Robot-assisted laparoscopic pyeloplasty (RALP) in children with complex pelvi-ureteric junction obstruction (PUJO): results of a multicenter European report

Pediatric Robot-Assisted Laparoscopic Pyeloplasty: Where Are We Now?

PURPOSE OF REVIEW

This review aims to provide an in-depth exploration of the recent advancements in robot-assisted laparoscopic pyeloplasty (RALP) and its evolving landscape in the context of infant pyeloplasty, complex genitourinary (GU) anatomy, recurrent ureteropelvic junction (UPJ) obstruction, cost considerations, and the learning curve.

RECENT FINDINGS

Recent literature highlights the safety and efficacy of RALP in treating the infant population, patients with complex GU anomalies, and recurrent UPJO which were all traditionally managed using the open approach. Cost considerations are evolving, with the potential for RALP to have a lesser financial burden. In addition, the learning curve for RALP is diminishing due to robust training programs and advances in research. RALP has become the gold standard in the treatment of UPJO in pediatric urology at many children's hospitals. Surgeon comfort and research in this space allow safe and successful reconstruction in the most challenging of cases.

Repositioning of Ureteropelvic Junction in Robot-assisted Laparoscopic Pyeloplasty

OBJECTIVE

To describe the technique of ureteropelvic junction (UPJ) repositioning in robot-assisted dismembered pyeloplasty as a modified approach during which the UPJ is brought to a new location to facilitate the anastomosis.

MATERIALS AND METHODS

Retrospective review of pediatric and adult cases of robot-assisted laparoscopic pyeloplasty performed between the years 2016 and 2022. In a select group of patients, repositioning of the UPJ was performed. Demographic data, surgical and post-surgical outcomes were compared to a group that underwent classical Anderson-Hynes (AH) dismembered pyeloplasty.

RESULTS

Overall, 70 patients underwent robot-assisted laparoscopic dismembered pyeloplasty and were included in the study, with 15 in the repositioning group and 55 in the AH group. The median age of patients included was 26 months (interquartile range (IQR) 7-203). Median operative time was 140 minutes (IQR 129-192) and 170 minutes (IQR 135-207) for the repositioning and AH group, respectively. The indications for UPJ repositioning were high UPJ insertion (n = 8), crossing vessel (n = 5), and renal malformations (n = 2). Clinical significance was shown in the Society of Fetal Urology classification and split renal function postoperatively, respectively (P <.001; P <.01). Postoperatively, both groups showed improvement in anterior posterior diameter (APD) and diuretic T1/2 (P = 0.48). There was 1 case of surgical failure requiring revisional surgery in the repositioning group (6.6%) and 3 in the AH group (5.5%) (P >.05). Overall, there were 3 cases of Clavien-Dindo Grade 3 complications, all in the AH group (2 cases of urine leak from anastomosis, 1 case of port side hernia).

CONCLUSION

Repositioning of the UPJ is optional in cases when the obstructed UPJ is in a suboptimal anatomical position.

Comparative efficacy and safety of different minimal invasive pyeloplasty in treating patients with ureteropelvic junction obstruction: a network meta-analysis

OBJECTIVE

In recent years, the minimally invasive surgical treatment methods of ureteropelvic junctional obstruction (UPJO) have been diverse, but its approach and choice of surgical method are controversial. This network meta-analysis (NMA) aimed to compare the safety and effectiveness of minimally invasive surgeries for UPJO, which included robotic or laparoscopic pyeloplasty, via the retroperitoneal or transperitoneal approach.

METHODS

We searched relevant RCTs in PubMed, Embase, Web of Science, the Cochrane Library, and CNKI. To assess the results of operative time, complications and success rate, pairwise, and NMA were carried out. The models for analyses were performed by Revman 5.3, Addis V1.16.8 and R software.

RESULTS

A total of 6 RCTs were included in this study involving four types of surgeries: transperitoneal laparoscopic pyeloplasty (T-LP), retroperitoneal laparoscopic pyeloplasty (R-LP), robot-assisted transperitoneal pyeloplasty (T-RALP), and robot-assisted retroperitoneal pyeloplasty (R-RALP). This study consisted of 381 patients overall. T-RALP had a quicker operational duration (SMD = 1.67, 95% CI 0.27-3.07, P = 0.02) than T-LP. According to the NMA's consistency model, T-RALP improved the surgical success rate more than T-LP (RR = 6303.19, CI 1.28 to 1.47 × 1011). Ranking probabilities indicated that RALP could be the better option than LP and retroperitoneal approach was comparable to transperitoneal approach. All procedures had high surgical success rates and few complications.

CONCLUSION

Outcomes for four surgical approaches used in the UPJO were comparable, with T-RALP being the most recommended approach. Selection between the transperitoneal and retroperitoneal approaches primarily depended on the surgeon's preference. Higher quality evidence is needed to further enhance the result.

Robot-assisted Laparoscopic Pyeloplasty: Experience of a Single Pediatric Institution, Including Long-term and Safety Outcomes

OBJECTIVE

To evaluate the efficacy and safety of robot-assisted laparoscopic pyeloplasty (RALP) and describe the short and long-term outcomes of pediatric RALP.

METHODS

We retrospectively reviewed all patients ..±21 years old who underwent primary RALP from 7/2007 through 12/2019. Patients were excluded from postoperative analysis if follow-up data after stent removal was not available. The primary outcome was surgical success, defined as radiographic improvement of hydronephrosis without need for reoperation. Secondary outcomes were time to reoperation and 90-day complication rate.

RESULTS

A total of 356 patients underwent primary repair of ureteropelvic junction obstruction during the study period; 29.ßpatients were limited to intraoperative data due to lack of follow-up imaging. Radiographic improvement at latest follow-up was seen in 308/327 (94.2%). Ten of 327 patients (3.1%) underwent reoperation: 7 were identified within 1 year of RALP and 3 were identified over 1 year after RALP. The median time to reoperation was 13.0 months (IQR 9.3-21.7). We defined long-term as>3 years after pyeloplasty. Over one-third (122/327, 37.3%) of the cohort had>3 years of follow-up, none of whom developed evidence of recurrent obstruction requiring reoperation beyond 3 years. Complications occurred within 90 days of surgery in 20/327 (6.1%).

CONCLUSION

This largest single-institution series confirms short- and long-term surgical effectiveness and safety of RALP. Our data also indicate that most patients who needed reoperation were identified within 1 year, and reoperation more than 3 years after RALP is rare.

Robotic-assisted pyeloplasty in children: a systematic review of the literature

Robotic pyeloplasty has become a natural progression from the development of open, then laparoscopic procedures to treat pediatric patients with ureteropelvic junction obstruction (UPJO). Robotic-assisted pyeloplasty (RALP) is now considered a new gold standard in pediatric MIS. A systematic review of the literature retrieved from PubMed and published in the last 10 years (2012-2022) was performed. This review underlines that in all children except the smallest infants, where the open procedure has benefits in terms of duration of general anesthetic and there are limitations in the size of instruments, robotic pyeloplasty is becoming the preferred procedure to perform in patients with UPJO. Results for the robotic approach are extremely promising, with shorter operative times than laparoscopy and equal success rates, length of stay and complications. In case of redo pyeloplasty, RALP is easier to perform than other open or MIS procedures. By 2009, robotic surgery became the most used modality to treat all UPJO and continues to grow in popularity. Robot-assisted laparoscopic pyeloplasty in children is safe and effective with excellent outcomes, even in redo pyeloplasty or challenging anatomical cases. Moreover, robotic approach shortens the learning curve for junior surgeons, who can readily achieve levels of expertise comparable to senior practitioners. However, there are still concerns regarding the cost associated with this procedure. Further high-quality prospective observational studies and clinical trials, as well as new technologies specific for the pediatric population, are advisable for RALP to reach the level of gold standard.

A systematic review and metaanalysis of open, conventional laparoscopic and robot-assisted laparoscopic techniques for re-do pyeloplasty for recurrent uretero pelvic junction obstruction in children

OBJECTIVE

About 3% of primary pyeloplasties may require a re-do pyeloplasty for recurrent uretero pelvic junction obstruction (UPJO) making it an uncommon operation even in large volume centers. In this MA we have compared the outcomes of open (OP), laparoscopic (LP) and robot assisted LP (RALP) approaches in managing recurrent UPJO.

METHODS

Pubmed/Index medicus etc. were searched for re-do pyeloplasty (Open OR Laparoscopic OR Robot-assisted) AND (Redo OR Reoperative OR failed) AND (child OR pediatric OR paediatric), for articles published between 2001 and 2021. Duplicate publications were identified and removed. Articles with grossly incomplete data and errors in reporting were excluded, as were articles reporting <5 cases. The systematic review was carried out according to PRISMA guidelines and meta-analysis of proportions was carried out using MetaXL 5.3.

RESULTS

A total of 18 articles on re-do pyeloplasty were included in the analysis. In total, there were 87, 77 and 123 redo pyeloplasties in OP, LP and RALP groups respectively. The I2 statistics for OP, LP and RALP showed low heterogeneity with I2 of 24%, 0% and 20% respectively. LFK index was 0.88, 0.30 and 1.62 for OP, LP and RALP respectively, suggesting no or minor publication bias. The overall success rates of OP, LP and RALP re-do pyeloplasty were 93.1% (95% CI 86-98), 92.1% (95% CI 83-96) and 89.4% (95% CI 83-96) respectively (summary table). The success rate between the techniques was not significantly different, with p values (x²) of 1 (OP vs LP), 0.5 (OP vs RALP) and 0.6 (LP vs RALP). Overall, redo RALP took significantly longer time than redo LP (p < 0.001, Fisher's). Overall, RALP had significantly shorter hospital stay than LP (p < 0.001) and LP had significantly shorter hospital stay than OP (p < 0.001). The complication rate was 9% in OP and LP and 16% in RALP, the difference being not statistically significant (p value 1, 0.26 and 0.27 for OP vs LP, OP vs RALP and LP vs RALP respectively, x²).

CONCLUSIONS

In conclusion MIS techniques (LP and RALP) seem to be good alternatives to OP for redo pyeloplasty in children, with comparable success and complications. Redo RALP had longer duration of surgery but shorter hospital stay than redo LP. With comparable success & complication rate between RALP and LP, this MA could not favor one over the other for redo pyeloplasty.

Laparoscopic and robot-assisted ureterocalicostomy for treatment of primary and recurrent pelvi-ureteric junction obstruction in children: a multicenter comparative study with laparoscopic and robot-assisted Anderson-Hynes pyeloplasty

Purpose

This multi-institutional study aimed to assess the outcomes of laparoscopic ureterocalicostomy (LUC) and robot-assisted laparoscopic ureterocalicostomy (RALUC) and compare them with laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children with pelvi-ureteric junction obstruction (PUJO).

Methods

The data of 130 patients (80 boys), with median age 7.6 years and median weight 33.8 kg, receiving minimally invasive treatment of PUJO over a 6-year period, were retrospectively analyzed. Patients were grouped according to the operative approach: G1 included 15 patients, receiving LUC (n = 9) and RALUC (n = 6), and G2 included 115 patients, receiving LP (n = 30) and RALP (n = 85). Patient characteristics and operative outcomes were compared in both groups.

Results

The median patient age and weight were significantly higher in G1 than in G2 [p = 0.001]. The median operative time was similar in both groups (157.6 vs 150.1 min) [p = 0.66] whereas the median anastomotic time was shorter in G1 than in G2 (59.5 vs 83.1 min) [p = 0.03]. The surgical success rate was similar in both groups (100% vs 97.4%) [p = 0.33]. Post-operative complications rate was higher in G1 than in G2 (20% vs 6.1%) but all G1 complications were Clavien 2 and did not require re-intervention.

Conclusion

LUC/RALUC can be considered safe and effective alternative approaches to LP/RALP for PUJO repair and reported excellent outcomes as primary and salvage procedures. Robot-assisted technique was the preferred option to treat most patients with recurrent PUJO in both groups.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03305-2.

Robotic Surgery in Pediatric Urology: A Critical Appraisal of the GECI and SIVI Consensus of European Experts

Background: This study aimed to create a consensus statement on the indications, applications, and limitations of robotics in pediatric urology. Methods: After a panel and interactive discussion focused on pediatric robotics, a televoting with 10 questions was administered to 100 pediatric surgeons/urologists attending the joint meeting of the French Group of Pediatric Laparoscopy (GECI)/Italian Society of Videosurgery in Infancy (SIVI) in 2021. The results of televoting were analyzed electronically using Mentometer software. Results: Ninety-four percent of participants stated that the cutoff weight for robotics should be >10-15 kg. A minimum of 20-30 procedures should be performed to become confident in robotics (74%). Pediatric urology is the main field of application (73%) and pyeloplasty is the best indication for robotics (63%). Technical problems may happen intraoperatively in 1/10-15 cases (64%). The mean duration of robotic procedures ranges from 150 to 200 minutes (72%). The main drawbacks of robotics are high costs and limited development of miniaturized instruments (74%). Ninety-five percent believed that the costs of robotics may significantly drop with the availability of more robotic brands. The main advantages of robotics over laparoscopy include improved dexterity, easier suturing, and better ergonomics (100%), whereas the main disadvantage of sharing the robot with other specialties is the wearing out of instruments (100%). Conclusions: This is the first consensus statement, endorsed by the GECI and SIVI societies, on the use of robotics in pediatric urology. The need to introduce more robotic brands on the market to lower the costs and to develop miniaturized instruments to be adopted in infants less than 10 kg emerged. Pediatric urology is the main field of application of pediatric robotics, and robotic pyeloplasty is the most common procedure performed. Proctorship is needed for the first 20-30 procedures and technical problems may occur intraoperatively in 1/10-15 cases. The main advantages of robotics over laparoscopy are improved dexterity, easier suturing, and better surgeon ergonomics.

Robotic-assisted laparoscopic pyeloplasty (RALP), for ureteropelvic junction obstruction (UPJO), is an alternative to open pyeloplasty in the pediatric population

We aimed to evaluate the safety and efficacy of RALP for UPJO in a heterogeneous pediatric population. The medical records of all patients with UPJO who underwent RALP over the last 6 years and completed at least 6 months of follow-up, were retrospectively reviewed. Data included age, sex, laterality, weight, preoperative and postoperative ultrasound and renal scintigraphy results, operation time, complications, length of hospital stay. We separately examined two groups: low-weight children (< 10 kg) and those who underwent RALP after failed pyeloplasty. One hundred patients with a median age of 18 months (range 2-216) underwent RALP. The median weight was 10 kg (range 4-90). The median operative time, including docking and console time, was 75 min (range 40-183). The median hospital stay was one day (range: 1-3). Ninety-eight percent of the patients showed improvement or stable hydronephrosis on postoperative imaging, with a better drainage curve on dynamic radionuclide scans. In two patients, the hydronephrosis worsened. One patient's ipsilateral UVJ was obstructed, and the other patient's UPJO recurred. The operative time was shorter in the low-weight group (p < 0.001), but the length of hospital stay and success rate were not different. Neither the hospital stay nor the success rate of redo RALP patients differed significantly from a control group of primary RALP patients. Our data show that RALP might be utilized as a universal approach in pediatric patients with UPJO.

Treatment of ureteropelvic junction obstruction and urolithiasis in children with minimally invasive surgery

BACKGROUND

Ureteropelvic Junction Obstruction (UPJO) is the most common congenital ureteral anomaly. Nowadays, according to the increasing incidence of urolithiasis, 20% of children with UPJO presents urolithiasis. Open pyeloplasty was the standard treatment before the introduction of minimally invasive surgery (MIS). Nevertheless, only scattered experiences on MIS were previously described and universal agreement on the treatment of UPJO plus urolithiasis is still missing.

OBJECTIVE

The study aim was to describe our experience with a series of pediatric patients affected by UPJO and urolithiasis treated with robot-assisted pyeloplasty (RAP) and endoscopic removal of stones using a flexible cystoscope and a stones basket in a singular tertiary referral center.

MATERIAL AND METHODS

We retrospectively reviewed our data from pediatric patients affected by UPJO and urolithiasis undergoing RAP between April 2013 and December 2019. The analysis was conducted on seven patients. All procedures were performed by one expert robotic surgeon and one endoscopic surgeon skilled in the management of urolithiasis.

RESULTS

The mean age was 7 years (IQR 4-16). The median stone area was 77.7 mm two (IQR 50.2-148.4). Most of them (71.4%) presented preoperative symptoms. The median operative time was 110 min (IQR 104-125) with a console time of 90 (IQR 90-105). The median length of stay was 5 days (IQR 4-5). Median follow-up was 16 months (IQR 10-25).

CONCLUSION

RAP with concomitant flexible ureteroscope is a safe and effective option for the simultaneous management of UPJO with urolithiasis with excellent outcomes in children.