Emerging Trends in Robotic Pyeloplasty for the Management of Ureteropelvic Junction Obstruction in Adults

Robot-assisted laparoscopic pyeloplasty is a valid option for ureteropelvic junction obstruction repair in adults with congenital renal abnormalities: a case series study

BACKGROUND

Congenital renal anomalies are rare but may be associated with obstruction of the ureteropelvic junction. Given the rarity of simultaneous ureteropelvic junction obstruction [UPJO] and renal anomalies in the adult population, there is limited literature on approaching these patients. We report our experience with robotic assisted laparoscopic pyeloplasty for UPJO repair in this subset of patients.

METHODS

Data on adult patients with simultaneous congenital renal abnormalities and UPJO who underwent robotic assisted laparoscopic pyeloplasty between 2008 and 2020 was reviewed. Pre-operative data, intraoperative parameters as well as post-operative data including symptom resolution and radiologic findings were recorded.

RESULTS

Ten patients, 4 female and 6 males, with a mean age of 47 years were identified as having simultaneous congenital renal abnormalities and UPJO. Anomalies identified were horseshoe kidney in four patients, duplex kidney with obstruction of one moiety in two patients, malrotated kidney in two patients, and pelvic kidney in two patients. Eight out of ten were symptomatic at presentation with flank pain being the most common symptom. Eight patients underwent robotic pyeloplasty via the dismembered technique, while two underwent robotic Y-V pyeloplasty. With a mean follow up time of 13 months, 8/9 (88%) symptomatic patients enjoyed symptom resolution. Post-op renogram was available for nine patients and showed resolution of obstruction in all patients (100%). One patient developed a urine leak which was managed successfully with drainage.

CONCLUSIONS

Robotic assisted laparoscopic pyeloplasty is a safe, feasible and effective surgical approach in management of adult patients with concomitant UPJO and renal anomalies.

Are there disparities in access to robot-assisted laparoscopic surgery among pediatric urology patients? US institutional experience

Objective

Literature suggests access to robotic surgery varies by race and payer status. We seek to investigate whether disparities exist in robot‐assisted laparoscopic surgery among the pediatric urology population at our tertiary academic medical center and, if so, to find plausible reasons why.

Methods

Retrospective analysis identified patients who underwent open or robot‐assisted laparoscopic surgery by a single surgeon at a tertiary care center between 2008 and 2019. Univariate and multivariate analyses determined the relationship of patient demographic and socioeconomic factors to procedure approach.

Results

Among 356 patients, race, age, American Society of Anesthesiologists status, and year of surgery were significant by univariate analysis. Insurance status was not significant (P = 0.066). Multivariate analysis indicated that age, American Society of Anesthesiologists status, and year of surgery were statistically significant (P < 0.001, P = 0.005, P < 0.001). By multivariate logistic regression, Black and Hispanic patient race were not significant with an odds ratio of 0.60 (0.35–1.02) (P = 0.061). In 60.2% of open cases, open approach selection was attributable to complex pathology, limitations of robotic approach, and surgeon's robot‐assisted laparoscopic learning curve.

Conclusions

Optimal procedure approach was determined by case complexity and surgeon's robot‐assisted laparoscopic learning curve and was independent of patient race and payer status. This study did not find racial or socioeconomic disparities in robotic surgery within pediatric urology at our tertiary medical center, inconsistent with previous literature.

Are robots the future? A case for robotic pyeloplasty as the gold standard treatment in ureteropelvic junction obstruction

PURPOSE OF REVIEW

Robotic pyeloplasty is still a relatively novel procedure. Clinically, early studies have shown high success rates, decreased complication rates, decreased length of hospital stay, and better cosmetic results. This goal of this article is to argue for the use of robotic pyeloplasty as the gold standard of ureteropelvic junction obstruction (UPJO) treatment. Results of studies that have compared robotic pyeloplasty with other procedures currently used are reviewed.

RECENT FINDINGS

Our study, a comprehensive review of published outcomes of robotic pyeloplasty and alternative therapies, consisted of 666 pediatric patients and 653 adult patients. Our review coincided with the previously established studies that robotic pyeloplasty shows equivalent surgical success rates as previous standard of care treatments. Open pyeloplasty has fallen out of favor as standard of care due to the increased length of hospital stay, increased adverse events, and the undesirable aesthetics.

SUMMARY

The use of robotic pyeloplasty has shown to have clinical outcomes that are consistent with other intervention for UPJO, with a potential decrease in length of stay and morbidity. More work has to be done to develop ways to decrease cost of the robot to help establish it as the gold standard for UPJO treatment.

Contemporary Analysis of Ureteral Reconstruction 30-Day Morbidity Utilizing the National Surgical Quality Improvement Program (NSQIP) Database: Comparison of Minimally Invasive Versus Open Approaches

OBJECTIVES

To characterize 30-day morbidity of upper ureteral reconstruction (UUR) and lower ureteral reconstruction (LUR) surgery by comparing open and minimally invasive surgery (MIS) approaches using a national surgical outcomes registry.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent UUR and LUR between 2007-2017. Primary endpoints included 30-day complications, transfusion, readmission, return to operating room (ROR), and prolonged postoperative length of stay (LOS). Multivariable logistic regression was performed to observe the association of MIS approach on 30-day outcomes.

RESULTS

3042 patients were identified with 2116 undergoing UUR and 926 undergoing LUR. Of 2116 patients undergoing UUR, 1733 (82%) were performed via MIS approach. On multivariable analysis, open approach for UUR was associated with increased odds of any 30-day complication (odds ratio (OR) 1.6 [1.1-2.4]; p=0.014), major complication (OR 1.8 [1.04-3.0]; p=0.034), transfusion (OR 3.7 [1.2- 11.5]; p=0.025), ROR (OR 2.0 [1.0-3.9]; p=0.047), and prolonged LOS (OR 5.4 [3.9-7.6]; p<0.001). Of the 926 patients undergoing LUR, 458 (49%) were performed via a MIS approach. On multivariable analysis, open approach for LUR was associated with increased odds of any 30-day complication (OR 1.5 [1.1-2.1]; p=0.028), minor complication (OR 1.7 [1.1-2.6]; p=0.02), transfusion (OR 8.1 [2.7-23.7]; p<0.001), and prolonged LOS (OR 4.2 [2.4-7.3]; p<0.001).

CONCLUSION

Utilization of a national surgical database revealed an open approach was associated with increased 30-day morbidity across multiple postoperative outcome measures. These findings suggest a MIS approach should be considered, when feasible, for upper and lower ureteral reconstruction.

Functional outcomes after robot-assisted pyeloplasty for ureteropelvic junction obstruction: A bi-centre experience

BACKGROUND

Robot-assisted pyeloplasty (RALP) for patients with clinically symptomatic ureteropelvic junction obstruction (UPJO) is increasing and needs assessment.

METHODS

Patients who underwent RALP for UPJO in two academic centres were included. Demographic and perioperative data were collected retrospectively. UPJO was evaluated by imaging pre- and post-surgery. Patients had follow-up consultations 3,6 and 12 months post-surgery. Global success was defined as a clinical response plus radiographic evidence of no further obstruction 3-months post-surgery.

RESULTS

Overall 214 patients (median age: 40 years [interquartile range:30.3-54.0]) were included. Fourteen patients (6.5%) had undergone previous surgery for UPJO. Thirty patients (14%) suffered complication: urinoma (n = 13; 6.1%), pyelonephritis (n = 15; 7%) and retroperitoneal haematomas (n = 2; 0.9%). Repeated early surgery was necessary in eight patients (3.6%). Seven patients had a recurrence of UPJO and six (2.9%) underwent repeated surgery. Radiological success rate was 96.7% whereas global success rate was 91%.

CONCLUSIONS

RALP was a reliable, effective and safe treatment for UPJO with a high global and radiologic success rate.

Trends in the diffusion of robotic surgery in prostate, uterus, and colorectal procedures: a retrospective population-based study

This study aimed to propose quantifiable metrics on the adoption lifecycle of robotic-assisted surgery (RAS) within and across prostate, hysterectomy, and colorectal procedures. This was a retrospective population-based cohort study of commonly performed RAS procedures in the US conducted from July 2001 to July 2015. The patients were identified from the Premier Hospital Database using International Classification of Diseases, 9th revision, Clinical Modification codes denoting prostate, uterus, and colorectal procedures. The Diffusion of Innovations theory was applied to percent RAS utilization to determine discrete eras of technology adoption. Overall and by-era patient baseline characteristics were compared between robotic and non-robotic groups. This study included a total of 2,098,440 RAS procedures comprising prostate (n = 155,342), uterus (n = 1,300,046), and colorectal (n = 643,052) procedures. Prostate (76.7%) and uterus (28.9%) procedures had the highest robotic utilization by the end of the study period and appear to be in the last adoption era (Laggard). However, robotic utilization in colorectal procedures (7.5%) was low and remained in the first era (Innovator) for a longer time (15 vs 60 vs 135 months). Whites, privately insured, patients with fewer comorbidities, and those admitted in large teaching hospitals were more likely to undergo RAS in the early study period. AS-associated patient and hospital profiles changed over time, suggesting that selected patient cohorts should be contextualized by overall adoption of a novel medical technology. The time-discretized analysis may also inform patient selection criteria and appropriate timing for clinical study stages proposed by the Idea, Development, Exploration, Assessment, Long-term study-Devices framework.

Minimally Invasive Versus Open Approach for Cystectomy: Trends in the Utilization and Demographic or Clinical Predictors Using the National Cancer Database

OBJECTIVE

To examine temporal national trends of operative approach for cystectomy and identify demographic or clinical predictive factors that influence choice of approach.

METHODS

We performed a retrospective cohort study of patients who underwent cystectomy for bladder cancer between 2010 and 2013 using the National Cancer Database. Approach was stratified by open vs minimally invasive (robotic or laparoscopic). Univariate Pearson chi-square and multivariate logistic regression analysis were used to assess the relationships between demographic and hospital factors and the receipt of minimally invasive or open surgical approach.

RESULTS

A total of 9439 patients met our inclusion criteria, of which 34.1% received a minimally invasive approach (MIA). Frequency of MIA increased from 26.3% in 2010 to 39.4% in 2013 (P < .0001). Univariate analysis identified statistically significant associations between year of diagnosis, sex, age, race, clinical T stage, insurance status, income, education, distance from hospital, facility type, geographic location, and facility cystectomy volume, and the choice of approach (all P < .01). On multivariate analysis, independent predictors of MIA included increasing year of diagnosis, male gender, lower clinical T stage, private insurance vs Medicaid, nonacademic vs academic program, northeastern geographic region, receipt of neoadjuvant chemotherapy, and lower cystectomy volume.

CONCLUSION

Utilization of MIA for cystectomy has increased nationally over the last several years likely due to increased surgeon familiarity with robotic laparoscopic pelvic surgery. Factors associated with MIA included male sex, locally confined disease, receipt of neoadjuvant chemotherapy, lower cystectomy volume centers, and nonacademic centers.

Variation in the Use of Open Pyeloplasty, Minimally Invasive Pyeloplasty, and Endopyelotomy for the Treatment of Ureteropelvic Junction Obstruction in Adults

BACKGROUND AND PURPOSE

Ureteropelvic junction obstruction is a common condition that can be treated with open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy. While all these treatments are effective, the extent to which they are used is unclear. We sought to examine the dissemination of these treatments.

PATIENTS AND METHODS

Using the MarketScan^® database, we identified adults 18 to 64 years old who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was ureteropelvic junction obstruction treatment (i.e., open pyeloplasty, minimally invasive pyeloplasty, endopyelotomy). We fit a multilevel multinomial logistic regression model accounting for patients nested within providers to examine several factors associated with treatment.

RESULTS

Rates of minimally invasive pyeloplasty increased 10-fold, while rates of open pyeloplasty decreased by over 40%, and rates of endopyelotomy were relatively stable. Factors associated with receiving an open vs a minimally invasive pyeloplasty were largely similar. Compared with endopyelotomy, patients receiving minimally invasive pyeloplasty were less likely to be older (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.95, 0.97) and live in the south (OR 0.52; 95% CI, 0.33, 0.81) and west regions (OR 0.57; 95% CI 0.33, 0.98) compared with the northeast and were more likely to live in metropolitan statistical areas (OR 1.52; 95% CI 1.08, 2.13).

CONCLUSIONS

Over this 9-year period, the landscape of ureteropelvic junction obstruction treatment has changed dramatically. Further research is needed to understand why geographic factors were associated with receiving a minimally invasive pyeloplasty or an endopyelotomy.

Trends in Mesh Use for Pelvic Organ Prolapse Repair From the Medicare Database

OBJECTIVE

To investigate recent trends in mesh use for pelvic organ prolapse (POP)-related reconstruction procedures.

MATERIALS AND METHODS

Using the 2001-2011 5% Medicare claims database, we identified POP diagnoses and related procedures. Transvaginal mesh use and sacrocolpopexy were first reported in 2005 and 2004, respectively.

RESULTS

A total of 613,160 cases of vaginal and abdominal POP repair procedures were identified. The majority of procedures involved multiple compartments. The rate of mesh use increased dramatically from 2% of repairs in 2005 to 35% by 2008. After the Food and Drug Administration warning in 2008, mesh use plateaued and then decreased in 2011. Mesh was used more commonly in younger (odds ratio [OR] 0.722, P < .001), white (OR 0.712-0.791 for other races, P < .001) women in the South (OR 0.741-0.848 for non-South regions, P < .001). Starting in 2008, the rate of sacrocolpopexy procedures almost doubled yearly until 2011. Sacrocolpopexy was more common in younger patients (49% in women <70 years) and in white women (88%); the majority of sacrocolpopexies were performed in the South (60%) and laparoscopically (83%-98%).

CONCLUSION

The treatment of POP has changed over time. The use of mesh increased significantly until 2008, after which it plateaued following the Food and Drug Administration warning regarding mesh-related complications. Concurrently, the number of sacrocolpopexy procedures increased significantly starting in 2008 as the use of laparoscopic and/or robotic technique and concern regarding transvaginal mesh increased.

An up-to-date overview of minimally invasive treatment methods in ureteropelvic junction obstruction

Introduction

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction have been developed and are bcoming more popular. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, for both the transperitoneal and retroperitoneal approaches. In this review, we aimed to analyze the current status of minimally invasive therapy of ureteropelvic junction obstruction.

Material and methods

A PubMed database search was conducted to examine minimally invasive treatments of ureteropelvic junction obstruction.

Results

A large number of cases have been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric populations. A clear advantage, in terms of hospital stay, of minimally invasive over open pyeloplasty was observed only in the adult population.

Conclusions

Studies have shown that minimally invasive pyeloplasty techniques are a safe, effective, and feasible in adult and pediatric populations.

The centralization of robotic surgery in high-volume centers for endometrial cancer patients--a study of 6560 cases in the U.S

OBJECTIVE

To evaluate the hospital and patient factors associated with robotic surgery for endometrial cancer in the United States.

METHODS

Data was obtained from the Nationwide Inpatient Sample from the year 2010. Chi-squared and multivariate analyses were used for statistical analysis.

RESULTS

Of the 6560 endometrial cancer patients who underwent surgery, the median age was 62 (range: 22 to 99). 1647 (25%) underwent robotic surgery, 820 (13%) laparoscopic, and 4093 (62%) had open surgery. The majority was White (65%). Hospitals with 76 or more hysterectomy cases for endometrial cancer patients per year (4% of hospitals in the study) performed 31% of all hysterectomies and 40% of all robotic hysterectomies (p<0.01). 29% of Whites had robotic surgery compared to 15% of Hispanics, 12% of Blacks, and 11% of Asians (p<0.01). Patients with upper-middle and high incomes underwent robotic surgery more than patients with low or middle incomes (p<0.01). 27% of Medicare patients and 26% of patients with private insurance had robotic surgery compared to only 14% of Medicaid patients and 12% of uninsured patients (p<0.01).

CONCLUSIONS

The majority of robotic surgeries for endometrial cancer were performed at a small number of high-volume hospitals in the United States. Socioeconomic status, insurance type, and race were also important predictors for the use of RS. Further studies are warranted to better understand the barriers to receiving minimally invasive surgery.

Robotic-assisted laparoscopic approaches to the ureter: Pyeloplasty and ureteral reimplantation

INTRODUCTION AND OBJECTIVES

The benefits of robotic surgery when compared to standard laparoscopy have been well established, especially when it comes to reconstructive procedures. The application of robotic technology to laparoscopic pyeloplasty has reduced the steep learning curve associated with the procedure. Consequently, this has allowed surgeons who are less experienced with laparoscopy to offer this treatment to their patients, instead of referring them to centers of excellence. Robotic pyeloplasty has also proved useful for repairing secondary UPJO, a procedure which is considered extremely difficult using a conventional laparoscopic approach. Finally, the pursuit of scarless surgery has seen the development of laparoendoscopic single site (LESS) procedures. The application of robotics to LESS (R-LESS) has also reduced the difficulty in performing conventional LESS pyeloplasty. Herein we present a literature review with regards to robotic-assisted laparoscopic pyeloplasty. We also discuss the benefits of robotic surgery with regards to reconstruction of the lower urinary tract.

MATERIALS AND METHODS

A systematic literature review was performed using PubMed to identify relevant studies. There were no time restrictions applied to the search, but only studies in English were included. We utilized the following search terms: Ureteropelvic junction obstruction and laparoscopy; laparoscopic pyeloplasty; robotic pyeloplasty; robotic ureteric reimplantation; robotic ureteroneocystostomy; robotic boari flap; robotic psoas hitch.

RESULTS

There has been considerable experience in the literature with robotic pyeloplasty. Unfortunately, no prospective randomized studies have been conducted, however there are a number of meta analyses and systematic reviews. While there are no clear benefits when it comes to surgical and functional outcomes when compared to standard laparoscopic pyeloplasty, it is clear that robotics makes the operation easier to perform. There is also a benefit to the robotic approach when performing a redo-pyeloplasty. Robotic pyeloplasty has also been applied to the pediatric population, and there may be a benefit in older children while in very young patients, retroperitoneal open pyeloplasty is still the gold standard. In the field of single incision surgery R-LESS is technically easier to perform than conventional LESS. However, the design of the current robotic platform is not completely suited for this application, limiting its utility and often requiring a larger incision. Optimized R-LESS specific technology is awaited. What is clear, from a number of analyses, is that robotic pyeloplasty is considerably more expensive than the laparoscopic approach, largely due to costs of instrumentation and the capital expense of the robot. Until cheaper robotic technology is available, this technique will continue to be expensive, and a cost-benefit analysis must be undertaken by each hospital planning to undertake this surgery. Finally, the benefits of upper tract reconstruction apply equally to the lower tract although there is considerably less experience. However, there have been a number of studies demonstrating the technical feasibility of ureteral reimplantation.

CONCLUSIONS

Robotic-assisted laparoscopic pyeloplasty is gaining popularity, likely due to the shorter learning curve, greater surgeon comfort, and easier intracorporeal suturing. This has allowed more surgeons to perform the procedure, improving accessibility. Robotic technology is also beneficial in the field of LESS. Nevertheless, the procedure still is not as cost-effective as the conventional laparoscopic approach, and until more affordable robotic technology is available, it will not be universally offered.

Robotic-assisted laparoscopic surgery: recent advances in urology

The aim of the present review is to summarize recent developments in the field of urologic robotic surgery. A nonsystematic literature review was performed to retrieve publications related to robotic surgery in urology and evidence-based critical analysis was conducted by focusing on the literature of the past 5 years. The use of the da Vinci Surgical System, a robotic surgical system, has been implemented for the entire spectrum of extirpative and reconstructive laparoscopic kidney procedures. The robotic approach can be applied for a range of adrenal indications as well as for ureteral diseases, including benign and malignant conditions affecting the proximal, mid, and distal ureter. Current evidence suggests that robotic prostatectomy is associated with less blood loss compared with the open surgery. Besides prostate cancer, robotics has been used for simple prostatectomy in patients with symptomatic benign prostatic hyperplasia. Recent studies suggest that minimally invasive radical cystectomy provides encouraging oncologic outcomes mirroring those reported for open surgery. In recent years, the evolution of robotic surgery has enabled urologic surgeons to perform urinary diversions intracorporeally. Robotic vasectomy reversal and several other robotic andrological applications are being explored. In summary, robotic-assisted surgery is an emerging and safe technology for most urologic operations. The acceptance of robotic prostatectomy during the past decade has paved the way for urologists to explore the entire spectrum of extirpative and reconstructive urologic procedures. Cost remains a significant issue that could be solved by wider dissemination of the technology.

National trends in the utilization of robotic-assisted radical cystectomy: an analysis using the Nationwide Inpatient Sample

OBJECTIVES

To determine temporal and regional trends in utilization of robotic-assisted radical cystectomy (RARC) in the United States and to explore factors associated with utilization of robotic assistance.

MATERIALS AND METHODS

Using 2009 to 2011 data from the Nationwide Inpatient Sample, we identified radical cystectomy cases that were performed using either open or robotic assistance and applied Nationwide Inpatient Sample discharge weights to determine national incidence. Univariable and multivariable logistic regressions were performed to assess regional trends and characteristics associated with having RARC. Descriptive analysis was performed using the chi-square test, the Student t test, and the Mann-Whitney U test.

RESULTS

Of the 29,719 radical cystectomy patients, 3,733 were RARC (12.6%). Although there was no change in the proportion of RARC performed annually (P = 0.702). Length of stay was 1 day longer for open cystectomy than RARC (P<0.001). On multivariate regression, patients whose primary payer was Medicaid were less likely than private insurance patients to undergo RARC (odds ratio = 0.60, P = 0.074). Additionally, patients in the south were at 50% reduced odds of undergoing RARC (odds ratio = 0.49, P = 0.044). Median hospital costs were $5,000 greater for RARC (P<0.001).

CONCLUSIONS

Regional variation in utilization should be monitored to ensure equal access to new technology and to assess potential overuse of new technology. Although RARC is associated with higher median hospital costs, further studies to assess its benefits are warranted.

Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?

PURPOSE

While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit.

MATERIALS AND METHODS

From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges.

RESULTS

We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001).

CONCLUSIONS

Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy.

Management of secondary pelviureteric junction obstruction

Pelviureteric junction obstruction (PUJO) of the kidney can lead to a number of different clinical manifestations, which often require surgical intervention. Although the success of pyeloplasty and endopyelotomy are good, there are still a number of patients who fail primary treatment and develop secondary PUJO. These treatment failures can be a challenging cohort to manage. This article aims to provide a comprehensive overview on the surgical options available to the urologist for managing secondary PUJO as well as providing some guidance on assessing factors that will influence management decisions.

Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis

CONTEXT

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized.

OBJECTIVE

To critically analyze the current status of laparoscopic and robotic repair of UPJO.

EVIDENCE ACQUISITION

A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria.

EVIDENCE SYNTHESIS

Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population.

CONCLUSIONS

Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.