 vs 219 min for ralp , p = 0.031 ) .
olsen and jorgensen reported their unique experience of retroperitoneal robotic - assisted pyeloplasty in 13 children with a median age of 6.7 years .
this early experience has been corroborated by a number of centres , demonstrating that advanced laparoscopic re - constructive surgery is feasible even in children .
a novel example of such advancement can be found in laparoendoscopic single - site ( less ) surgery . performing surgery through a single site of access
holds the promise of decreased morbidity , lower blood loss , shorter convalescence and improved cosmesis .
given the non - extirpative nature of the pyeloplasty procedure , this patient cohort has proven to be the ideal candidates for less surgery .
there are now several studies in the published literature demonstrating the feasibility and efficacy of less pyeloplasty in both children and adults .
although comparative studies have failed to demonstrate any objective advantage of the less pyeloplasty operation , it is important to realize that less surgery is still a fairly new technique .
further technological developments and additional studies will ultimately define its role in the field of urologic surgery , and subsequently , its application for the pyeloplasty procedure .
laparoscopic foley 's yv pyeloplasty is a safe and effective technique in appropriately selected cases of primary upj obstruction in children .
the operative time and post - operative hospitalization was significantly less when compared with laparoscopic dismembered pyeloplasty .
post - operative recovery of renal function was similar to those who underwent laparoscopic dismembered pyeloplasty .
 introduction : laparoscopic dismembered pyeloplasty is an acceptable option for ureteropelvic junction ( upj ) obstruction in the paediatric population . 
 we compared our results of laparoscopic dismembered and non - dismembered foley 's yv pyeloplasty.materials and methods : children presenting with hydronephrosis secondary to upj obstruction formed the study group . 
 foley 's yv plasty was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres . 
 children were followed up for urinary infection , and renogram was repeated after 3 months.results:during the study period , 108 children ( 63 male and 45 female ) with a mean age of 4.94  2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children ( 5 male and 6 female ) with a mean age of 4.00  1.776 years underwent laparoscopic foley 's yv plasty . 
 there were no major peri - operative complications noted and conversion to open was not necessary in any child . 
 renogram done at 3 months post - operatively showed good drainage and improvement of renal function.conclusions:laparoscopic foley 's yv pyeloplasty is a safe and effective technique in appropriately selected cases of primary upj obstruction in children . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS