Primary laparoscopic pyeloplasty in children: A single-center experience of 279 patients and analysis of possible factors affecting complications

Long-term outcome of retroperitoneoscopic one-trocar-assisted pyeloplasty: a single-center and single-surgeon experience

PURPOSE

The aim of this study was to assess the long-term outcomes of retroperitoneoscopic one-trocar-assisted pyeloplasty (OTAP) for ureteropelvic junction obstruction (UPJO) in children.

METHODS

This retrospective analysis included 70 pediatric cases, all under the age of 5, diagnosed with UPJO and treated with the OTAP technique between May 2011 and June 2013 by a single surgeon. A single 10 mm operative scope with a 5 mm working channel was utilized to mobilize the ureteropelvic junction (UPJ) and exteriorize it through the trocar insertion site. Subsequently, conventional Anderson-Hynes dismembered pyeloplasty was conducted extracorporeally. Patient's demographics, operative time, hospital stay, complications, and success rate were evaluated.

RESULTS

Seventy pediatric patients (65 males and 5 females) underwent OTAP, with ages at the time of operation ranging from 1 month to 5 years (mean = 22.6 ± 18.6 months). The mean operative time was 74.8 ± 15.2 min. There was a significant reduction in the mean renal pelvis size from 34.3 ± 8.1 mm preoperatively to 13.8 ± 4.7 mm postoperatively (p < 0.05). Moreover, the mean differential renal function (DRF) increased from 47.9 ± 9.8% preoperatively to 51.2 ± 5.9% postoperatively (p < 0.05). All patients experienced an uneventful postoperative recovery, with a median hospital stay of 3.4 days. The success rate was 95.7%, with a median follow-up time of 75 months (range: 6-125 months).

CONCLUSION

OTAP is a safe and feasible minimally invasive technique to correct ureteropelvic junction obstruction in children. It could be considered as a treatment of choice for children under the age of 5 as it combines the advantages of open and retroperitoneoscopic pyeloplasty and presents excellent long-term outcomes.

TRIAL REGISTRATION NUMBER

NCT06349161 April 4th, 2024, retrospectively registered.

Risk factors for adverse outcomes after pediatric pyeloplasty: A retrospective cohort study

PURPOSE

To identify the risk factors for adverse outcomes after pediatric pyeloplasty.

METHODS

We conducted a retrospective review of all children under the age of 14 years who underwent primary pyeloplasty for unilateral ureteropelvic junction (UPJ) obstruction at a single teaching hospital in Tunisia between January 1, 2013, and December 31, 2022.

RESULTS

A total of 103 patients were included. Median age of patients at surgery was 27 months (interquartile range [IQR], 13-44). On ultrasound, median renal pelvic anteroposterior diameter was 3.2 cm (IQR, 2.3-4), and the median renal cortex thickness (RCT) was 2.5 mm (IQR, 2-3.5). Median differential renal function (DRF) on preoperative radionuclide renal scan was 40% (IQR, 30-46). Postoperative adverse outcomes occurred in 28 patients (27.2%). These included 19 cases of urinary tract infections (UTIs), 11 cases of UPJ restenosis, four cases of UPJ leakage, two cases of urinoma, and two cases of diversion-related complications. Multivariate logistic regression analysis revealed two factors significantly and independently related to postoperative negative outcomes: RCT <3 mm and DRF > 50%.

CONCLUSION

Our study demonstrated that preoperative RCT on ultrasound of less than 3 mm and preoperative DRF on radionuclide renal scan of more than 50% were independent risk factors for adverse outcomes following pediatric pyeloplasty. These factors could be of interest in identifying, early on, patients who will develop postoperative negative outcomes, giving them more attention and support, and explaining the prognosis to the patient and family.

Failure in Double-J stent inserting in laparoscopic pyeloplasty of ureteropelvic junction obstruction: the clinical features and outcomes

BACKGROUND

Double-J (DJ) stent placement is an important procedure during laparoscopic pyeloplasty (LP). Failing to insert the DJ stent may indicate the patient was also complicated with uretero-vesical junction obstruction (UVJO), and surgeons have to change to another alternative drainage method. In the present study, we analyzed the risk factors of failure of DJ stent placement during the LP and reviewed the clinical outcomes of these challenging pyeloplasties.

METHODS

We retrospectively analyzed the clinical data of patients with ureteropelvic junction obstruction (UPJO) who underwent LP in our department from January 2016 to September 2020. For patients who developed a difficult process of inserting the DJ stent, the externalized uretero-pyelostomy (EUP) stent was indwelled. Patients were finally divided into two groups: DJ group and EUP group. The primary outcomes were recurrent UPJO, postoperative uretero-vesical junction obstruction (UVJO) and complications.

RESULTS

A total of 535 patients were included in the study, of which 37 patients (6.9%) failed to insert the DJ stent. Age was younger, and weight was lower (P < 0.05) in the EUP group. Within follow-up, recurrent UPJO occurred in ten (1.87%) patients, nine in the DJ group and one in the EUP group (P > 0.05). The incidence of postoperative UVJO in the EUP group was significantly higher than in the DJ group (10.8% vs. 0.2%, P < 0.01). 74 patients (13.8%) developed complications after surgery, 12 patients (32.4%) in the EUP group, significantly higher than that in the DJ group (32.4% vs. 12.4%, P < 0.01). Compared with the DJ group, the larger APD were observed in the EUP group at three months postoperatively (3.50 [3.02;4.58] vs. 2.20 [1.50;2.88], P < 0.05), but the difference vanished in further follow-up.

CONCLUSION

The failure of DJ stent placement tends to occur in patients with younger age, lower weight, and larger preoperative APD. Failure may not increase the recurrent UPJO rate, but may indicate a higher probability of postoperative UVJO and may develop more postoperative complications and slower recovery.

Double J stent combined with pyelostomy tube in pediatric laparoscopic pyeloplasty: a 5-year clinical experience in a single center

OBJECTIVE

To compare the outcome of using a double J (DJ) stent combined with pyelostomy tube with a DJ stent alone in laparoscopic pyeloplasty (LP) for pediatric ureteropelvic junction obstruction (UPJO).

METHODS

A retrospective review of all patients with UPJO treated with LP between January 2017 and November 2021 was conducted in our center. According to different postoperative drainage methods patients were divided into a DJ stent group (52 cases) and a DJ stent combined with pyelostomy tube group (combination group, 41 cases). Operative time, bleeding volume, perirenal drainage stent removal time, postoperative hospital stay, postoperative complications, and renal function recovery were compared between the two groups. Renal ultrasound and diuretic renogram (DR) were used for preoperative and postoperative follow-up.

RESULTS

A total of 52 patients were in the DJ stent group and 41 patients in the combination group. The mean hospital stay was 6.46 ± 2.66 days in the DJ stent group and 5.22 ± 1.63 days in the combination group (p < 0.05). Postoperative complications developed in 14 out of 52 patients in the DJ stent group (26.9%), while complications developed in 8 out of 41 patients in the combination group (19.5%) (p > 0.05). Non-catheter-related complications developed in 10/52 patients in the DJ stent group (19.2%) and only 1/41 patients in the combination group (2.4%) (p < 0.05). The renal function and renal cortex thickness in both groups were improved.

CONCLUSION

Both the DJ stent drainage and the DJ stent combined with pyelostomy drainage are safe and effective. We should fully consider the patient's preoperative and intraoperative conditions and choose appropriate drainage methods. A DJ stent combined with pyelostomy tube can reduce non-catheter related complications, facilitate postoperative recovery, and the hospital stay was significantly shorter than the DJ stent group. However, it is necessary to pay attention to the nursing treatment of the pyelostomy tube and guard against the occurrence of pyelostomy tube shedding.

Early and Long-term Complications of Robotic Assisted Laparoscopy in Infants and Children

BACKGROUND

Robotic-assisted laparoscopy still lacks wide acceptance in infants and children. We developed the service and report the largest single institution experience of complications over a period of 11 years.

METHODS

Between March 2006 and May 2017, consecutive infants and children who underwent robotic assisted laparoscopy under the care of two laparoscopic surgeons were studied. Data for patients, surgeons, year of surgery, operation, and timing, nature, grades of complications were assessed.

RESULTS

A total of 601 robotic procedures (45 different types) were carried out in 539 patients. Of these 31 (5.8%) were converted, none for operative complications. These and another 4 with complicated co-morbidity were excluded, leaving 504 patients for further analysis. There were 60 (11.9%) complications in 57 (11.3%) patients. Mean (SD) age was 7.7 years -/+5.1 with the youngest being 4 weeks. Concomitant or bilateral robotic and non-robotic procedures took place in 8.1% and 13.3% of patients respectively. Significant medical co-morbidity and abdominal scarring were present in 29% and 14.9% of patients respectively. Complications occurred in theatre 1.6%, hospital 5.6%, 28 days 1.2%, and late 3.6%. Mean follow up was 7.6 years -/+ 3.1 SD. Over-all postoperative complication rate was 10.3%: CD grade I 6.5% (33), II 0.6% (3), and IIIa/b 3.2% (16) which included 1.4% (7) re-do surgery. Most (11/16) grade III occurred late. There were no bleeding, grade IV or V complications, surgical mortality, or technology related complications.

CONCLUSIONS

Complications are low even during the learning phase and while developing the new technique. Most complications occurred early and were minor. Most high-grade complications presented late.

LEVELS OF EVIDENCE

2B.

Latitudes and attitudes: A multinational study of laparoscopic pyeloplasty in children

PURPOSE

The Anderson-Hynes technique has been the treatment of choice for primary ureteropelvic junction obstruction in children. Laparoscopic approach has shown similar outcomes to open, with advantages of shorter hospital stay and less pain. We reviewed the experience of 11 geographically diverse, tertiary pediatric urology institutions focusing on the outcomes and complications of laparoscopic pyeloplasty.

MATERIALS AND METHODS

A descriptive, retrospective study was conducted evaluating patients undergoing Anderson-Hynes dismembered laparoscopic pyeloplasty. Centers from four different continents participated. Demographic data, perioperative management, results, and complications are described.

RESULTS

Over a 9-year period, 744 laparoscopic pyeloplasties were performed in 743 patients. Mean follow-up was 31 months (6-120m). Mean age at surgery was 82 months (1 w-19 y). Median operative time was 177 min. An internal stent was placed in 648 patients (87%). A catheter was placed for bladder drainage in 702 patients (94%). Conversion to open pyeloplasty was necessary in seven patients. Average length of hospital stay was 2.8 days. Mean time of analgesic requirement was 3.2 days. Complications, according to Clavien-Dindo classification, were observed in 56 patients (7.5%); 10 (1%) were Clavien-Dindo IIIb. Treatment failure occurred in 35 cases with 30 requiring redo pyeloplasty (4%) and 5 cases requiring nephrectomy (0.6%).

CONCLUSION

We have described the laparoscopic pyeloplasty experience of institutions with diverse cultural and economic backgrounds. They had very similar outcomes, in agreement with previously published data. Based on these findings, we conclude that laparoscopic pyeloplasty is safe and successful in diverse geographics areas of the world.

Open Pyeloplasty in Infants under 1 Year-Proven or Meaningless?

The use of minimally invasive surgery (MIS) to treat ureteropelvic junction obstruction (UPJO) in children has significantly increased. Nowadays, open pyeloplasty (OP) seems to lose importance. The aim of this study is to evaluate the safety and efficacy of OP in infants < 1 year. Medical records of patients < 1 year with UPJO who had undergone retroperitoneal OP (January 2008-February 2022) at our institution were retrospectively analyzed. Included patients were operated on according to a modified Anderson-Hynes technique. All clinical, operative, and postoperative (1 month-5 years' follow-up) data were collected. Additionally, a nonvalidated questionnaire was sent to the patients/parents. A total of 162 infants (124 boys) met the inclusion criteria. The median age at surgery was 3 months (range: 0-11 months). The median operation time was 106 min (range: 63-198 min). None of the patients had severe surgical complication (Clavien-Dindo > 3). The nonvalidated questionnaire showed a high impact of quality of life. Follow-up was in median 30.5 months (0-162 months). OP is still a reliable procedure with good long-term results especially in infants < 1 year of age, which can be performed in a variety of centers.

Febrile urinary tract infection after Double-J stent removal is associated with restenosis after laparoscopic pyeloplasty: A propensity score matched analysis of 503 children

OBJECTIVE

To analyze the association between the febrile urinary tract infection (fUTI) after Double-J (DJ) stents removal and restenosis after laparoscopic pyeloplasty (LP).

STUDY DESIGN

We retrospectively reviewed the clinical data of patients who were treated with transperitoneal LP for ureteropelvic junction obstruction from 2016 to 2020. Patients were divided into two groups according to whether they developed fUTI after DJ stent removal within 48 h. The 1:3 Propensity Score Matched (PSM) method was used to balance confounding variables.

RESULTS

503 patients were included in the study. 28 (5.57%) patients developed fUTI after DJ stent removal. Compared with the non-fUTI group, age was younger, and weight was lower (P < 0.05) in the fUTI group. Restenosis occurred in 11 (2.2%) patients, of which six patients developed fUTI after DJ stent removal. The revision surgery rate in the fUTI group was significantly higher than in the non-fUTI group (21.4% vs. 1.1%, P < 0.01). After PSM, the results remained consistent. For 492 patients without restenosis, 22 patients developed fUTI. Compared with the non-fUTI group, the larger anteroposterior diameter (APD) and higher APD/cortical thickness (P/C) ratio were observed in the fUTI group at three months and six months postoperatively (P < 0.05), but the difference vanished at 12 months and 24 months after surgery (Figure).

DISCUSSION

FUTI after DJ stent removal is not uncommon after LP, and surgeons are often concerned about the possibility of restenosis. In the present study, although our results demonstrated a significant association between them, restenosis patients comprise only about 20% of fUTI patients. Based on our clinical observations, fUTI is often developed in children from 1 to 6 years of age, and the younger patients may be afraid of voiding because of the postoperative pain after DJ stent removal. Besides, intraoperative manipulation of DJ stent removal may lead to transient edema in the anastomotic site, causing the fUTI. For patients who develop fUTI after DJ stent removal but without persistent symptoms, the transient worsening of hydronephrosis during the early postoperative period may not impact long-term outcomes (As shown in Figure). Additional follow-up is needed to prevent the deterioration of renal function.

CONCLUSIONS

Our result demonstrated that fUTI after DJ stent removal is associated with restenosis after LP. For fUTI patients without restenosis, APD and P/C ratio exhibited transient worsening at three months and six months postoperatively, decreasing gradually during follow-up. Patients who develop fUTI after DJ stent removal should be monitored.

Risk Factors of Urinary Tract Infection in Pediatric Patients with Ureteropelvic Junction Obstruction after Primary Unilateral Pyeloplasty

Objective

Ureteropelvic junction obstruction (UPJO) represents to a leading cause of fetal hydronephrosis, which is associated with urinary tract infection (UTI) and urinary stone disease. This study is aimed at investigating risk factors of UTI in pediatric patients with UPJO after primary unilateral pyeloplasty.

Methods

The records of a consecutive series of patients undergoing primary pyeloplasty at a single institution between June 2015 and November 2021 were retrospectively reviewed. Demographic and clinical characteristics, including age, gender, weight, height, body mass index (BMI), creatinine (Cr), blood urea nitrogen (BUN), estimated glomerular filtration rate (eGFR), neutrophil ratio, lymphocyte ratio, neutrophil/lymphocyte ratio, renal pelvis anteroposterior diameter (APD), renal cortex thickness, caliectasis, open or laparoscopic pyeloplasty, and internal drainage or external drainage, were collected and analyzed. The incidence of postoperative UTI and its risk factors was analyzed.

Results

A total of 504 patients were enrolled in the study, and they were classified into the UTI group (n = 188) and non-UTI group (n = 361). Univariate analysis of the incidence of UTI revealed that age, gender, weight, height, BMI, surgical modality, Cr level, BUN level, neutrophil ratio, lymphocyte ratio and neutrophil/lymphocyte ratio, renal cortex thickness, and postoperative drainage modality were associated with UTI incidence after pyeloplasty in pediatric patients with UPJO. Multivariate analysis revealed that male gender, <19 months, weight < 11.5 (kg), height < 83 (cm), BMI < 17.09, BUN > 4.08 (mmol/L), and internal drainage were risk factors of postoperative UTI in pediatric patients with UPJO.

Conclusion

Our study demonstrated that male gender, <19 months, weight < 11.5 (kg), height < 83 (cm), BMI < 17.09, BUN > 4.08 (mmol/L), and internal drainage were risk factors of UTI in pediatric patients with UPJO after primary unilateral pyeloplasty, which may provide reference for prophylactic antibiotics for those patients with risk factors.

Attaining competency and proficiency in open pyeloplasty: a learning curve configuration using cumulative sum analysis

INTRODUCTION

The learning curves for minimally invasive pyeloplasty techniques have been described in the past. However, the learning curve in achieving competency in open pyeloplasty has not been described. Hence, we aim to evaluate a single surgeon series of open pyeloplasty technique using the cumulative sum (CUSUM) methodology.

METHODS

We retrospectively reviewed all open pyeloplasties performed by a single surgeon (AJL) between January 2008 and March 2020. Collected variables included: sex, age at surgery, operative time, hospital stay, pre-operative ultrasound, pre-operative nuclear scans, pre-operative anteroposterior diameter, associated anomalies, laterality (left or right), type of stent, pre-operative split renal function, and duration of follow-up. A CUSUM analysis was used: the highest peak, plateau and downward trends for complications (defined as Clavien-Dindo classification ≥ 3b) were identified on the plot and set as the transition points between five phases (learning, competency, proficiency, case-mix, and mastery).

RESULTS

Based on the CUSUM analysis, the index surgeon reached the competency phase after performing their 13th open pyeloplasty and became proficient after the 70th case. In the case-mix phase (104th-126th cases), where the surgeon may be performing more complex cases while increasing trainee involvement, there was a slight increase in complication rates. After the 126th case, the surgeon entered the mastery phase, where there was consistent decreasing trend in complications.

CONCLUSIONS

Surgeons performing open pyeloplasty in children following completion of their surgical training will continue to learn through their early cases until achieving competency. Technical competency may be reached after the 13th case. In this report, we looked at the number of cases to become proficient in open pyeloplasty procedure in children. A surgeon may achieve technical proficiency in the procedure after their 13th case.

Laparoscopic transposition for crossing vessels (vascular hitch) in pure extrinsic pelvic-ureteric junction obstruction: a successful case report of a 2-year-old infant with horseshoe kidney

BACKGROUND

Pediatric hydronephrosis induced by pelvic-ureteric junction obstruction (PUJO) is treated by dismembered pyeloplasty (DP) via open and laparoscopic surgery. The etiology of PUJO involves both intrinsic stenosis and extrinsic compression of crossing vessels (CVs). PUJO owing to CVs is also treated by DP, as there is no consensus concerning this vascular condition. We encountered a 2-year-old infant with pure extrinsic PUJO combined with horseshoe kidney who successfully underwent laparoscopic transposition for CVs (vascular hitch).

CASE PRESENTATION

A 2-year-old boy was prenatally diagnosed with left multicystic dysplastic kidney (MDCK) and right hydronephrosis and received a definitive diagnosis after birth. At 6 months old, renal scintigraphy revealed a non-functioning pattern in the left kidney and an obstructive pattern in the right, showing no response to furosemide loading. The patient also had recurrent urinary tract infection, and his right hydronephrosis gradually worsened. We decided to perform surgery for the right PUJO. Preoperative enhanced computed tomography detected three right renal vessels independently branching from the abdominal aorta. The middle renal vessels were located at the ventral side of the pelvis and coincident with the site of PUJO. These vessels were suspected of being CVs. The patient underwent laparoscopic surgery electively. A 5-mm trocar was inserted at the umbilicus for a 5-mm, 30° rigid scope. Two additional ports were then inserted under laparoscope inspection. The dilated right pelvis and CVs were detected after ascending colon mobilization. To confirm the pathogenesis of PUJO, the CVs were dissected and taped. After taping the CVs, an intraoperative diuretic test was performed using furosemide loading. Peristalsis of the right ureter was recognized, and the extrinsic PUJO owing to the CVs was definitively confirmed. We therefore performed transposition for the CVs (vascular hitch procedure). The CVs were mobilized in the cranial direction and those were wrapped by dilated pelvis. The post-operative course was uneventful. The renal scintigraphy findings improved and showed a favorable response of furosemide loading.

CONCLUSIONS

The laparoscopic vascular hitch procedure is minimally invasive and effective for extrinsic PUJO due to CVs. Anastomotic stricture after Anderson and Hynes DP can be prevented by appropriate patient selection.

Outcomes and costs analysis of Externalized PyeloUreteral versus internal Double-J ureteral stents after paediatric laparoscopic Anderson-Hynes pyeloplasty

BACKGROUND

The gold standard treatment for Uretero-Pelvic Junction Obstruction (UPJO) is laparoscopic dismembered pyeloplasty according to the Anderson-Hynes technique. The internal Double-J ureteral (DJ) and the Externalized PyeloUreteral (EPU) stents are usually the drainage of choice. Only a few articles have compared the clinical impact of the different drainage techniques on the perioperative morbidity and none presented a cost analysis of the incurred hospital stay.

OBJECTIVE

To present the clinical outcome and financial analysis of a cohort of children who underwent a laparoscopic pyeloplasty comparing the use of the DJ versus EPU stent.

STUDY DESIGN

Retrospective study of consecutives children who underwent laparoscopic Anderson-Hynes pyeloplasty in a single tertiary paediatric referral centre from January 2017 to March 2020. Patients were grouped according to the type of stent used: DJ stent vs EPU stent.

RESULTS

Fifty-three laparoscopic pyeloplasties were performed on 51 patients: 27 (50.9%) had an EPU stent and 26 (49.1%) a DJ stent. There was no statistically significant difference between the two patient groups with regards to surgical time, hospital stay, stent-related complications or the need for re-do surgery. All the EPU stents were removed with an outpatient admission 8.1 days ± 3.1 after surgery while the DJ stents were removed with a cystoscopy 61.6 days ± 30.2 after surgery (p value < 0.001). On a financial analysis (Figure), the hospital costs for stent removal were significantly lower for the EPU stent group (£ 686.7 ± 263.4 vs £ 1425 ± 299.5, p value < 0.01).

DISCUSSION

Both drainage methods have some disadvantages. Possible complications associated with DJ stents include migration and artificial vesicoureteral reflux which may lead to higher incidence of Urinary Tract Infections. Possible disadvantages of the EPU stent insertion are related to the damage of the renal parenchyma and to the risk of developing skin site infections and urinary leaks. However, in our series the EPU stent has not been associated with a higher incidence of bleeding, leakage or discomfort. In addition to clinical considerations, there is a financial implication to be considered. With this regard, the EPU stent was associated with a significant reduction in the incurred hospital costs.

CONCLUSIONS

The use of DJ and EPU stents is equivalent in regards of overall complications and success rates. DJ and EPU stents provided comparable success and complication rates, however the latter avoids the need of an additional general anaesthesia and reduces the overall incurred hospital costs.

Early Robotic-Assisted Laparoscopic Pyeloplasty for Infants Under 3 Months With Severe Ureteropelvic Junction Obstruction

Objective: To present our primary experience of robotic-assisted laparoscopic pyeloplasty (RALP) for severe ureteropelvis junction obstruction (UPJO) infants under 3 months. Methods: We performed a retrospective study of 9 infants under 3 months who underwent RALP for severe UPJO between April 2017 and March 2019 in our center. The severe UPJO was defined as infants with severe hydronephrosis (Society of Fetal Urology grades III or IV, anteroposterior diameter >3 cm or split renal function <40% or T 1/2 >20 min) involving bilateral, solitary kidney, or contralateral renal hypoplasia UPJO at the same time. All clinical, perioperative, and postoperative information was collected. Results: There were four bilateral UPJO cases, two solitary kidney UPJO cases and three unilateral UPJO with contralateral renal hypoplasia cases included. One single surgeon performed RALP on all of the infants. The mean age of the infants was 1.62 ± 0.54 months. The mean operative time was 109.55 ± 10.47 min. The mean estimated blood loss was 19.29 ± 3.19 ml, and the mean length of hospital stay was 5.57 ± 0.73 days. According to the ultrasonography results, all patients had a significant recovery of renal function at 12 months after the operation. Conclusions: To maximize the protection of renal function, early RALP is a safe and feasible option for the treatment of severe UPJO in infants under 3 months.