Comparative analysis of laparoscopic and open ureteroureterostomy for the treatment of pediatric duplicated kidneys: a clinical efficacy and safety study

Introduction

Duplicated kidney malformation is a common anomaly in the pediatric urinary system, with an incidence rate of 0.8–1% (1). Duplicated kidneys are classified into complete and incomplete types, with the former being more common than the latter. The majority of patients with duplicated kidneys are asymptomatic, often discovered incidentally during prenatal examinations or postnatal check-ups. Some patients may experience recurrent urinary tract infections, dribbling outside of the voiding period, difficulty in urination caused by ureteral cysts, abdominal pain, progressive decline in renal function, and worsening of hydronephrosis (2-4). The management options for completely duplicated kidney anomalies with surgical indications include anomalous single ureter reimplantation, double ureteral sheath reimplantation, distal ureteral cystostomy, upper and lower pole ureteroureterostomy (UU), and upper pole nephrectomy (5). Among these treatment methods, UU has been proven to be an effective intervention for managing anomalies associated with ureteral duplication (6). At the same time, with the continuous advancement of minimally invasive surgical techniques, laparoscopy and robot-assisted laparoscopic surgery have been successfully applied in pediatric patients (7).

This study compared the efficacy of laparoscopic and traditional open surgery in the treatment of pediatric completely duplicated kidneys, aiming to provide a more scientific and rational choice of surgical intervention, and enhance treatment safety and effectiveness. Through a retrospective analysis of 30 cases of pediatric completely duplicated kidneys treated at the Children’s Hospital of Anhui Province from February 2017 to January 2023, we comprehensively compared the clinical outcomes of these two surgical approaches. This analysis aimed to further assess their impact on patient renal function, urinary excretion function, and related symptoms. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-23-621/rc).

Methods

This study was a retrospective cohort study. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by the Ethics Committee of Anhui Provincial Children’s Hospital (No. EYLL-2023-005). Eligible patients were enrolled after obtaining written informed consent from their legal guardians.

General information

We collected clinical data from 30 pediatric patients with duplicated kidneys treated at the Department of Pediatric Urology, Children’s Hospital of Anhui Province, from February 2017 to January 2023. Patients were divided into two groups based on the surgical approach: the laparoscopic ureteroureterostomy (LUU) group with 20 cases and the open ureteroureterostomy (OUU) group with 10 cases. The average age in the LUU group was 3.7±3.4 years, while in the OUU group, it was 1.6±1.3 years. Clinical presentations included recurrent febrile urinary tract infections (FUTI), non-voiding dribbling, and pain in the flank or abdomen on the affected side. Both groups had two cases of bilateral duplicated kidneys, all presenting with hydronephrosis of the upper left kidney and ureter. Preoperative examinations for the patients included urinary system ultrasound, computed tomography (CT) scans (Figure 1) or magnetic resonance urography (MRU) (Figure 2), intravenous pyelography (IVP) (Figure 3), and voiding cystourethrography (VCUG). Due to the absence of a nuclear medicine department in our hospital, some patients completed diuretic renal scintigraphy in external hospitals. The anomalies involved abnormalities in the connection between the ureter and bladder, including obstruction at the distal end of the ureter, ureteral orifice foreign bodies, and distal ureteral cysts, all located in the upper ureter. Detailed information on the patients is presented in Table 1.

Figure 1 Computed tomography scan indicating left-sided complete duplex kidney, with upper kidney and ureter showing hydronephrosis, along with signs of twisting and dilation.

Figure 2 Magnetic resonance urography shows left-sided upper kidney hydronephrosis, tortuous dilation of the left upper ureter, and distal narrowing.

Figure 3 Intravenous pyelography reveals left-sided duplex kidney with upper kidney hydronephrosis and tortuous dilation of the upper ureter (indicated by arrows).

Inclusion and exclusion criteria

Inclusion criteria: (I) complete duplication of the kidney; (II) presence of hydronephrosis in the upper kidney with abnormal connection of the upper kidney ureter to the bladder; (III) absence of abnormalities in the lower kidney or ureter; (IV) manifestation of symptoms such as urinary incontinence, abdominal pain, or recurrent urinary tract infections.

Exclusion criteria: (I) incomplete duplication of the kidney; (II) abnormal connection of the lower kidney ureter to the bladder; (III) concurrent ureteropelvic junction obstruction in the upper or lower kidney ureter.

Surgical methods

LUU

A curved incision was made near the navel, and a 5 mm trocar was inserted to establish CO₂ pneumoperitoneum. A laparoscope was inserted into the abdominal cavity. Trocars of 3 and 5 mm were inserted horizontally below the navel along the outer edge of the bilateral rectus abdominis muscles. Instrumentation was introduced through these trocars. Under ultrasound guidance, the pelvic peritoneum and abdominal peritoneum on the affected side were incised at the bifurcation of the iliac vessels at the entrance of the pelvic cavity. The lower segment of the upper ureter was exposed, showing significant curvature and dilation throughout. The dilated ureter was dissected, reaching up to the entrance of the pelvic cavity. The lower ureter was exposed, and its pelvic segment was dissected laterally. At this level, the upper ureter was severed, and the proximal end was trimmed in a “V” shape. The “V”-shaped slope of the upper ureter was aligned and sutured with the longitudinal incision of the lower ureter. The lower segment of the dissected upper ureter was freed from the pelvic bladder wall and ligated and severed at its end. A pelvic drainage tube was left in place (Figure 4).

Figure 4 Laparoscopic surgical steps: (A) laparoscopic view of the bilateral lower ureters on the affected side, showing marked tortuous dilation of the upper ureter (indicated by arrow); (B) mobilization of the pelvic segment of the upper and lower ureters; (C) longitudinal incision made in the lower ureter; (D) transection of the upper ureter; (E) alignment of the oblique upper ureter and longitudinal lower ureter incision; (F) initiation of the anastomosis between the upper and lower ureters; (G) completion of the anastomosis between the upper and lower ureters; (H) the distal end of the mobilized upper ureter is clamped using a homelock clip and transected; (I) overall view of the laparoscopic procedure.

OUU

An incision was made at the McBurney’s point or the inverted McBurney’s point, approximately 4–6 cm in length. The skin and subcutaneous tissue were incised, and the muscles were bluntly and sharply dissected. The peritoneum was pushed upward and medially, exposing the posterior peritoneum. The upper renal ureter was dilated. The upper renal ureter was carefully dissected, and the lower renal ureter was located near the bladder. At this point, the upper renal ureter was severed from the curved portion. The residual ureter at the distal end was ligated. A longitudinal incision of about 1 cm was made in the lower renal ureter. The sloping surface of the upper ureter was aligned with the longitudinal incision of the lower ureter. Active bleeding was checked for and ensured to be absent. A drainage tube was left behind the posterior peritoneum (Figure 5).

Figure 5 Open surgery steps: (A) make an incision at the anti-McBurney point; (B) incise the skin and subcutaneous tissue, separate the muscles, expose the peritoneum, and then dilate the upper ureter after traversing it; (C) cut off the traversing upper ureter; (D) trim the traversing upper ureter; (E) mobilize and release the lower ureter; (F) longitudinally incise the upper ureter; (G) align and anastomose the upper and lower ureters at the distal end; (H) completion of distal end anastomosis of the upper and lower ureters; (I) check for bleeding, reposition the ureter.

The surgeries in both groups were performed by experienced pediatric urology surgeons, who possess extensive expertise in managing repeat kidney surgeries. They are capable of accurately assessing the condition, selecting the optimal surgical approach. During the surgeries, they demonstrate flexibility in handling unexpected situations and take measures to safeguard critical structures, ensuring smooth procedures and achieving optimal therapeutic outcomes.

Statistical analysis

All data from this group of children were collected, and statistical analysis was performed using SPSS 21.0 software. The statistical methods employed included the Chi-squared test and independent samples t-test. A significance level was set at P<0.05, indicating a statistically significant difference.

Results

All 30 patients underwent the procedures successfully, and there were no conversions to open surgery in the LUU group. The laparoscopic surgery duration was 178.8±60.71 min, intraoperative blood loss was 4.3±0.92 mL, drain removal occurred at 1.8±0.6 days postoperatively, and the length of hospital stay was 4.2±2.2 days. In comparison, the open surgery duration was 181.6±37.8 min, drain removal occurred at 2.3±0.7 days postoperatively, intraoperative blood loss was 6.4±4.06 mL, and the length of hospital stay was 5.8±1.8 days. Although the differences were not statistically significant, the LUU group showed shorter operative times. Notably, the LUU group demonstrated a significant reduction in intraoperative blood loss, drain removal time, and postoperative hospital stay, with statistically significant differences. Postoperatively, one patient in each group experienced urethral infections after catheter removal, both of which were successfully treated with oral cefuroxime. All patients had a postoperative period of double-J stent retention, with removal occurring at 4–6 weeks via cystoscopy. Three months after double-J stent removal, patients underwent a follow-up urologic ultrasound examination. Preoperatively, the LUU group had a mean upper renal pelvis anteroposterior diameter of 20.4±8.59 mm, postoperatively it was 14.82±6.58 mm; the preoperative upper renal ureter diameter was 15.05±4.45 mm, postoperatively it was 7.05±5.77 mm; and the preoperative upper renal parenchymal thickness was 4.32±1.56 mm, postoperatively it was 5.55±1.49 mm. In the OUU group, preoperative measurements were as follows: upper renal pelvis anteroposterior diameter of 23.7±8.81 mm, postoperatively it was 20.6±7.18 mm; upper renal ureter diameter was 13.54±5.31 mm preoperatively, and 12.4±5.17 mm postoperatively; upper renal parenchymal thickness was 3.7±0.83 mm preoperatively, and 4.5±0.71 mm postoperatively. Preoperatively, there were no significant differences between the LUU and OUU groups in terms of upper renal pelvis anteroposterior diameter, upper renal ureter diameter, and upper renal parenchymal thickness. However, in terms of postoperative recovery indicators, the LUU group outperformed the OUU group, with significant differences in upper renal pelvis anteroposterior diameter, upper renal ureter diameter, and upper renal parenchymal thickness, all statistically significant (P<0.05). Detailed intraoperative and postoperative data are presented in Table 2.

Throughout the study, we employed various methods to monitor patients. We maintained a detailed patient database recording basic information, surgical specifics, recovery, and follow-up progress. Regular phone check-ins tracked post-surgery symptoms and overall well-being. Additionally, patients attended routine hospital visits for exams and imaging to evaluate surgical outcomes. These strategies ensured accurate and thorough data collection during follow-ups. Long-term follow-up of the 30 patients revealed no postoperative hydronephrosis or worsening of hydronephrosis in the lower kidneys and ureters. Patients with preoperative dribbling symptoms experienced symptom resolution postoperatively. Patients with preoperative flank pain had relief of symptoms postoperatively. No cases of FUTI, anastomotic stricture, bladder-ureteral reflux, residual ureteral syndrome, or abdominal discomfort were reported postoperatively.

Discussion

Duplicated kidney is a congenital anomaly of the urinary system, commonly occurring in female children (8). The occurrence probability is approximately equal between the left and right sides, with bilateral cases being less common (9). The characteristic feature of duplicated kidneys is that one kidney is divided into upper and lower independent excretory systems on one side, usually separated by a shallow groove, each with its own renal pelvis, ureter, and blood vessels (10). The etiology of its occurrence may be attributed to the development of a ureteric bud from the lower end of the nephric duct during the embryonic period. If the distal branching of the ureteric bud on the same side occurs prematurely or if two ureteric buds develop, duplicated renal pelvis and duplicated ureters can form in the late embryonic period (11). Duplicated ureters can be classified into incomplete (Y-shaped) duplicated ureters and complete duplicated ureters (12). In complete duplicated kidneys, according to the Weigert-Meyer rule, the ureter of the upper kidney has a lower opening position, which may lead to clinical symptoms in female patients such as dribbling urine, narrow opening, formation of ureteral cyst at the distal end, or urinary tract infections and voiding abnormalities associated with reflux. On the other hand, the ureter of the lower kidney opens above the bladder externally, with a shorter and more direct opening, making it prone to bladder-ureter reflux (13). In our study, all 30 cases of the condition were caused by abnormalities at the upper ureteral bladder junction, including ureteral ectopic opening, distal narrowing of the ureter, and the formation of a cyst at the distal end of the ureter.

The treatment principles for duplicated kidneys include preserving renal function as much as possible, eliminating obstruction and vesicoureteral reflux (VUR), controlling urinary tract infections, maintaining controllable voiding, minimizing surgical interventions, and reducing complications as much as possible (14). The recent retrospective study suggests personalized treatment for duplicated kidneys, including partial nephrectomy, bladder-to-ureter reimplantation, and ureteral cyst decompression, with minimally invasive surgery preferred (15). In our study, we utilized UU, which is the most widely used technique for preserving renal units. Compared to partial nephrectomy, UU is safer, better preserves renal function, and carries lower risks, while offering the advantages of a simpler procedure, smaller incision, faster recovery, and eliminating the risk of bladder-ureteral reflux compared to bladder-to-ureter reimplantation. Additionally, it helps to avoid injury to the lower pole vessels, reducing the occurrence of complications such as bleeding and urinary leakage from the surgical site (16). Concerns about the possibility of “yo-yo” reflux in UU are theoretical, and these concerns have not been fully substantiated in the literature series reported previously (17,18). The principle of UU is to handle the normal recipient ureter at the minimal level, preserving its function and anatomical integrity. Simultaneously, the donor ureter’s distal end should be appropriately trimmed to ensure an adequate diameter at the anastomosis, maintaining normal urine drainage. The anastomosis needs to be tightly and securely sutured to prevent urine leakage and dehiscence (19). The UU procedure can be performed through open surgery, laparoscopy, or robot-assisted laparoscopy (20-22). This study utilized both laparoscopic and open approaches to perform the UU procedure. The results of this study demonstrate that both methods of UU show favorable clinical efficacy and safety in treating pediatric duplicated kidneys. Both surgical groups were able to improve postoperative renal and ureteral dilation, as well as enhancing renal cortical thickness, indicating that UU can facilitate the recovery of renal function. Symptoms of preoperative dribbling urine in patients were significantly improved postoperatively, with the disappearance of dribbling urine symptoms and the absence of urinary tract infections. Patients experiencing preoperative flank pain had relief from pain symptoms after the surgery. This further confirms the significant therapeutic effect of UU in improving clinical symptoms in patients.

Our research results indicated that both surgical groups were able to successfully complete the procedures. Although there was no statistically significant difference in the operative time, the average duration of laparoscopic surgery was shorter than that of open surgery. This may be attributed to differences in surgical techniques and individual anatomical structures. It is noteworthy that the LUU group demonstrated higher precision and minimally invasive characteristics, which have a positive impact on reducing tissue damage, lowering the risk of infection, and promoting faster recovery (23). The LUU procedure showed several advantages over open surgery. The LUU group exhibited significant statistical differences in terms of blood loss, time to removal of the drainage tube, and postoperative hospital stay. Laparoscopic surgery, with its small incisions and enhanced visibility, reduces the risk of surgical trauma and vascular injury. The establishment of pneumoperitoneum helps minimize vascular bleeding during the surgical process. These factors contribute to the reduced blood loss in laparoscopic surgery (24,25). In addition, laparoscopic surgery, by expanding the field of view and using fine instruments, enables more precise operations, reducing the risk of postoperative urinary leakage and facilitating early removal of the drainage tube. Minimally invasive surgery reduces tissue damage, alleviates postoperative pain, shortens recovery time, and lowers the risk of complications and infections, ultimately leading to a shorter hospital stay for patients (26). Although we observed statistically significant differences, it is important to note that various factors in actual clinical practice may influence surgical outcomes, such as the experience of the surgeon and the preoperative condition of the patient. These results are expected to improve patients’ quality of life and overall satisfaction with the surgery. Regarding postoperative complications, both groups had one case of urinary tract infection, with a lower incidence in the LUU group compared to the OUU group, but the difference was not statistically significant.

Concerning the improvement of renal function and morphology after surgery, our study found no significant differences in preoperative indicators such as the upper renal pelvis anteroposterior diameter, upper renal ureter diameter, and upper renal parenchymal thickness between the two groups. However, notably, the LUU group showed significantly better performance in these key indicators after surgery compared to the OUU group. This suggests that LUU provides a more significant protective effect on postoperative renal structure and function. Specifically, patients in the LUU group experienced greater improvements in the upper renal pelvis anteroposterior diameter, upper renal ureter diameter, and upper renal parenchymal thickness, contributing to the maintenance of normal renal morphology and function. Furthermore, laparoscopic surgery has a significant advantage in terms of surgical scar aesthetics. The small incisions in laparoscopic surgery result in finer and more concealed postoperative scars. The periumbilical incision is easily hidden by the folds around the umbilicus, and the meticulous operation reduces damage to surrounding tissues, facilitating rapid healing, reducing inflammation and swelling, and lowering the risk of scar tissue formation (27). These observed results not only highlight the superiority of laparoscopic surgery in terms of surgical outcomes but also provide a scientific basis for choosing a more protective surgical approach to maximize the preservation of patients’ renal function.

Conclusions

UU is a safe and effective method for treating pediatric completely duplicated kidneys. In comparison to open surgery, laparoscopic surgery offers advantages such as minimal, trauma, faster postoperative recovery, and smaller surgical scars. It facilitates better restoration of upper kidney function and improvement in clinical symptoms. Although this study suggests that LUU may offer certain advantages in treating complete duplicated kidneys in children, its reliability and generalizability are limited by factors such as small sample size, retrospective design, lack of long-term follow-up data, and absence of blinding and randomization. Therefore, larger sample size, randomized controlled trials, and multicenter designs are needed in future studies to further validate these findings. We hope the findings of this study will provide valuable insights for the treatment of pediatric duplicated kidneys, guiding future clinical practice and research.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-23-621/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-23-621/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-23-621/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-23-621/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by the Ethics Committee of Anhui Provincial Children’s Hospital (No. EYLL-2023-005). Eligible patients were enrolled after obtaining written informed consent from their legal guardians.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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