Introduction: Calyceal diverticulum (CD) in pediatric patients is rare and often asymptomatic; however, when treatment is required, management can be challenging. Open or laparoscopic techniques are typically pursued if endoscopic or percutaneous approaches are unsuccessful. To our knowledge there are only six pediatric cases reported in the literature utilizing the robotic-assisted laparoscopic approach; none of them presented with abscesses. This video presents a robotic-assisted diverticulectomy with closure of the diverticular ostium, marsupialization of the diverticular edges and harvesting of an omental flap in a patient with a large, chronically infected CD.
Methods: This is a 15-year-old female with Saethre-Chotzen syndrome without history of urinary tract infections (UTIs) or kidney stones. She presented with a two-week history of fever, vomiting and crampy left flank pain with a renal ultrasound and CT scan revealing a 6.6cm renal abscess in the upper left kidney. A drain was placed by interventional radiology and urology was later consulted due to persistent output. Antegrade studies revealed a CD, and after two unsuccessful endoscopic treatments the robotic approach was pursued. The procedure began with cystoscopic placement of a 5 Fr ureteral catheter. The left colon was mobilized medially and carried towards the kidney until the nephrostomy tube localized the CD, which was unroofed with a vessel sealer. The ostium was identified by injecting normal saline into the 5 Fr catheter and then tested after closure. Omental flap was placed within the diverticular cavity to cover the recently closed ostium and minimize dead space. A closed suction drain and left ureteral stent was placed, and an indwelling Foley was left for optimal drainage.
Results: Operative time was 280 minutes. Estimated blood loss was 150ml. Pain was controlled immediately in the post-operative (PO) period. A regular diet was given on PO Day 1; and she was discharged on PO Day 4. The foley catheter, drain and ureteral stent were removed sequentially on PO Day 2, PO Day 9, and seven weeks later, respectively. At 3 months follow-up, she is asymptomatic.
Conclusions: In symptomatic patients with CD where endoscopic management has failed, the robotic approach is a safe and feasible method in pediatric patients, even in cases complicated by chronic infection as demonstrated in this video.
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