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Pediatric calyceal diverticulum treatment: our experience with endoscopic and laparoscopic approaches
Christopher Long, MD, Dana A. Weiss, MD, Arun K. Srinivasan, MD, Aseem R. Shukla, MD.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Introduction: Calyceal diverticulum is a rare entity in the pediatric population. Management options in adults include ureteroscopy, percutaneous ablation, and laparoscopic decortication. No consensus exists in the pediatric population for treatment.
Materials and methods: We queried our prospectively maintained, internal review board approved database to identify all patients undergoing treatment for a calyceal diverticulum from January 2007 through the present. We reviewed the clinical indications for intervention, radiographic appearance, type of intervention, and post-operative results. All procedures began with cystoscopy and retrograde pyelogram to evaluate the ostia, neck diameter and length, and size of the diverticulum. Endoscopic treatment included ureteroscopic visualization of the mouth of the diverticulum with subsequent holmium laser incision and fulguration of the urothelium within the diverticulum. A single or double stent was placed after ablation to keep patency of the ostia while healing. The laparoscopic approach was performed via a traditional approach or via a single port. After endoscopic retrograde and pyelogram with stent placement, the lateral wall of the diverticulum was excised, the neck of the diverticulum was sutured, and the base of the cavity was fulgurated with the argon beam.
Results: There were 13 patients who underwent 15 procedures for a calyceal diverticulum. Median age was 12.5 (range 23mo-17 years). Indications for intervention include: pain and increasing size of diverticulum (8/5), hematuria (3/15), UTI (3/15), and calculi (1/15). 11 of the 15 patients underwent endoscopic management while 4 underwent single port laparoscopic decortication. All were stented post-intervention with a median duration of 43 days (15-120 days). Follow up imaging at median of 9 months (2-48 months) revealed either complete resolution or significant reduction in the size of the calyceal diverticulum post therapy. All patients had resolution of their pain and/or hematuria except for 2 failures (pain, increasing size). Their symptoms resolved after a second intervention. There were 2 complications: the first was a postoperative DVT in a 17 yo after laparoscopic decortication; the second complication was a hematoma post endoscopic ablation. This resolved spontaneously. The first failure was initially managed endoscopically and required laparoscopic ablation 1 month later for persistent pain. A second, delayed failure occurred in a patient that underwent endoscopic dilation but developed persistent pain due to a narrowed infundibulum 4 years later.
Conclusions: The pediatric calyceal diverticulum can be successfully treated with the same minimally invasive options as in adults. The endoscopic approach should be the first line option. The laparoscopic approach is more invasive but should be considered for very large diverticula that are exophytic with thin overlying parenchyma, and is successful in the setting of narrow ostia to the diverticulum that is not amenable to endoscopic ablation.


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