Mini-laparoscopic pyeloplasty to treat UPJO in infants

Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures

Surgical techniques are evolving in Pediatric Surgery, especially in the area of minimal access surgery (MAS) where indications for applications are expanding. Miniaturization of instruments, using natural orifices, single incisions, or remotely controlled robot-assisted procedures, promises to increase the benefits of MAS procedures in pediatrics. Many pediatric pathologies are rare, and specialized surgical and anesthesiologic instruments are necessary to manage them, defined as "orphan devices", for which development and dissemination on the market are slowed down or sometimes hindered by regulatory standards and limiting financial conflicts of interest. In pediatric surgery, it is of utmost importance to work in a multidisciplinary way to offer a surgical path that is safe and supported by technological advances. For this reason, optimizing pediatric anesthesia is also a crucial factor where technological advances have made monitoring more precise, thereby enhancing safety in the operative room. The development of customized instruments and technologies should be supported by pediatric research and should be adapted to the individualities of the small patient. This overview outlines the importance of dedicated instruments developed for the safe completion of MAS procedures in pediatrics.

Minimally invasive pyeloplasty versus open pyeloplasty for ureteropelvic junction obstruction in infants: a systematic review and meta-analysis

Background

To compare the perioperative outcomes and success rates of minimally invasive pyeloplasty (MIP), including laparoscopic and robotic-assisted laparoscopic pyeloplasty, with open pyeloplasty (OP) in infants.

Materials and Methods

In September 2022, a systematic search of PubMed, EMBASE, and the Cochrane Library databases was undertaken. The systematic review and meta-analysis were conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with the study registered prospectively in the PROSPERO database (CRD42022359475).

Results

Eleven studies were included. Dichotomous and continuous variables were presented as odds ratios (OR) and standard mean differences (SMD), respectively, with their 95% confidence intervals (CI). Compared to OP, a longer operation time and shorter length of stay were associated with MIP (SMD: 0.96,95% CI: 0.30 to 1.62, p = 0.004, and SMD: -1.12, 95% CI: -1.82 to -0.43, p = 0.002, respectively). No significant differences were found between the MIP and OP in terms of overall postoperative complications (OR:0.84, 95% CI: 0.52 to 1.35, p = 0.47), minor complications (OR: 0.76, 95% CI: 0.40 to 1.42, p = 0.39), or major complications (OR: 1.10, 95% CI: 0.49 to 2.50, p = 0.81). In addition, a lower stent placement rate was related to MIP (OR: 0.09, 95% CI: 0.02 to 0.47, p = 0.004). There was no statistical difference for success rate between the MIP and OP (OR: 1.35, 95% CI: 0.59 to 3.07, p = 0.47). Finally, the results of subgroup analysis were consistent with the above.

Conclusions

Our meta-analysis demonstrates that MIP is a feasible and safe alternative to OP for infants, presenting comparable perioperative outcomes and similar success rates, albeit requiring longer operation times. However, it is essential to consider the limitations of our study, including the inclusion of studies with small sample sizes and the combination of both prospective and retrospective research designs.

Laparoscopic aspirator bracket: a new instrument facilitating the aspiration and exposure of operative field simultaneously in laparoscopic nephron-sparing surgery

Background

This study aims to describe a novel laparoscopic aspirator bracket (LAB) and its use in laparoscopic nephron-sparing surgery (NSS) by a simple enucleation (SE) technique.

Methods

A total of 123 renal tumor cases who underwent laparoscopic NSS via LAB or laparoscopic aspirator between July 2017 and April 2021 were retrospectively analyzed. General characteristics, perioperative data and postoperative follow-up data of patients were compared.

Results

The application of LAB in laparoscopic renal tumor SE surgery shortened the operation time (88.58 ± 38.25 vs. 102.25 ± 35.84 min, p < 0.05) and improved the zero ischemia rate (18.75% vs. 3.39%, p < 0.05), shortened warm ischemia time (16.17 ± 5.16 vs. 19.39 ± 5.62 min, p < 0.05) and decreased intraoperative blood loss (166.19 ± 111.60 vs. 209.15 ± 127.10 ml, p < 0.05). In addition, the serum creatinine and eGFR values in the LAB group also showed faster and better renal function recovery.

Conclusion

The new LAB could aspirate and expose the operative field with a single instrument. In operations that need to expose and aspirate simultaneously, such as in renal tumor simple enucleation, it could shorten operation time, reduce intraoperative blood loss and improve the postoperative renal function recovery.

Pediatric Minimally Invasive Surgery-A Bibliometric Study on 30 Years of Research Activity

Background: Pediatric minimally invasive surgery (MIS) is a standard technique worldwide. We aimed to analyze the research activity in this field. Methods: Articles on pediatric MIS (1991−2020) were analyzed from the Web of Science™ for the total number of publications, citations, journals, and impact factors (IF). Of these, the 50 most cited publications were evaluated in detail and classified according to the level of evidence (i.e., study design) and topic (i.e., surgical procedure). Results: In total, 4464 publications and 53,111 citations from 684 journals on pediatric MIS were identified. The 50 most cited papers were published from 32 institutions in the USA/Canada (n = 28), Europe (n = 19), and Asia (n = 3) in 12 journals. Four authors (USA/Europe) contributed to 26% of the 50 most cited papers as first/senior author. Hot topics were laparoscopic pyeloplasty (n = 9), inguinal hernia repair (n = 7), appendectomy, and pyloromyotomy (n = 4 each). The majority of publications were retrospective studies (n = 33) and case reports (n = 6) (IF 5.2 ± 3.2; impact index 16.5 ± 6.4; citations 125 ± 39.4). They were cited as often as articles with high evidence levels (meta-analyses, n = 2; randomized controlled trials, n = 7; prospective studies, n = 2) (IF 12.9 ± 22.5; impact index 14.0 ± 6.5; citations 125 ± 34.7; p > 0.05). Conclusions: Publications on laparoscopic pyeloplasty, inguinal hernia repair, appendectomy, and pyloromyotomy are cited most often in pediatric MIS. However, the relevant number of studies with strong evidence for the advantages of MIS in pediatric surgery is missing.

Exploration the potential mechanism of the SIRT1 and its target gene FOXO1/PPARGC1A in uteropelvic junction obstruction

Background

Uteropelvic junction obstruction (UPJO) is a common surgical condition, which refers to the blockage of urine flowing through kidney into proximal upper ureter. However, the underlying mechanism of UPJO is poorly understood, especially the regulated and targeted genes of sirtuin 1 in UPJO.

Methods

We sequenced three renal tissues on the obstructed side of independent children with <20% differential renal function (DRF) and three samples with >40% DRF. Gene expression values were obtained and compared for differentially expressed genes (DEGs). Protein-protein interaction (PPI) analysis was conducted to identify the overlapping proteins of DEGs and Sirtuin 1 (SIRT1). The co-expression genes of overlapped genes were computed using Pearson correlation coefficient. The potential role of SIRT1 gene in UPJO was explored by resequencing 3 microarray data from RNA interference (RNAi) SIRT1 lines of renal tubular epithelial (NRK52E) cells in rat and three control datasets were sequenced again. The DEGs were obtained as parallel. GO/KEGG enrichment analysis and co-expression network were conducted to explore the underlying mechanism, particularly shared pathways or function in GO/KEGG enrichment analysis results.

Results

A total of 427 up-regulated genes and 1,099 down-regulated genes were identified among 3 mRNA-seq of renal tissue on the obstructed side of the independent children with <20% DRF and 3 samples with >40% DRF. According to prediction using the Search Tool for Retrieval of Interacting Genes/Proteins, 2 PPIs, FOXO1 and PPARGC1A, were identified among 2,524 DEGs, predicted as targets of SIRT1. Gene set enrichment analysis (GSEA) of their co-expression genes showed they may co-participate in biological activities including fatty acid degradation, regulation of signal transduction by p53 mediator. Moreover, GSEA results of DEGs was confirmed through RNAi SIRT1 lines of rat renal tubular epithelial (NRK52E) cells.

Conclusions

UPJO may cause abnormal phenotypic changes of renal tubular epithelial cells through SIRT1/FOXO1 mediated protein transport, establishment of protein localization, and intracellular transport. In addition, UPJO is involved in regulation of signal transduction, regulation of intracellular estrogen receptor signaling pathways, and nucleoprotein localization through SIRT1/PPARGC1A-mediated p53 mediators, causing abnormal phenotypic changes in renal tubular epithelial cells.

Comparison between mini-laparoscopy, conventional laparoscopy and open approach for ureteropelvic junction obstruction treatment in children

INTRODUCTION

The aim of the study was to compare 3 mm mini-laparoscopy (mini LP), standard 5 mm laparoscopy (LP) and open surgery for pediatric pyeloplasty in a single center.

METHODS

Patients who underwent pyeloplasty from 1997 to 2017 at Hospital Sant Joan de Déu were prospectively collected. Demographic data, clinical, surgical and radiological variables were assessed. A multivariate logistic regression analysis was performed in order to identify risks for surgical complications, urinary leak and need for redo-surgery.

RESULTS

340 pyeloplasties were performed in this period: 197 open, 30 LP and 113 mini LP. Independent risk factors for surgical complications in a multivariate logistic regression model were: LP (vs mini LP, OR = 3.95; 95% CI: 1.13-13.8), higher differential renal function (each point more increases the risk 6%; 95% CI: 1-11%), older children (every year increases the risk 1.11 times; 95% CI: 1.002-1.225). Open surgery, pelvis diameter or the use of different stents were not risk factors. This model had an 80% PPV and a 92% NPV. LP (OR = 4.65; 95% CI: 1.08-19.96) and longer surgical time (OR = 1.014; 95% CI: 1.003-1.025) were independent risk factors for urinary leak. Higher pelvis diameter (OR = 0.93; 95% CI: 0.87-0.99) and the use of external stents were independent protective risk factors for urinary leak (OR = 0.09; 95% CI: 0.01-0.72). We have not found independent risk factors for redo-surgery in a multivariate logistic regression model.

CONCLUSION

mini LP can be safely and effectively used to perform pyeloplasty in pediatric patients of all ages.