title: Pediatric calyceal diverticulum treatment: An experience with endoscopic and laparoscopic approaches.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: The John W. Duckett Center for Pediatric Urology at the Children's Hospital of Philadelphia, Philadelphia, PA, USA. Electronic address: longc3@email.chop.edu.
authors.forename: C J
authors.initials: CJ
authors.lastname: Long
authors.affiliation: The John W. Duckett Center for Pediatric Urology at the Children's Hospital of Philadelphia, Philadelphia, PA, USA. Electronic address: weissd1@email.chop.edu.
authors.forename: D A
authors.initials: DA
authors.lastname: Weiss
authors.affiliation: The John W. Duckett Center for Pediatric Urology at the Children's Hospital of Philadelphia, Philadelphia, PA, USA. Electronic address: kolon@email.chop.edu.
authors.forename: T F
authors.initials: TF
authors.lastname: Kolon
authors.affiliation: The John W. Duckett Center for Pediatric Urology at the Children's Hospital of Philadelphia, Philadelphia, PA, USA. Electronic address: srinivasana3@email.chop.edu.
authors.forename: A K
authors.initials: AK
authors.lastname: Srinivasan
authors.affiliation: The John W. Duckett Center for Pediatric Urology at the Children's Hospital of Philadelphia, Philadelphia, PA, USA. Electronic address: shuklaA@email.chop.edu.
authors.forename: A R
authors.initials: AR
authors.lastname: Shukla
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004240:Diverticulum / Q000150:complications / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007669:Kidney Calculi / Q000150:complications / Q000601:surgery*; D007670:Kidney Calices / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D011446:Prospective Studies; D016896:Treatment Outcome; D018666:Ureteroscopy / Q000379:methods*
keywords: Calyceal diverticulum; Laparoscopy; Minimally invasive surgery; Pediatric urology; Ureteroscopy