Miniature pyeloplasty as a minimally invasive surgery with less than 1 day admission in infants

The efficacy of robotic-assisted laparoscopic pyeloplasty for pediatric ureteropelvic junction obstruction: a systematic review and meta-analysis

To evaluate the safety and effectiveness of robotic-assisted laparoscopic pyeloplasty (RALP) for treating pediatric ureteropelvic junction obstruction through an extensive comparison of RALP, open pyeloplasty (OP) and laparoscopic pyeloplasty (LP). We conducted a comprehensive search of the following databases: PubMed, Excerpta Medica Database, Cochrane Library, Web of Science database, China National Knowledge Infrastructure, WanFang Data, and China Biology Medical Disc. Baseline data were compared, the sources of heterogeneity were assessed, and publication biases were detected. This study was registered with PROSPERO (CRD42023415667). 26 studies with 6074 cases performing pyeloplasty were included, and the overall data are comparable. Our analysis showed no significant difference in success rate and postoperative complications between RALP and OP, and RALP is associated with a shorter length of stay (LOS) (MD - 1.00 95%CI - 1.45 to - 0.55, p < 0.0001). In addition, compared to LP, RALP was associated with a shorter anastomosis time (MD - 18.35 95%CI - 29.88 to - 6.82, p = 0.002) and fewer postoperative analgesics (MD - 0.09 95% CI - 0.18 to - 0.01, p = 0.03); however, RALP has a longer operative time (OT) (MD 52.39, 95% CI 39.75-65.03, p < 0.00001) and higher cost. The heterogeneity of OT may be influenced by factors, such as age and region, while the heterogeneity of LOS primarily stems from regional differences. No significant publication bias was detected. Our meta-analysis shows that RALP can be an alternative to OP and LP with a high success rate, minimal postoperative complications, and shorter LOS. In addition, RALP contributes to reduce anastomosis time and postoperative analgesic drugs. However, further well-designed, large-scale, randomized controlled trials with additional parameters are needed to conduct a more comprehensive analysis of heterogeneity.

Recurrent UPJ obstruction following paediatric pyeloplasty is associated with an initial <2.5cm incision open surgical approach

OBJECTIVES

To determine the risk factors that affect surgical outcomes for pediatric pyeloplasty, and whether this may be related to the choice of operative approach.

METHODS

A retrospective cohort study was performed to evaluate clinicodemographic and operative characteristics of children undergoing dismemberment pyeloplasty by 2 senior pediatric urologists in our tertiary institution between Jan 2008 - Dec 2017. Outcomes included overall complications, re-stenosis, and revision pyeloplasty based on clinic-radiological parameters. Bivariate analysis with Chi-square and Mann-Whitney U test followed by multivariate logistic regression with backward likelihood analysis determined an adjusted effect estimate of the identified significant indicators for inferior peri-operative outcomes related to management.

RESULTS

A total of 185 (93 open, 92 Laparoscopic) cases with an average follow-up of 31.3±27.4 months were analyzed. Complications occurred in 21 (11.4%) patients. 12 (6.5%) experienced recurrent UPJ obstruction with 10 (5.4%) undergoing redo-pyeloplasty. Of these, 9 were performed open and 1 laparoscopically. Multivariate logistic regression identified open pyeloplasty as an independent predictor for overall complications (HR 3.29, 95%CI 1.14, 9.51), recurrent UPJ obstruction (HR 49.8, 95%CI 3.09, 803.2) and redo-pyeloplasty (HR 9.75, 95%CI 1.21, 78.6) compared to a laparoscopic approach. Missed crossing vessels were identified in seven redo-cases, which all were from prior open pyeloplasty.

CONCLUSIONS

An initial open approach was identified as an independent predictor of future complications due to a higher incidence missed crossing vessels at initial repair. Surgeons need to remain especially mindful of this phenomenon when working in a confined open field.

Retroperitoneoscopy-Assisted Dismembered Pyeloplasty With Single-Site Plus One Port in Older Children With Congenital Hydronephrosis

INTRODUCTION

This study aimed to clarify the advantage of retroperitoneoscopy-assisted dismembered pyeloplasty with single-site plus one port (RPSPO) for pediatric congenital hydronephrosis in patients aged ≥7 years.

METHODS

We retrospectively compared a group of patients aged ≥7 years (study group) with patients aged <7 years (comparison group), who underwent RPSPO between August 2015 and August 2018, in terms of preoperative patient characteristics, intra- and perioperative results, and postoperative results.

RESULTS

The study group consisted of eight patients. The median body weight at surgery was 27 kg (20-38 kg). The median age at surgery was 102.5 m (87-139 m). The severity of hydronephrosis on the affected side graded by the Society for Fetal Urology grade was grade 3 in one case and grade 2 or less in all other cases. All patients underwent a ^99m Tc-MAG3 renogram. Comparison between the two groups showed significant differences in body weight at surgery (p = 0.003), age (p < 0.001), and preoperative hydronephrosis grade (p = 0.007), but the median length of the skin incision was 20 mm in both groups, with no significant difference (p = 1.000). Redo pyeloplasty was not required in any patient in either group.

CONCLUSION

RPSPO is an advantageous procedure for older children because it allows precise ureteropelvic neoanastomosis under direct vision and the same wound size as in younger children.

Evolving trends in peri-operative management of pediatric ureteropelvic junction obstruction: working towards quicker recovery and day surgery pyeloplasty

OBJECTIVE

To describe the evolution of practice patterns for pediatric pyeloplasty and determine how these changes have impacted length of stay (LOS), reoperation rates and return emergency department (ER) visits.

METHODS

We reviewed our pyeloplasty database from 2008 to 2020 at a quaternary pediatric referral center and we included children 0-18 years undergoing pyeloplasty. Variables captured included: age, sex, baseline and follow-up anteroposterior diameter (APD) and differential renal function (DRF). We also collected data on the use of drains, catheters and/or stents, nausea and vomiting prophylaxis, opioids, regional anesthesia, and non-opioid analgesia. Outcomes were LOS, reoperation rates and ER visits.

RESULTS

A total of 554 patients (565 kidneys) were included. Reoperation rate was 7%, redo rate 4% and ER visits 17%. There was a trend towards less opioids, indwelling catheters and internal stents and increasing non-opioid analgesia, externalized stents, and regional anesthesia during the study period. Same-day discharge (SDD) was possible for 88 (16%) children with no differences in reoperation or readmission rates between SDD and admitted (ADM). There was a difference in ER visits (21 [24%] vs. 26 [6%]; p = 0.04) for SDD vs. ADM, respectively. On multivariate analysis, the only predictor of ER visits was younger age. Patients < 7 months were more likely to present to ER (15/41; 37% vs. 6/47, 13%; p = 0.009). Multivariate analysis determined indwelling catheters and opioids were associated with ADM while dexamethasone and ketorolac with SDD.

CONCLUSION

Progressive changes in care have contributed to a shorter LOS and increasing rates of SDD for pyeloplasty patients. SDD appears to be feasible and does not result in higher complication rates. These data support the development of a pediatric pyeloplasty ERAS protocol to maximize quicker recovery and foster SDD as a goal.

Use of retrograde pyelogram to plan for miniature open incision in pediatric pyeloplasty

INTRODUCTION

As robotic-assisted surgery becomes increasingly utilized for pediatric ureteropelvic junction (UPJ) obstruction, open surgeons have countered by using muscle-splitting, miniature (≤2 cm) incisions. To prepare for this type of incision during pyeloplasty, it is necessary to define the exact location of the UPJ. The use of retrograde pyelogram (RPG) at the time of pyeloplasty helps the surgeon to identify the exact location of UPJ, and thus be able to use a muscle-splitting, miniature incision for open pyeloplasty.

OBJECTIVE

We hypothesize that when performing a muscle-splitting, miniature incision open approach; preoperative RPG frequently changes the traditional pyeloplasty flank incision at the tip of the 11th or 12th rib.

MATERIALS & METHODS

A retrospective review of open pyeloplasties performed by a single surgeon at our institution from 7/1/2010 to 12/31/2018 was performed to determine rate of use of RPG, open pyeloplasty incision location and to determine what factors are predictive of incisional site.

RESULTS

114 of 122 (93.4%) patients with 115 renal units had pyeloplasties with preoperative RPG performed. Of the 8 procedures without RPG, two had a pelvic kidney diagnosed prior to surgery, two had narrow ureteric orifices that were difficult to cannulate, and four had associated reflux. In 31/115 (27%) pyeloplasties the incision was changed from a standard incision position at the 11th or 12th rib to an alternative incision (i.e. extended muscle-transecting incision at the tip of the 11th or 12th rib, or to an alternate incision site including Gibson, McBurney's incision, or low anterior abdominal incision). 84/115 (73.0%) had a miniature (<2 cm) incision at the tip of the 11th or 12th rib. Grade IV hydronephrosis was a significant predictor for changing the traditional incision site (p = 0.02). Preoperative nephrostomy tube insertion was also associated with an increased likelihood of having an alternate incision (p = 0.04). Incision site was not significantly affected by age of the patient at surgery, patient sex, size of the affected kidney, T1/2 times of <30 min, split function of <30%, kidney length differential, or laterality.

CONCLUSION

The consistent use of RPG prior to pyeloplasty helps surgeons to plan for a small muscle-splitting, miniature open incisions. In our experience, 27% of pyeloplasties required alternative incision sites based on the results of pre-operative RPG.

Minimally invasive open pyeloplasty in children: Long-term follow-up

OBJECTIVE

Our aim was to report the long-term follow-up for minimally invasive open pyeloplasty in children.

MATERIAL AND METHODS

A total of 213 children with a mean age 16.33 months underwent miniature open pyeloplasty for ureteropelvic junction obstruction between January 2010 and May 2016. Anderson-Hynes dismembered pyeloplasty was performed through a subcostal miniature incision. The intraoperative and postoperative parameters including surgical operative time, incision size, intraoperative blood loss volume, postoperative analgesic use, hospital stay, complications, and success rate were documented.

RESULTS

The mean surgery time was 65 min (50-85 min), and incision size was 16.99 mm (12-36 mm). None of the patients required blood transfusion or narcotic analgesics in the postoperative period. The mean hospital stay was 21.97 h (10-48 h). Minor side effects included urinary tract infection (3.8%) and urinary leakage in one case (0.004%). Major complications were not observed. The mean antero-posterior pelvic diameter before and after surgery was 28.69 ± 11.54 mm and 15.89 ± 9.29 mm, respectively with a mean difference of 12.78 mm, which shows a significant decrease (P value = 0.001). The success rate was 98.1% with a mean follow-up of 21.43 months (3-56 months). Two of the recurrences occurred in the first postoperative year, another one after 1.5 years, and the last one after 4 years.

CONCLUSION

Our study confirms minimally invasive open pyeloplasty in children as a safe and efficient procedure with the least complication and hospital stay rate in comparison with other minimally invasive techniques. Moreover, long-term follow-up is a requirement in pyeloplasty surgery.

Reverse Tubularized Pelvis Flap Method for the Treatment of Long Segment Ureteropelvic Junction Obstruction

OBJECTIVE

The most common cause of urinary obstruction is ureteropelvic junction (UPJ) obstruction. In short stenosis, a dismembered pyeloplasty is performed, but for long segment stenosis, the procedure is not well defined. We present the reverse flap ureteroplasty method, which we prepared from the pelvis for use in long segment UPJ obstruction.

METHODS

Between 2007 and 2016, we operated on 6 cases (4 males, 2 females) with an age range of 2-6 months. After reaching the UPJ region, depending on the length of the long segment obstruction, a flap measuring 25-35 mm in length was prepared from the pelvis so that its width would be 10-12 mm on the pelvis side and 10 mm in the distal portion. It was then reversed and tubularized with an absorbable suture over a 10-French nelaton catheter. The end of this ureter and the end of the distal ureter were spatulated and anastomosed. A double J and minivac drain were used in each case.

RESULTS

There were no complications in the postoperative period of all our patients. They were all discharged with good health. Follow-up with renal ultrasonography showed that the anteroposterior diameters were decreased and that parenchymal thicknesses had returned to normal. Secondary stenosis, flap necrosis, and retraction did not develop.

CONCLUSION

Because the blood supply of the pelvis is increased in patients with UPJ obstruction, a reverse flap of adequate length with preserved blood supply can be achieved and tubularized. We suggest that this method will be appropriate for the treatment of long segment UPJ obstruction.

Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances. Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures. Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame. Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery

OBJECTIVE

Our aim was to assess the outcomes of infant robot-assisted laparoscopic (RAL) upper urinary tract reconstruction.

MATERIALS AND METHODS

The medical records of all infants who underwent RAL upper urinary tract reconstruction were reviewed. Patients less than 1 year of age at surgery were included. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed.

RESULTS

Ten infants met the study criteria. There were five right and five left-sided procedures. Eight pyeloplasties (4 right, 4 left) and two ureteroureterostomies (1 right single system, 1 left duplex system) were performed. The median age was 8 months (range 3-12 months). Median weight was 7.7 kg (range 5.8-10.9 kg). Median operative time was 128 min (range 95-205 min). There was no significant blood loss or intraoperative complications. One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. Median hospital stay was 1 day (range 1-2). Median follow-up was 10 months (range 3-18 months). Complications included one urinary leak, one ileus, and one urinary tract infection. Hydronephrosis improved in all patients.

CONCLUSIONS

Infant RAL upper urinary tract reconstruction is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants.

External extension of double-J ureteral stent during pyeloplasty: inexpensive stent and non-cystoscopic removal

PURPOSE

The purpose of the study is to describe our experience with the application of externalized double-J ureteral stent (DJUS) during pyeloplasty for correction of ureteropelvic junction obstruction (UPJO) in order to avoid cystoscopy for stent removal.

MATERIALS AND METHODS

Pyeloplasty was performed in 523 infants with UPJO using miniature pyeloplasty technique. After removing the obstructed segment, a 3-Fr. DJUS was placed into the ureter. In order to avoid cystoscopy for the removal of the stent, a feeding tube was passed through the skin and renal pelvis via a separate stab incision, connected to the DJUS and secured to the external body surface (skin), and the pyeloplasty was completed. The feeding tube along with the stent was removed after 3-4 weeks, respectively. Postoperative follow-up visits were performed 1, 3, and 6 months after the procedure.

RESULTS

The mean operative time was 49 min (range 41-79). Patients were discharged after 17 ± 2 h (mean ± SD). No patient experienced bladder spasm or anticholinergic administration. Forty-four patients (8.4 %) experienced minor complications including non-febrile urinary tract infections and mild hematuria. No major complication including urinoma, leakage, and stent migration or displacement was observed during the follow-up period. Stent removal was tolerated by 99.8 % of patients in an outpatient setting with minimal discomfort without performing cystoscopy.

CONCLUSIONS

Using external DJUS along with a pyelocutaneous stent extension during pyeloplasty is a safe, feasible, and beneficial technique. This technique resulted in high success rate with minimal cost and no renal injury. The non-cystoscopic stent removal and elimination of urethral catheterization following pyeloplasty are the other advantages of this technique.

Duration of urinary leakage after open non-stented dismembered pyeloplasty in pediatric patients

OBJECTIVE

We aimed to determine the duration and associated complications of postoperative urinary leakage in pediatric patients undergoing open, non-stented dismembered pyeloplasty for ureteropelvic junction obstruction.

METHODS

A retrospective review of 100 patients who underwent an open non-stented dismembered pyeloplasty between 2003 and 2008 was performed. Duration of urinary leakage and postoperative complications were tabulated. Patients were considered to have a dry anastomosis if the Penrose drain was removed within one week of surgery.

RESULTS

Duration of leakage ranged from 0 to 27 days. 86% had Penrose drain removal within 7 days of surgery and were considered dry.14 patients demonstrated a persistent urinary leakage (PUL) ranging from 7 to 27 days. Complications of any type were significantly more likely in the group with prolonged drainage (p = .0126). UTI and obstruction were not significantly more likely to occur in patients with PUL (p = .0931 and p = .2616 respectively). Only one patient with PUL required placement of a ureteral stent.

CONCLUSION

We demonstrate that stentless dismembered pyeloplasty is feasible with a low rate of urinary drainage beyond one week. The character and quality of the slightly increased complications in those that demonstrated PUL were not great and not bothersome enough to warrant routine stenting.

The outcome of initial endoscopic treatment in the management of concomitant vesicoureteral reflux and ureteropelvic junction obstruction

OBJECTIVE

To report the results of a single-center experience with the endoscopic injection of Deflux as the initial minimally invasive approach in patients with vesicoureteral reflux (VUR) and coexisting obstruction at the ureteropelvic junction (UPJO) level who presented with VUR.

METHODS

Between May 2004 and July 2011, 2810 children with a diagnosis of VUR were referred to our center; 143 (5%) had concomitant UPJO. On the basis of the study inclusion criteria, 76 were included. All patients received antibiotic therapy. VUR and UPJO resolved in 50 children without the need for further intervention, and 26 underwent endoscopic Deflux injection by applying the hydrodistention autologous blood injection technique (HABIT). All patients received antibiotic prophylaxis until resolution of VUR was confirmed on voiding cystourethrogram (VCUG). Patients underwent follow-up visits at 1, 6, and 12 months postoperatively.

RESULTS

At a mean follow up of 20.0 ± 1.6 months, 20 of those with concomitancy showed resolution of VUR and the coexisting UPJO after the first injection (success rate, 76.9%), and 2 resolved after the second injection, leading to an overall success rate of 84.6%. Finally, 3 patients required further ureteral reimplantation, and 3 underwent pyeloplasty for correction of UPJO by applying miniature pyeloplasty technique. Differential renal function was preserved in all patients.

CONCLUSION

Performing an initial endoscopic injection of Deflux in the management of concomitant VUR and UPJO provides promising results in terms of spontaneous resolution of obstruction at the UPJ level and complete resolution or decrease in hydronephrosis.

Endoureterotomy as the initial management of concurrent ureteropelvic and ureterovesical junction obstruction after failed conservative therapy

OBJECTIVE

To present the results of our experience with endoureterotomy as the initial management of ureterovesical junction obstruction (UVJO) with coexisting primary or secondary obstruction at the ureteropelvic junction (UPJO) level.

METHODS

A total of 490 children with 561 ureterorenal units were referred to our center for further management of UVJO. Of these, 47 ureterorenal units had concomitant UPJO. All patients underwent endoureterotomy. Patients were monitored by performing clinical examinations, urine culture, ultrasonography, and radionuclide renal scan.

RESULTS

Mean procedure time for endoureterotomy was 20 minutes (range, 14-33 minutes). No postoperative complications were observed. With a mean follow-up of 27 months, 39 of the 47 ureters with concomitancy (82.97%) showed resolution of both pathologies after the initial endoureterotomy, and 4 patients experienced resolution after redo endoureterotomy, with an overall success rate of 91.48%. Three ureterorenal units (6.38%) underwent further ureteral reimplantation. Pyeloplasty was performed on 3 ureterorenal units (6.38%), which led to complete resolution in all.

CONCLUSION

Performing initial endoureterotomy for the management of UVJO concomitant with UPJO provides promising results in spontaneous resolution of UPJO and complete resolution or decrease in hydronephrosis and can be proposed as an effective and safe temporizing alternative in selected patients.

[Pyeloplasty without intrarenal stent in pediatric patients]

PURPOSE

In spite of advances in minimally invasive endoscopic surgery, open dismembered pyeloplasty continues to be used in many pediatric centers, especially in small children. The purpose of this work is to present our experience in the performance of this technique using a minimally invasive open pyeloplasty without intrarenal stents.

MATERIAL AND METHODS

A retrospective review was made of patients between July 1992 and July 2009. During this time, 348 patients underwent open dismembered pyeloplasty. A total of 310 patients (89%), 223 boys and 87 girls, underwent open pyeloplasty without intrarenal stent. The incision was from 2 to 2.5 cm in the flank. An extrarenal drain (3-5 days) and a bladder catheter (< 24 hs) were placed in all patients.

RESULTS

A total of 319 pyeloplasties were performed without intrarenal catheter in our Service. Of these, 174 (54.5%) were on the left side, 127 (39.8%) on the right side and 9 (5.6%) were bilateral. Age interval was 14 days to 18 years, 58% of the children being younger than 12 months at the time of surgery. With a mean follow-up of 6.7 years (17 years to 11 months), 312 pyeloplasties (97.8%) were successful, with persistence of the obstructive patient in 7 patients who required a new open pyeloplasty (2.2%). Other complications were: prolonged drainage (6), wound infection (1), and urinary infection (2). Mean stay was 22 hours.

CONCLUSIONS

Open dismembered pyeloplasty is a safe and effective treatment choice for pyeloureteral stenosis in children and can be done without intrarenal stents with no detriment to its success.