Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery

Our experience with management of congenital urological pathologies in adulthood: What pediatric urologists should know and adult urologists adopt in pediatric practice experience

Purpose

To summarize our experience in the management of congenital anomalies in the kidney and urinary tract (CAKUT) in adults.

Materials and methods

We conducted a retrospective chart review of all adult patients who underwent primary surgical intervention for CAKUT between 1998 and 2021.

Results

The study included 102 patients with a median age of 25 (interquartile range, 23-36.5). Of these, 85 (83.3%) patients reported normal prenatal ultrasound, and the remaining 17 (16.7%) patients were diagnosed with antenatal hydronephrosis. These patients were followed-up conservatively postnatally and were discharged from follow-up because of the absence of indications for surgical intervention or because they decided to leave medical care. All studied adult patients presented with the following pathologies: 67 ureteropelvic junction obstructions, 14 ectopic ureters, 9 ureteroceles, and 6 primary obstructive megaureters, and the remaining 6 patients were diagnosed with vesicoureteral reflux. Forty-three percent of the patients had poorly functioning moieties associated with ectopic ureters or ureteroceles. Notably, 67% of patients underwent pyeloplasty, 9% underwent endoscopic puncture of ureterocele, 3% underwent ureteral reimplantation, 6% underwent endoscopic correction of reflux, 7% underwent partial nephrectomy of non-functioning moiety, and the remaining 9% underwent robotic-assisted laparoscopic ureteroureterostomy. The median follow-up period after surgery was 33 months (interquartile range, 12-54). Post-operative complications occurred in 5 patients (Clavien-Dindo 1-2).

Conclusions

Patients with CAKUT present clinical symptoms later in life. Parents of patients diagnosed during fetal screening and treated conservatively should be aware of this possibility, and children should be appropriately counseled when they enter adolescence. Similar surgical skills and operative techniques used in the pediatric population may be applied to adults.

A review of robotic-assisted laparoscopic partial nephrectomy in the management of renal duplication anomalies

Open and purely laparoscopic partial nephrectomy or heminephrectomy has been the standard management for renal duplication anomalies for symptomatic children with non-functional renal moieties. While robotic-assisted laparoscopic partial nephrectomy (RALPN) has been established as a safe and feasible option for the management of renal duplex anomalies, there remains a paucity of data on this topic. The aim of this study is to comprehensively review all available outcomes data and update the use of emerging technologies in robotic surgery which continue to make RALPN a viable and advantageous option in the management of renal duplex anomalies.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience

BACKGROUND

Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy.

OBJECTIVE

This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy.

STUDY DESIGN

The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up.

RESULTS

Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n = 13), complete ureteral duplication (n = 2), periureteral diverticulum (n = 2), ectopic megaureter requiring dismembering (n = 1). The median operative time was 155 min for unilateral and 211.5 min for bilateral repairs. The clinical + radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n = 5, 8.7%), febrile urinary tract infection (UTI) (n = 6, 10.5%) and gross hematuria (n = 3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p = 0.002] and bilateral repair [p = 0.001] and post-operative urinary retention was more frequent in simple cases [p = 0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p = 0.001] (Table).

DISCUSSION

This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy.

CONCLUSION

REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Surgical management of complicated duplex kidney: A tertiary referral centre 10-year experience

AIM

The management of a complicated duplex kidney remains a challenge for paediatric urologists. The aim of this study is to report a 10-year experience of the surgical management of complicated duplex kidney in a single tertiary care paediatric referring hospital.

MATERIALS AND METHODS

Clinical records of all children who undergone a surgical procedure for complicated duplex systems between January 2009 and March 2019 at our institution were retrospectively reviewed. Clinical manifestations, surgical procedures, complications and follow-up were collected and analysed. Logistic regression was performed to explore if any patient's characteristic or underlying associated comorbidity (ureterocoele, ectopic ureter, obstruction, etc.,) could be positively linked to the chance to develop recurrent urinary tract infections (UTIs).

RESULTS

We have identified 95 children who received a surgical treatment for 102 complicated duplex kidneys. The presence of an ureterocoele was recorded in 41 (43.2%) patients, an ectopic ureter in 25 (26.3%), a vesicoureteral reflux (VUR) in 40 (42.1%), a vesicoureteric junction obstruction in 24 (25.3%) and an ureteropelvic junction obstruction in 3 (3.2%). An invasive approach such as an heminephrectomy (71.6%) was required in the majority of cases. Higher risk of developing a UTI has been demonstrated in children diagnosed postnatally (P < 0.001) and in those with an associated obstruction (P < 0.05).

CONCLUSIONS

No standardised management could be recommended for the surgical treatment of complicated duplex kidney. Children without antenatal diagnosis and with either an upper tract obstruction or VUR are at greater risk to develop UTI and need to be looked after more closely.

Treatment for complete bilateral duplex kidneys with severe hydronephrosis and ureterectasis of the upper moiety in a child: A case report and literature review

Aim

To explore the treatment experience of the duplex kidney.

Method

A case of the complete bilateral duplex kidney with severe hydronephrosis and ureterectasis in the upper moiety of the kidney diagnosed in the Department of Urology of Kunming Children's Hospital from 2021 to 2022 was retrospectively analyzed and relevant literature was reviewed.

Results

A 2-month-old baby girl was admitted to the hospital because of hydronephrosis of bilateral kidneys found by prenatal ultrasound for 3 months and fever for 3 days. After being given the relevant examinations, the girl was diagnosed with complete bilateral duplex kidneys with severe hydronephrosis and ureterectasis in the upper moiety, and urinary tract infection. The patient's urinary tract infection was poorly controlled after positive anti-infective therapy, so a bilateral ureterostomy was performed. After the surgery, urinary tract infection was soon cured. A bilateral ureteroureterostomy was performed 13 months later, and the patient recovered after 7 days.

Conclusion

Cutaneous ureterostomy combined with late ureteroureterostomy for children with complete bilateral duplex kidneys with severe hydronephrosis in the upper moiety and ureter are not only beneficial to caregivers’ nursing after the operation, but also have significance for salvaging renal function.

A novel method of transvesicoscopic ureteral reimplantation of an ectopic ureter with a mate ureter in a duplex kidney

Introduction

The reimplantation of an ectopic ureter is still performed as an open surgery, although laparoscopic or robot‐assisted laparoscopic surgery has gained popularity as a minimally invasive treatment for pediatric urological disorders.

Case presentation

A 15‐day‐old Japanese boy was referred to our hospital with right hydronephrosis. A detailed examination revealed complete ureteral duplication on the right side and a dilated ectopic upper pole ureter, opening into the prostatic urethra. Since the patient had recurrent febrile urinary tract infections, we performed plication and ureteral reimplantation of the dilated ectopic ureter using a transvesicoscopic surgical method at the age of 2 years and 5 months.

Conclusion

We safely performed transvesicoscopic ureteral reimplantation for an ectopic upper pole ureter with a mate ureter in a duplex kidney, following the detection of an ectopic ureter within the bladder, due to the prior understanding of the wrapping of both ureters in a common sheath.

Upper or lower tract approach for duplex anomalies? A bi-institutional comparative analysis of robot-assisted approaches

Optimal management of duplication anomalies may include an upper or lower tract surgical approach. In the contemporary era, the robot-assisted laparoscopic heminephrectomy (RALHN) and robot-assisted laparoscopic ipsilateral ureteroureterostomy (RALIUU) are viable interventions predicated on clinical, institutional and surgeon preferences. We present a multi-institutional comparative analysis aiming to compare the outcomes of RALHN and RALIUU to see if either of the approaches confers an advantage over the other in treating duplex renal anomalies needing intervention. We completed a retrospective review of consecutive children undergoing RALIUU at Hospital A and RALHN at Hospital B from January 2009 to March 2017. The primary outcome was 'surgical success' defined by the resolution of clinical symptoms, improved radiological parameters, and no unplanned subsequent interventions till the time of study completion. Secondary outcomes included operative parameters, complications, and subsequent urinary infections. There were 39 RALIUU and 28 RALHN. Baseline demographic and clinical parameters across two cohorts were similar. The primary outcome of 'surgical success' was 100% across both cohorts. There were no major surgical complications, and the incidence of postoperative urinary tract infection was minimal and similar for both groups. Operative time favored RALHN; blood loss and analgesic requirements were minimal in both cohorts. Both RALIUU and RALHN are definitive surgical interventions in children with complex duplex moieties, delivering satisfactory surgical outcomes with a low complication profile and marginal differences in the postoperative patient outcomes. This pilot bi-institutional study provides the basis for a larger collaboration to further define optimal techniques, standardize surgical care pathways, and interrogate long-term outcomes.

A novel transvesicoscopic ureteral reimplantation technique to treat an infantile ectopic ureter in a single system

An ectopic ureter is a significant urinary tract malformation often treated during early childhood and is surgically managed based on its condition. Generally, only extravesical ureteral reimplantation is available as a treatment option for an ectopic ureter with well-preserved renal function. This report describes a case of a 28-months-old girl with an ectopic ureter in a single system who experienced repeated febrile urinary tract infections, successfully treated using a transvesicoscopic ureteral reimplantation as a minimally invasive treatment. To the best of our knowledge, this is the first report of transvesicoscopic ureteral reimplantation for an ectopic ureter in a single system.

Robotic versus laparoscopic ipsilateral uretero-ureterostomy for upper urinary tract duplications in the pediatric population: A multi-institutional review of outcomes and complications

OBJECTIVE

To review and compare robotic ipsilateral uretero-ureterostomy (RIUU) and laparoscopic ipsilateral uretero-ureterostomy (LIUU) in terms of safety, efficacy, and outcomes.

MATERIALS AND METHODS

A retrospective chart review, including all pediatric patients who underwent RIUU and LIUU at 5 different medical centers, between 2015 and 2019, was performed. Patient's demographics, perioperative data, surgical techniques, complications, and results were compared.

RESULTS

The study included 66 pediatric patients, 22 RIUU and 44 LIUU. Median age at surgery was 12 month (IQR 7-52) and median weight was 12 kg (IQR 9-16). Upper to lower IUU was performed in 55 cases and lower to upper IUU in 11 cases. Median operative times for RIUU and LIUU were 90 min (IQR 75-97.5) and 112.5 min (IQR 81.5-121.25), respectively (p = 0.034). Clavien-Dindo grade 3 postoperative complications occurred in two LIUU patients. One patient underwent an ancillary procedure with laparoscopic distal ureteral stump removal. All patients had resolution of symptoms and improvement in hydronephrosis or a non-obstructed curve on MAG3 diuretic renal scan.

CONCLUSION

RIUU and LIUU are both safe and effective minimally invasive approaches for duplex upper urinary tract anomalies in the pediatric population. RIUU demonstrated shorter operating times .

Hydronephrosis and Hydroureter Improvement Rates in Robotic-Assisted Laparoscopic Uretero-Ureterostomies: Does Anastomotic Site Matter?

OBJECTIVE

To compare improvement/change of hydronephrosis and hydroureter in patients with complete ureteral duplications that underwent upper and lower robotic-assisted laparoscopic uretero-ureterostomies. The hypothesis being that improvement of hydronephrosis and hydroureter between the two groups was similar.

METHODS

35 subjects met inclusion criteria and were reviewed retrospectively. 'Upper' anastomoses were defined as those being done below the lower pole of the kidney (Group 1), while 'lower' anastomoses were those done below the iliac vessels (Group 2). Primary variables analyzed were antero-posterior and diameter measurements of the renal pelvis and ureter, respectively, before and after surgery. Secondary variables included operative time, length of hospital stay, and complication rates.

RESULTS

Group 1 consisted of 20 subjects while Group 2 consisted of 15 subjects. Presenting diagnoses were hydronephrosis in 31 subjects and incontinence in 4 subjects. Group 1 mean AP renal diameters decreased by 62.9% (P<.05), while Group 2 decreased by 65.4% (P<.05). Group 1 mean hydroureter diameter measurements decreased by 80.3% (P<.05), while Group 2 decreased by 83% (P<.05). The improvement in hydronephrosis and hydroureter between the two groups was not statistically different. Group 1 median operative time (271 minutes) was longer than Group 2 (201 minutes) (P<.05). There was no significant difference in hospital stay between the groups and there were no significant complications within the cohort.

CONCLUSION

The improvement rate of hydronephrosis and hydroureter is similar in upper versus lower RAL UU. Operative time was significantly shorter in the lower anastomosis group.

Dorsal lumbotomy for pediatric upper pole hemi-nephrectomy: Back (door) to the future?

INTRODUCTION

Upper pole heminephrectomy (UHN) is performed for two main indications in children: ectopic ureterocele and duplication anomalies with upper pole ectopy, both in the context of a poorly functioning upper pole moiety. Current popular techniques for conducting UHN include laparoscopic (LPN) and robot-assisted laparoscopic (RAPN).

OBJECTIVE

To evaluate outcomes following dorsal lumbotomy (DL), an open approach used historically for pyeloplasty and pyelolithotomy, and in which no clinical trials or exclusive case-series have been conducted for upper pole hemi-nephrectomy (UHN) in children. We ultimately aim to compare our outcomes following DL at our centre to that of published outcomes of minimally invasive approaches to UHN.

STUDY DESIGN

Institutional board review was obtained (H18-03716) for a retrospective review of 50 UHN performed in 49 consecutive pediatric patients using the DL approach by a single surgeon between 2001 and 2019. Clinical variables and indicators included age, sex, weight, skin-to-skin time, total operating room time, duration of hospital stay, post-operative complications, analgesic requirements, and post-operative ultrasound results.

RESULTS

Of 50 UHN performed, 23 had a presurgical diagnosis of ectopic ureter, and 27 ureterocele. Mean weight of patients was 12.61 kg, and the mean age at surgery was 24.55 months. Mean (range) for time between skin incision and closure was 88.5 (62-132) minutes, and the mean (range) total operating room time was 138.5 (70-180) minutes. There were neither intraoperative complications nor transfusions. The mean (range) post-operative opioid delivered was 0.73 (0.00-2.00) mg/kg/day. Mean (range) post-operative ibuprofen delivered was 5.41 (0.00-37.73) mg/kg/day. Median length of hospital stay was 2 days. No patient received post-operative prescriptions for narcotics at discharge. There were no wound complications. One patient had secondary atrophy of the lower pole. Secondary lower tract surgery, unrelated to surgical approach, was performed in five patients. Ten patients experienced a urinary tract infection at some point after surgery.

CONCLUSION

DL is safe, feasible, and produces operative outcomes and times comparable to that of laparoscopic and robotic techniques. These findings as well as operative costs should be considered when selecting a surgical technique for UHN.

Laparoscopy combining with ureteroscopy for horseshoe kidney accompanying with duplicate kidney and a ureteral calculus: a case report

BACKGROUND

Horseshoe kidney (HSK) is a common renal fusion anomaly, occurring in about 1 in 400-600 individuals. In addition, the incidence of duplicated collecting system is about 0.8%.

CASE PRESENTATION

This report documents an extremely rare case, which was treated by multiple procedures in the same operative session to accomplish laparoscopic amputation of the HSK isthmus, resection of duplicate kidney and ureteroscopic lithotripsy.

CONCLUSION

Results showed that minimally invasive surgery with use of multiple endoscopes may be a feasible choice for this patient population with complicated comorbid renal conditions.

Long-Term Follow-Up of Laparoendoscopic Single-Site Partial Nephrectomy for Nonfunctioning Moieties of Renal Duplication and Fusion Anomalies in Infants and Children

Objectives: To report on long-term follow-up and outcomes of infants and small children who have undergone laparoendoscopic single-site (LESS) partial nephrectomy to manage upper urinary tract duplication and fusion anomalies. Materials and Methods: A retrospective review was performed evaluating outcomes of pediatric patients who underwent LESS partial nephrectomy for upper urinary tract duplication and fusion anomalies from January 2012 to July 2015, by a single surgeon at a tertiary pediatric referral center. Demographic and perioperative data were reviewed as well as follow-up imaging. Descriptive statistics were used for analysis. Results: A total of 18 patients were identified. Additional access was used for two patients to complete the procedure. Median follow-up was 39 months. No short-term complications were encountered. Three patients were noted to have abnormal postoperative ultrasounds: two perinephric fluid collections and one atrophy of the remaining ipsilateral moiety. One fluid collection resolved completely, and the other decreased in size. Complete atrophy of the ipsilateral moiety occurred. No secondary procedures were required. Conclusions: LESS partial nephrectomy is safe for renal duplication and fusion anomalies with good long-term outcomes. Although it can be safely performed, it is a technically demanding procedure and has been discontinued in favor of robotic partial nephrectomy.

Application of indocyanine green in pediatric surgery

The use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in many fields in adult surgery, such as sentinel lymph node mapping, intra-operative solid tumor identification, and organ perfusion assessment. However, the clinical application of ICG in pediatric surgery is just at the beginning. This review paper presents the advantages, current applications and potential developments of NIR fluorescence imaging with ICG in our field.

Retroperitoneal robot-assisted laparoscopic upper pole heminephrectomy in adult patients with duplex kidneys

Background: To report our experience with retroperitoneal robot-assisted laparoscopic upper pole heminephrectomy in adult patients with duplex kidneys. Methods: We retrospectively reviewed the medical records of 7 patients who underwent retroperitoneal robot-assisted laparoscopic upper pole heminephrectomy at our institution between September 2014 and July 2017. Of the robot-assisted laparoscopic procedures, 5 were on the left and 2 on the right side. Results: All patients underwent robot-assisted laparoscopic surgery successfully in a totally retroperitoneal manner without conversion to open surgery. The mean operative time was 175 mins (range 140-270). The mean estimated blood loss was 84 mL (range 20-200). The mean postoperative hospital stay was 7 days (range 5-9). No major intraoperative and postoperative complications occurred. All patients had a resolution of their presenting symptoms after surgery at a mean follow-up of 24 months (range 14-38). Conclusion: Our initial clinical experience suggests that robot-assisted laparoscopic upper pole heminephrectomy using a retroperitoneal approach for a duplex kidney appears to be safe with acceptable perioperative outcomes.

Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter?

PURPOSE

Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes.

MATERIALS AND METHODS

All patients with duplex systems who underwent IUU between 2010 and 2016 were retrospectively reviewed. Patients were sorted into two groups based on pre-operative imaging: those having <10% upper pole moiety function (UPMF) and those having ≥ 10% UPMF. Outcomes assessed were postoperative complications (Clavien-Dindo classification), need for secondary surgery, and radiological outcomes.

RESULTS

The study cohort comprised 53 children with ectopia or ureterocele affecting the upper pole in a duplex system, 21 with UPMF <10% (median function 0% and median age 1.49 years) and 32 with UPMF ≥ 10% (median function 15% and median age 0.91 years). Median follow-up was 27.4 months and 27.6 months. In both the groups, prenatal hydronephrosis was the most common presentation (57% and 56%, respectively; p = 0.18) followed by urinary tract infection. Mann-Whitney U test comparing the two groups revealed no significant differences in any of the outcomes assessed. No patient required secondary surgery.

CONCLUSION

Ipsilateral ureteroureterostomy is a safe, definitive surgical intervention that preserves the renal architecture in children with duplex collecting systems regardless of upper pole function.

Robotic Ureteral Reconstruction in the Pediatric Population

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.

A contemporary single-institution retrospective cohort study comparing perioperative outcomes between robotic and open partial nephrectomy for poorly functioning renal moieties in children with duplex collecting systems

INTRODUCTION

Studies evaluating robotic-assisted laparoscopic partial nephrectomy (RALPN) are limited to case series, amounting to a lack of studies directly comparing perioperative outcomes for RALPN to open partial nephrectomy (OPN).

OBJECTIVE

To compare perioperative outcomes between RALPN and OPN.

METHODS

A single-institution, retrospective cohort study was performed to compare perioperative outcomes (operative time (OT), length of stay (LOS), complications, readmissions, postoperative interventions, loss in size of the residual moiety, and the presence of postoperative 'contained fluid collections') for RALPN and OPN between February 2007 and July 2014. Descriptive statistics were calculated and unadjusted analyses performed, including Chi-squared/Fisher's exact for categorical variables and Wilcoxon rank sum for continuous variables.

RESULTS

During the study period, 43 partial nephrectomies were performed for benign disease: 27 (63%) RALPN and 16 (37%) OPN. The RALPN cohort was significantly older than the OPN cohort (3.5 vs. 0.8 years; P = 0.003). The cohorts were otherwise similar regarding race, American Society of Anesthesiologist score (ASA), affected moiety, laterality, associated anomalies, moiety function, and surgical indication. Robotic-assisted laparoscopic partial nephrectomy was associated with a significantly shorter LOS (1 vs. 3 days; P = 0.002). Operative time and complication rates were comparable. The OPN group had a longer median follow-up (2.7 years vs. 1.1; P = 0.03). No differences were observed between the cohorts for readmissions, postoperative interventions, loss in size of residual moiety, or development of 'contained fluid collections'. These outcomes are reported in the Summary Table. 'Contained fluid collections' occurred more frequently after lower pole resections (73% vs. 30%; P = 0.009).

DISCUSSION

This study is one of the few to directly compare RALPN to OPN, and demonstrated that RALPN has comparable (if not better) outcomes than OPN. In particular, RALPN provides the advantage of a shorter LOS. Avoiding the flank incision used in OPN may also offer reduced pain; however, this was not studied here and the literature provides weak evidence for this effect. This unadjusted analysis may have been confounded by its short median follow-up and significantly younger OPN cohort.

CONCLUSION

In this contemporary comparative analysis, RALPN predicted a similar median OT and safety profile to OPN while offering the advantage of a shorter LOS. Regardless of surgical cohort, there were no adverse effects on the residual renal moieties and postoperative 'contained fluid collections' occurred with notable frequency and were independently associated with lower pole pathology.

Robot-assisted laparoscopic common sheath ureteral reimplantation in duplex ureters: LUAA technique tips for optimal outcomes

OBJECTIVE

To describe surgical tips for robot-assisted laparoscopic (RAL) common sheath ureteral reimplantation using the previously reported LUAA technique in patients with duplex renal collecting systems, and to assess the efficacy of this technique by reviewing operative outcomes in a single-institution case series.

METHODS

We retrospectively reviewed a consecutive series of patients with duplicated collecting systems and vesicoureteral reflux (VUR) who underwent RAL extravesical common sheath ureteral reimplantation at a single medical center from 2010 to 2017. We included all duplex ureters requiring antireflux surgery. A standardized technique (LUAA) was used in each case, with additional tips used as described herein: a) careful common sheath ureteral mobilization, b) wide detrusorotomy with adequate detrusor flap elevation from the mucosa, and c) appropriate tension during tunnel detrusorraphy. Patient demographics, perioperative data, and follow-up imaging were reviewed. Radiographic resolution was defined as absence of VUR on voiding cystourethrogram (VCUG) performed 4 months postoperatively. Only patients undergoing ureteral reimplantation for VUR were included. Those with ureterovesical junction obstruction were excluded.

RESULTS

A total of 13 patients underwent RAL common sheath ureteral reimplantation, with three bilateral cases for a total of 16 duplicated ureters reimplanted. Mean age at surgery was 3.64 ± 1.04 years. Mean operative time was 125.1 ± 30.73 min in unilateral cases and 200 ± 51.18 in bilateral cases. Complete resolution of VUR was achieved in 14 of 16 ureters (87.50%). There were no high-grade complications (IIIV on the Clavien-Dindo scale). There were two grade II complications in our cohort, with a mean follow-up of 17.18 ± 18.41 months.

CONCLUSIONS

We report a radiographic success rate of 87.50% for RAL common sheath ureteral reimplantation in children with duplicated ureters, using the LUAA technique with several additional technical considerations. In our experience, careful mobilization of the ureter to preserve vascularity, a wide detrusorotomy to adequately elevate the detrusor flaps, and appropriate tension during detrusorraphy are essential components to optimize outcomes and prevent complications.

Evaluating Outcomes of Differential Surgical Management of Nonfunctioning Upper Pole Renal Moieties in Duplex Collecting Systems

OBJECTIVE

To evaluate the management and clinical outcomes of nonfunctioning upper pole moieties treated with either upper pole heminephrectomy or upper pole preservation with lower ureteral reconstruction at a single tertiary institution.

METHODS

After Institutional Review Board (IRB) approval, patients with duplicated systems undergoing upper pole heminephrectomy, ureteroureterostomy, or common sheath ureteral reimplantation from 2012-2017 were identified. Only patients with a nonfunctioning upper pole moiety on ultrasound or renal scan were included. Patients undergoing upper pole heminephrectomy were compared to those undergoing upper pole preservation with respect to demographics, anatomic variations preoperatively, and postoperative outcomes.

RESULTS

Twenty-seven (57%) patients underwent upper pole preservation with lower ureteral reconstruction; 20 (43%) patients underwent upper pole heminephrectomy. Patients undergoing lower ureteral reconstruction were older (1.63 vs 2.76 years, P = .018) and more commonly presented with lower pole vesicoureteral reflux (67% vs 25%, P = .008). No significant difference in postoperative complications was seen between the two groups. After ureteroureterostomy, one patient developed new onset symptomatic reflux to the upper pole requiring intravesical reimplantation. In the heminephrectomy group, 4 of 11 patients with ureteroceles had ureterocelectomy with concomitant lower pole reimplantation. After heminephrectomy, two additional patients required further interventions: ureterocele excision and transurethral polyp excision.

CONCLUSION

For patients with nonfunctional upper poles, lower tract reconstruction is a safe alternative to upper pole heminephrectomy. No significant difference in outcomes was seen. Considering that nearly 1 of 3 of patients with upper pole heminephrectomy required additional lower urinary tract procedures, pursuing upper pole preservation with lower urinary tract reconstruction may be favorable.

Partial nephrectomy for small children: Robot-assisted versus open surgery

OBJECTIVES

To compare the outcomes of robot-assisted heminephrectomy for duplex kidney in children with those of open heminephrectomy.

METHODS

The present retrospective multicentric analysis reviewed the records of robot-assisted versus open heminephrectomy carried out for duplex kidney in children from 2007 to 2014. Demographic data, weight, surgical time, hospital stay, complications and outcome were recorded. Follow up was based on a clinical review, renal sonography and dimercaptosuccinic acid renal scintigraphy.

RESULTS

A total of 15 patients underwent robot-assisted heminephrectomy, and 13 patients underwent retroperitoneal heminephrectomy by open approach. All patients weighed <15 kg. The mean age at the time of surgery was 20.2 months (range 7-39 months) in the robotic group, and 18.4 months (range 6-41 months) in the open group. The mean hospital stay was statistically longer for the open surgery group (6.3 days, range 5-8 days vs 3.4 days, range 1-7 days; P < 0.001). Regarding postoperative pain control, total morphine equivalent intake was statistically greater for the open group (0.52 mg/kg/day vs 1.08 mg/kg/day; P < 0.001). No patient lost the remaining healthy moiety. There was no significant difference in terms of operating time, complication rate or renal outcomes.

CONCLUSIONS

Robot-assisted heminephrectomy in small children seems to offer comparable renal outcomes with those of its standard open surgery counterpart. Specific technical adjustments are necessary, which typically increase the set-up time.

Robot-assisted laparoscopic pyeloureterostomy in infants with duplex systems and upper pole hydronephrosis: Variations in double-J ureteral stenting techniques

OBJECTIVE

We describe our experience with robot-assisted laparoscopic (RAL) pyeloureterostomy in infants with duplex systems and upper pole hydronephrosis with an emphasis on the various double J (DJ) ureteral stent placement techniques.

METHODS

We used our RAL pyeloureterostomy technique in two female infants with duplex systems and upper pole hydronephrosis. For case 1, we introduced the DJ stent and placed it in the recipient lower pole ureter during the robotic operation in an antegrade fashion. For case 2, we inserted the DJ stent during retrograde pyelography prior to the robotic procedure in a retrograde fashion, and the proximal portion of the stent was placed across the anastomosis into the upper pole renal pelvis.

RESULTS

Postoperatively, each of the patients were discharged on postoperative day 1 without complications. The postoperative renal ultrasound at 3 months demonstrated marked improvement of the right upper pole hydronephrosis in both patients.

CONCLUSION

RAL pyeloureterostomy represents a minimally invasive option for upper tract reconstruction of duplex systems with upper pole hydronephrosis in infants. The DJ stent can be placed at the beginning or during the procedure. The stent can be placed in the lower pole ureter or across the anastomosis into the upper pole renal pelvis.