Pediatric calyceal diverticulum treatment: An experience with endoscopic and laparoscopic approaches.

Introduction The symptomatic calyceal diverticulum is a rare event in the pediatric population. In adults, surgical options include ureteroscopy, percutaneous ablation, and laparoscopic decortication but there is a lack of experience in the literature with these techniques. Objective We present our experience with both the ureteroscopic and laparoscopic approach to treating the pediatric calyceal diverticulum. Study design We performed a retrospective case series looking at patients who underwent treatment for calyceal diverticulum at our institution from January 2009 to May 2014. We reviewed patient demographics, indications for intervention, radiographic appearance, type of intervention, and perioperative outcomes. Ureteroscopic approach included dilation of infundibulum and ablation of diverticular cavity. Laparoscopic approach included ablation of the diverticulum with argon diathermy with or without surgical closure of the ostium. Results There were 13 patients who underwent 15 procedures for symptomatic calyceal diverticulum (Table). Median age was 11 years. Indications for intervention were: pain and increasing size of diverticulum (8/15, 55%), hematuria (3/15, 20%), UTI (3/15, 20%), and calculi (1/15, 5%). 11/15 (73%) procedures were managed endoscopically and 4/15 (27%) were managed with laparoscopic decortication. Ureteral stent was left in all patients for a mean duration of 51 days (15–120 days). Follow up imaging at median of 2.1 years (0.5–4 years) revealed an initial success rate of 85% (11/13 patients). Two patients failed initial intervention (persistent pain/increasing size) necessitating successful secondary minimally invasive procedures. There were 2 (13%) complications: a perinephric hematoma post endoscopic ablation which resolved spontaneously and a deep venous thrombosis in a patient with a coagulation disorder in the laparoscopic group. Discussion Limitations of our study include its retrospective design, lack of standardization of the treatment approach amongst the four treating surgeons, and the small number of patients requiring intervention for this relatively rare diagnosis. Our study is the largest to date in the pediatric population and is the first to report outcomes with ureteroscopic management of the calyceal diverticulum. Conclusions We found that the pediatric calyceal diverticulum can be successfully treated in a minimally invasive manner. The endoscopic approach should be the first line option for patients with small, endophytic diverticula, particularly those located in the upper and mid pole. The laparoscopic approach is more invasive but should be considered for large diverticula that are exophytic with thin overlying parenchyma. Table . Summary of patient data. Complications classified according to clavien-dindo system. Endoscopic Laparoscopic Number of patients 9/13 (73%) 4/13 (27%) Size: median cm (range) 2.3 (1.3–3.5) 5.8 (2–10) Median decrease in size (cm) 1.0 (0–2) 3.0 (2.4–7.2) Median OR time, minutes (range) 69 (13–97) 172 (107–197) Median length of stay, days (range) 0.25 (0.2–1.2) 2 (1.9–4) Failure of initial therapy 2/9 0/4 Complications Repeat procedure 2 (Clavien IIIb) Perinephric hematoma 1 (Clavien I) DVT 1 (Clavien II)