Laparoscopic Pyeloplasty Compared with Open Pyeloplasty in Children

A Pilot Study to Determine the Role of Spatulating the Ureter During Pyeloplasty in Children for Ureteropelvic Junction Obstruction in the Robotic Era

Purpose: Spatulation during ureteropelvic junction obstruction repair was evaluated in children treated by robot-assisted retroperitoneal pyeloplasty anastomosis (RRPA). Methods: Intraoperative video recordings (IVRs) of RRPA (n = 22 ureters) performed at a single institute between 2018 and 2022 were reviewed blindly by 5 independent surgeons for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and spatulation ranking as superior (+1), inferior (-1), or unnecessary (0). The retroperitoneal space was accessed in the lateral decubitus position using a closed technique under direct vision to avoid air leakage and subcutaneous emphysema. All subjects had a Double-J stent (4.7F) placed. Results: Subjects had similar demographics and preoperative ureter diameters. IVRs were RRPA with spatulation of the ureter on the lateral side (RRPA +SP) (n = 13) and RRPA without spatulation of the ureter (RRPA -SP) (n = 9). Overall DOS scores and coefficients of variation for time taken to place one suture were similar. Total anastomotic time was significantly shorter for RRPA -SP; 67.9 ± 8.4 minutes versus 57.9 ± 9.2 minutes, P = .01. Overall spatulation ranking was 0. Postoperative scanning showed improved drainage in 12 of 13 (92%) in RRPA +SP and 8 of 9 (88%) in RRPA -SP; differences were not significant. One anastomotic stricture in RRPA -SP required open repair. Conclusions: RRPA was quicker and more precise without spatulation. Outcomes of scanning 1 year after RRPA were similar for RRPA -SP and RRPA +SP.

Comparative study between ureter first approach and conventional open Anderson-Hynes pyeloplasty in paediatric patients: A prospective randomised study

BACKGROUND

Uretero-pelvic junction obstruction is the most common form of congenital anomaly of the kidney and urinary tract with an incidence of about 1/1.000-1.500 of births and the aetiology and pathogenesis of this anomaly are still unclear until now.

METHODS

This is a prospective randomized comparative study conducted from March 2022 to December 2022. Thirty children with uretero-pelvic junction obstruction were included and randomly divided into two groups according to a 1:1 ratio (computer-generated randomization, single blind). Fifteen cases (12 males and 3 female) were subjected to ureter first approach pyeloplasty, and another fifteen (9 males and 6 female) were subjected to conventional Anderson Hynes pyeloplasty.

RESULTS

The mean age of all patients was 6.7 ± 5.4 years in ureter first approach group and 5.1 ± 4.3 years in conventional Anderson-Hynes pyeloplasty group. There were no significant differences between the two groups regarding age, gender, presentation, side, preoperative renogram and post-operative renogram. Also, there were no significant differences between the two groups regarding operative time (in first group 110.3 ± 12.4 and in the second group 111.2 ± 12.0 with p < 0.836), pre and post-operative complication rate. Two cases of urinary tract infections in the first group, one of them having fever, and four cases in the second group, two of them having fever (p < 0.651); four cases of loin pain in the first group and one case in the second group (p < 0.330); one case in the first group having pro- longed leakage of urine for 7 days in post-operative period (p < 0.309). However GFR and t 1⁄2 improved significantly after operation in both groups (p < 0.001).

CONCLUSIONS

Ureter first approach is a simple and effective procedure in children with good short term outcomes and could be done safely especially for beginners and less expert surgeons. Finally, it can overcome the problem of long ureteric stricture that may be found intraoperatively because you can shift easily to a flap procedure and complete a tension free anastomosis.

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.

Effectiveness of a Laparoscopic Training Model for Pediatric Surgeons During COVID-19 Pandemic: A Single-Center Experience

Background: During COVID-19 pandemic, many restrictions were applied in the field of health care. For this reason, we decided to adopt the laparoscopic simulator Laparo^® Analytic to allow the trainees of our pediatric surgery training program to continue their training activity, and we determined its impact on their surgical education. Methods: We used Laparo Analytic Simulator for laparoscopic surgery training among the residents of our center. Fifteen residents from different years of the pediatric surgery program participated in this study. Each participant performed a 2-hour training session per week, consisting of three different exercises: Rubber Bands, Knotting, and Suturing. For each training session, the following parameters were analyzed: training time, economy of movement, smoothness, instrument activity (IA), instrument visibility (IV), and instrument symmetry. Results: Results were collected after the first training session (T₀), at 3 months after the beginning of the study (T₁) and at 6 months after the beginning of the study (T₂). At T₂ of training with Laparo Analytic Simulator, residents were able to complete their tasks significantly faster (P = .001) and had a significant improvement in smoothness of movements, IA, IV, and instrument symmetric movements during the tasks analyzed. Conclusion: On the basis of our results, we believe that Laparo analytic is an excellent system to adopt in minimally invasive surgery (MIS) training programs, in particular, during periods of surgical restrictions, as COVID-19 pandemic, or in centers with a limited MIS activity.

Comparison of laparoscopic pyeloplasty vs. robot-assisted pyeloplasty for the management of ureteropelvic junction obstruction in children

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is a commonly observed abnormality in pediatric urology. Minimally invasive approaches have gained popularity in recent years. Studies have demonstrated excellent results with both laparoscopic pyeloplasty (LAP) and robot-assisted pyeloplasty (RAP). Few studies have compared the experience of both procedures performed in a single institution. Our objective is to compare laparoscopic pyeloplasty and robot-assisted pyeloplasty in the Puerto Rican pediatric population.

METHODS

We conducted a retrospective cohort study using our clinic's database on patients with UPJO that were operated by the same surgeon (MPB) from 2008 to 2019. Statistical analysis was conducted of demographics, preoperative studies, perioperative data and complications of both procedures. This study was approved by our local IRB committee.

RESULTS

A total of 86 patients that underwent pyeloplasty with at least 3 years of follow up were recorded for this study. Laparoscopic pyeloplasty and robot-assisted pyeloplasty were performed in 44 (51.1%) and 42 (48.8%) patients, respectively. Patient age ranged between 4 months and 17 years (LAP group - mean age of 6.19 years/RAP group - mean age of 7.07 years). Success rates was high in this series (LAP - 100% and RAP -95%). Using Wilcoxon signed rank test and Mann whitney sum test, significant differences between preoperative and postoperative hydronephrosis grading were observed in both LAP and RAP groups. However, no significant difference was seen regarding reduction of hydronephrosis grading when comparing both groups. No intraoperative complications were seen on either group.

CONCLUSION

Both LAP and RAP are safe and effective procedures that can properly manage UPJO. Our study shows that, under experienced hands, pure laparoscopic pyeloplasty achieves comparable results to robotic assisted laparoscopic pyeloplasty. Pediatric urologists should be comfortable offering either of these approaches as they demonstrate high success rates in our pediatric population. Selection of LAP vs. RAP approach depends on the Surgeon's preference or experience, and on institutional availability. Minimally invasive therapies will continue to gain popularity with future advances in laparoscopic and robotic technology.

Evaluation of transverse dorsal lumbotomy in management of PUJ obstruction in patients younger than 6 months

OBJECTIVE

The transverse dorsal lumbotomy approach provides excellent exposure to the PUJ and causes minimal tissue damage. In this study, we assess the efficacy of dorsal lumbotomy in PUJ obstruction in children younger than 6 months.

METHODS

All children less than 6 months who were managed with the dorsal lumbotomy approach between 2009 and 2017 were reviewed prospectively. Data included: demographic data, pre/post-operative renal ultrasound scan with SFU grading and RDS, operative time, post-operative complications, and follow up results.

RESULTS

A total of 42 children with a mean age of 4.4 ± 1 months were included. On pre-operative RDS, all patients had an obstructive pattern and a SRF of 30.3 ± 9.3. The mean operative duration was 49 min and analgesia was minimal. Post-operative ultrasound at 6 months showed an improvement in hydronephrosis (p < 0.05) and a mean SRF of 39.3 ± 6.1 (p < 0.001).

CONCLUSION

Transverse dorsal lumbotomy approach is a safe and efficient alternative in patients less than 6 month.

Laparoscopic versus open pyeloplasty in children: experience of 226 cases at one centre

INTRODUCTION

The aim of the study was to compare the efficacy of laparoscopic versus open dismembered pyeloplasty in children.

MATERIAL AND METHODS

Two hundred and twenty-six Anderson-Hynes pyeloplasties were performed, out of which 131 by open access (OP) and 95 by laparoscopic access (LP). Retrospective analysis of data was performed. The median follow-up was 3 years for LP patients and 6 years for OP patients (p < 0.05).

RESULTS

Success was achieved in 87 (91.57%) patients who had LP surgeries and in 121 (91.7%) patients who had OP (p > 0.05). Eight patients in the LP group and nine in the OP group required another surgery because of recurrent UPJO, and one patient in the OP group required a nephrectomy. The median operating time was 125 min (range: 70-225) for LP surgeries and 90 (40-200) for OP surgeries (p < 0.05). In the last 30 LP procedures, operation time decreased to a median of 95 min. Improvement in ultrasound analysis of the kidney was achieved in 89.06% of patients who had LP and 82.35% of patients who had OP. A stable or better function of the kidney in diuretic renography was achieved in 87.5% of patients in the LP group and 96.15% of patients in the OP group.

CONCLUSIONS

Laparoscopic and open pyeloplasty is a highly efficient procedure employed to treat UPJO in children with comparable success rates in both groups. In experienced hands, it is possible to reduce the LP operation time to that comparable to the OP group.

Robot-assisted vs laparoscopic pyeloplasty in children with uretero-pelvic junction obstruction (UPJO): technical considerations and results

BACKGROUND

Although both laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) have reported excellent clinical outcomes, no evidence is currently available about the best surgical approach for surgical treatment of children with uretero-pelvic junction obstruction (UPJO).

OBJECTIVE

This study aimed to compare the outcomes of LP and RALP in children with UPJO.

STUDY DESIGN

The medical records of all patients with UPJO, who underwent LP or RALP in three pediatric urology units over a 2-year period, were retrospectively reviewed. The authors excluded open pyeloplasty and cases with complex anatomy such as horseshoe kidney. A dismembered Anderson-Hynes pyeloplasty was performed in all cases.

RESULTS

Sixty-seven patients (39 boys and 28 girls) with a median age of 4 years (range 8 months-14 years) were included. Thirty-seven patients (55.2%) underwent RALP, and 30 patients (44.8%) underwent LP. Three patients of RALP group presented a recurrent UPJO. No significant difference was found in the median total operative time between RALP (133 min) and LP (139 min) (P = 0.33). The median anastomotic time was significantly shorter in RALP (79 min) compared with LP (105.5 min) (P = 0.001). Overall surgical success rate was 96.7% for LP and 100% for RALP (P = 0.78). As for postoperative complications, the authors recorded re-stenosis of UPJO in one LP patient (3.3%), who underwent redo-RALP.

DISCUSSION

According to the authors experience, robotic surgery should be indicated in patients older than 18-24 months with a body weight > 10-15 Kgs. Laparoscopic pyeloplasty requires advanced laparoscopic skills related to intracorporeal suturing. However, the learning curve of suturing in robotics is much shorter compared with laparoscopy. In fact, during LP, the authors have to place 2-3 transabdominal stay sutures to stabilize the uretero-pelvic junction, before performing the anastomosis. Conversely, the authors never needed to place stay sutures in RALP.

CONCLUSIONS

The study experience suggested that RALP and LP give excellent results in children with UPJO. Laparoscopic pyeloplasty can be considered more minimally invasive than RALP because 3-mm trocars are adopted instead of 8-mm robotic ports. However, LP is technically challenging and has a bad ergonomics for the surgeon. Conversely, RALP is technically easier compared with LP, especially in redo procedures, with an excellent ergonomics. The main disadvantages of RALP remain high costs and size of robotic instruments. The choice to perform LP or RALP should be tailored to the individual case, considering patient's age and surgeon's experience.

Laparoscopy versus robotic-assisted pyeloplasty in children: preliminary results of a pilot prospective randomized controlled trial

PURPOSE

The aim of this randomized controlled trial (RCT) is to compare the outcomes of conventional laparoscopic pyeloplasty (LP) versus robotic-assisted laparoscopic pyeloplasty (RALP) in the treatment of ureteropelvic junction obstruction (UPJO) in children.

METHODS

A total of 53 patients with UPJO were randomized as LP (Group 1, n: 27) and RALP (Group 2, n: 26). Redo cases and patients with anatomical abnormalities were excluded. Urinary ultrasound was performed at postoperative 3, 6 and 12 months; whereas, diuretic renal scintigraphy was performed at 1 year. Failure was defined as progressive hydronephrosis on ultrasound, decline in renal function, or symptom relapse. All parameters were statistically compared.

RESULTS

The mean age of the patients was 55.53 ± 57.25 months. There were no statistical differences between the groups in terms of patient gender, body mass index, laterality, preoperative renal function, renal pelvis antero-posterior diameter and presence of crossing vessel. Mean total operative time in LP group was longer than RALP (139 min vs 105 min, respectively, p = 0.001). The hospital stay was similar between the two groups. After a mean follow-up of 12.43 ± 5.34 months, the complication and success rates were found comparable. Only two patients required re-do pyeloplasty in LP group. The mean total cost of RALP procedure was approximately four times higher than LP.

CONCLUSIONS

This is the first RCT comparing LP and RALP in pediatric population. Both LP and RALP are safe and effective in children with comparable success and complication rates. Operative time was longer for LP; whereas, total cost was higher for RALP.

Comparison of 30-day postoperative outcomes of open and minimally invasive pyeloplasty utilizing the prospective National Surgical Quality Improvement Program-Pediatric database

INTRODUCTION

Open pyeloplasty (OP) has traditionally been the standard for the operative management of ureteropelvic junction obstruction in children. With advances in minimally invasive pyeloplasty (MIP) techniques, it is quickly becoming a popular alternative in both adult and pediatric population.

OBJECTIVE

To evaluate the differences in outcomes between MIP and OP for the surgical correction of ureteropelvic junction obstruction in children.

STUDY DESIGN

Data were obtained from the pediatric National Surgical Quality Improvement Program 2012-2017. We identified 1280 patients who underwent MIP and 1190 patients who underwent OP between 2012 and 2017. Propensity score matching was utilized to adjust for baseline differences. Univariate and multivariable regression were performed to assess odds of complications and procedure-related readmission.

RESULTS

Patients who underwent OP had a significantly decreased operative time (192.42 vs 142.00 min, p < 0.001) compared to MIP. There was no significant difference in the rates of overall peri-operative complications (3.7% [MIP] vs 2.4% [OP] p = 0.397). On multivariable analysis, patients undergoing OP had a lower risk of procedure-related readmission (odds ratio [OR] 0.404, 95% confidence interval [CI] 0.157-0.951, p = 0.046) than MIP. In a multivariable linear regression model, the risk of having any postoperative complication, regardless of surgical approach, decreased with increasing patient age (OR 0.945, 95% CI 0.893-0.996, p = 0.037).

DISCUSSION

Although recent small, retrospective institutional studies have found decreased hospitalization time of MIP as compared to OP, in our large prospective database, we found no such association. While some studies suggest a higher rate of wound complications in the OP group, this was not reproduced in our study as well. MIP was, in fact, associated with higher rate of readmissions as compared to the OP group, which may act as a surrogate of long-term complications in these patients.

CONCLUSION

MIP offers an alternative to OP in the pediatric population with similar rates of peri-operative complications. However, our study shows decreased odds of procedure-related readmission in OP, which may serve as a surrogate for less postoperative complications in these patients.

From Laparoscopic Pyeloplasty to Robot-Assisted Laparoscopic Pyeloplasty in Primary and Reoperative Repairs for Ureteropelvic Junction Obstruction in Children

PURPOSE

Robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) are both minimally invasive surgical options to correct ureteropelvic junction obstruction in children. There are limited data reporting surgeons' experience of switching from LP to RALP and comparing the outcomes of the two procedures.

METHODS

We conducted a retrospective study on 63 consecutive children who underwent either LP or RALP by the same surgeon in a tertiary center from January 2008 to November 2016. LP had been the standard practice until January 2014 when it was replaced by RALP in short transition.

RESULTS

Thirty-seven LP and 26 RALP were successfully performed in children aged 2 months to 16 years. There was no difference between the two groups in age, body weight, laterality, clinical presentations, preoperative imagings, primary/reoperative repairs. The overall success rates were 34/37 (91.9%) and 25/26 (96.2%) for LP and RALP, respectively (P > .05). RALP was associated with shorter length of stay (3.1 days versus 4.0 days; P = .03). Surgeon-in-training participation was greater in RALP group (P < .001). There was no difference in operative time, complication rates, and analgesic requirement between the two groups.

CONCLUSIONS

Surgeons proficient in LP can adapt quickly to RALP, achieving comparable outcomes. Robotic technology may facilitate training on minimally invasive pyeloplasty.

Comparative, Prospective, Case-Control Study of Open versus Laparoscopic Pyeloplasty in Children with Ureteropelvic Junction Obstruction: Long-term Results

INTRODUCTION

We compare open pyeloplasty (OP) versus laparoscopic pyeloplasty (LP) in children in a multicenter, prospective, case-control study.

MATERIALS AND METHODS

From May 2007 to March 2009, a program was established at Hospital Garrahan, the reference center, to perform LP with a mentoring surgeon that would attend the institution once a month. Every new case of ureteropelvic junction obstruction (UPJO) diagnosed in the reference institution was offered to participate in the study. If the patient was enrolled, it was scheduled for LP. The following patient diagnosed with UPJO was operated on with open technique and served as a case-control. In three other facilities, patients were only offered LP and had a matched control open case at the reference institution. The first end point of the study was patient recovery: analgesia requirement and length of hospitalization (LOH). The second end point of the study was resolution of UPJO in long-term follow-up for the two techniques. Demographic data, surgical time, perioperative complications, analgesia requirement, analgesia score during hospitalization, LOH, and outcome were recorded. Both groups received the same postoperative indications for pain control. Parents were asked to assess pain in their children every 4 h postoperatively and to complete a pain scale chart to which the nurses were blinded.

RESULTS

Fifteen OP and 15 LP were compared. Groups were similar with regard to sex, age, weight, and laterality. Mean surgical time was longer in LP than in OP group (mean 188 versus 65 min) (p < 0.01). Hospitalization was shorter for LP group with a mean of 1.9 versus 2.5 days for OP group (p < 0.05). Postoperative analgesia requirement was significantly higher in the OP group with a mean use of morphine of 1.7 versus 0.06 mg/kg in the LP group (p < 0.05). Pain scores were similar in both the groups. At a mean follow-up of 58 months there were no failures.

CONCLUSION

In this prospective comparative cohort, LP was a longer procedure than OP. Both procedures had the same efficacy and complication rates, but patients undergoing LP needed fewer narcotics for pain control and had a shorter hospitalization.

Pyeloplasty techniques using minimally invasive surgery (MIS) in pediatric patients

Hydronephrosis is the most common presentation of ureteropelvic junction (UPJ) obstruction. We reviewed literature, collecting data from Medline, to evaluate the current status of minimally invasive surgery (MIS) approach to pyeloplasty. Since the first pyeloplasty was described in 1939, several techniques has been applied to correct UPJ obstruction, but Anderson-Hynes dismembered pyeloplasty is established as the gold standard, to date also in MIS technique. According to literature several studies underline the safety and effectiveness of this approach for both trans- and retro-peritoneal routes, with a success rate between 81-100% and an operative time between 90-228 min. These studies have demonstrated the safety and efficacy of this procedure in the management of UPJ obstruction in children. Whether better the transperitoneal, than the retroperitoneal approach is still debated. A long learning curve is needed especially in suturing and knotting.

Umbilical only access laparoscopic pyeloplasty in children: Preliminary report

BACKGROUND

Over the past three decades, laparoscopic surgery has become a well-established alternative to open surgery in the management of ureteropelvic junction (UPJ) obstruction. Currently, several efforts are being made, aimed at further reducing the morbidity associated with conventional laparoscopy. We report our experience with modified umbilical port laparoscopic pyeloplasty in children.

MATERIALS AND METHODS

Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. A 5 mm endoscopic port was placed on the inferior umbilical crease. The two 3 mm instruments were introduced through puncture sites created a few mm superior and lateral to the endoscopic port, under vision. Total operating time, the time taken for insertion of double pigtail catheter, time taken for pyeloplasty anastomosis and complications were noted.

RESULTS

During the study period, 16 children underwent modified umbilical only access laparoscopic pyeloplasty. The total operating time and the time for insertion of double pigtail catheter were significantly more in our earlier half of cases.

CONCLUSIONS

Modified umbilical port laparoscopic pyeloplasty reduces the morbidity associated with conventional multiport laparoscopy without the need of expensive multichannel cannulas, curved laparoscopic instruments and longer laparoscopic endoscopes. Though crossing instruments are a factor which prolongs the duration of surgery, it does not hinder complex suturing needed during pyeloplasty.

Laparoscopic pyeloplasty in infants: single-surgeon experience

INTRODUCTION

Although laparoscopic pyeloplasty (LP) is popular in children, its role in infants is less well defined. It is presumed that infant LP is technically challenging, with a higher failure rate.

OBJECTIVE

To consider the hypothesis that LP can be safely and successfully performed in infants.

METHODS

The records of 111 infants that underwent LP from March 2009 to December 2013 with at least 1 year of follow-up, were retrospectively reviewed. The results of pre- and postoperative imaging studies (ultrasound (US) and diuretic renogram (DR)), operative details and complications were noted. Pre- and postoperative parameters were compared using statistical software.

RESULTS

The details are given in the Table. Laparoscopic pyleoplasty was successfully completed using three ports in all children without any open conversions. There were complications in 14 children (12%); 13 did not require a second intervention and the final outcome was not affected. One child (1%) had a re-obstruction with worsening hydronephrosis (HDN) 2 months after stent removal; she underwent successful redo LP. Median follow-up was 2 years; LP was successful in relieving the obstruction in 115 kidneys (99%); all had follow-up US, while 76 children had follow-up DR. The tests showed significant reduction in HDN (mean pre-operative anteroposterior diameter (APD) of renal pelvis, 34.4 mm (SD 13.4) versus mean post-operative APD 10.6 mm (SD 5.7), p < 0.001) and improved drainage in all kidneys. In unilateral cases, there was significant improvement in mean split renal function (SRF) of the operated kidneys (pre-operative 22.1% (SD 8.6) versus post-operative 35.6% (SD 11.4), p < 0.001).

DISCUSSION

Over the past 6 years, all pyeloplasties at our unit have been performed by laparoscopy, irrespective of the age or weight of the child. In this large retrospective series, it is demonstrated that infant LP is a safe and successful operation; pyeloplasty in this age group not only resulted in significant reduction of hydronephrosis, but also in significant functional improvement. The results are comparable to published series comparing open pyeloplasty to laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70 to 96%, and complication rates ranging from 0 to 24% for open pyeloplasty.

The robotic-assisted laparoscopic pyeloplasty: gateway to advanced reconstruction

Robotic pyeloplasty is now commonly performed for children with ureteropelvic junction obstruction. Because surgical robotics is a tool that facilitates pyeloplasty and other reconstructive urologic operations, the indications for robotic-assisted laparoscopic pyeloplasty are the same as those for an open pyeloplasty but offer distinct advantages with respect to visualization, range of motion, and ease of laparoscopic suturing. In this review, the authors discuss the operative approach for robotic pyeloplasty in children and the extensions of the basic techniques to challenging clinical scenarios.

Preliminary experience with laparoscopic Foley's YV plasty for ureteropelvic junction obstruction in children

INTRODUCTION:

Laparoscopic dismembered pyeloplasty is an acceptable option for ureteropelvic junction (UPJ) obstruction in the paediatric population. We compared our results of laparoscopic dismembered and non-dismembered Foley's YV pyeloplasty.

MATERIALS AND METHODS:

Children presenting with hydronephrosis secondary to UPJ obstruction formed the study group. Foley's YV plasty was planned whenever it was observed that a tension free dismembered pyeloplasty was not possible in spite of all possible manoeuvres. Children were followed up for urinary infection, and renogram was repeated after 3 months.

RESULTS:

During the study period, 108 children (63 male and 45 female) with a mean age of 4.94 ± 2.78 years underwent laparoscopic dismembered pyeloplasty and the remaining 11 children (5 male and 6 female) with a mean age of 4.00 ± 1.776 years underwent laparoscopic Foley's YV plasty. There were no major peri-operative complications noted and conversion to open was not necessary in any child. Renogram done at 3 months post-operatively showed good drainage and improvement of renal function.

CONCLUSIONS:

Laparoscopic Foley's YV pyeloplasty is a safe and effective technique in appropriately selected cases of primary UPJ obstruction in children.

Double J or transrenal transanastomotic stent in laparoscopic pyeloplasty in infants and children: a comparative study and our technique

PURPOSE

We compared our experience with intra- and extracorporeal stenting in laparoscopic transabdominal pyeloplasty in children and adolescents. As the placement of transanastomotic stents during laparoscopy can be difficult, we developed a technique for laparoscopic transrenal stent placement.

SUBJECTS AND METHODS

Eighty-six consecutive patients who underwent laparoscopic transabdominal pyeloplasty in our institution from December 2003 to November 2012 were retrospectively analyzed. Initially we antegradely placed the double J catheter (n=48), whereas in later patients transrenal/transcutaneous stents were inserted (n=38), either via a cannula from the flank (n=33) or from the inside-out by transrenal puncture using a specially constructed spear (n=5). End points of the analysis were stent-related technical problems and complications and the need for reoperation.

RESULTS

Sixty-two boys and 24 girls with a mean age of 5.6 years (range, 78 days-17.3 years) and mean weight of 22.1 kg (range, 5.5-71 kg) underwent laparoscopic transabdominal pyeloplasty. The most common technical problem in the double J group was inability to place the double J catheter in 9 of the 48 patients. In combination with other complications such as dislocations, urinary tract infections, or catheter occlusions, this led to an overall complication rate of 35% in the group that underwent double J catheter insertion versus 13% in the group with transrenal stenting (P<.05). In the whole series, 4 patients required a redo pyeloplasty, all of them in the double J group.

CONCLUSIONS

We recommend transrenal stents to facilitate stent removal without general anesthesia and to minimize complications such as stent dislocation. The initial experience with our simple device for transrenal puncture and stent placement is promising.

The 'double hitch' manoeuvre in laparoscopic pyeloplasty - early experience

Intra-corporeal anastomosis in laparoscopic pyeloplasty is laborious, time consuming and challenging. 14 children underwent laparoscopic dismembered pyeloplasty using a three port, transperitoneal approach over a one year period in whom a novel approach ("double hitch" manoeuvre) (Group-2, n = 9) was used and operating times compared with the conventional "single hitch" (Group-1, n = 5). The mean operating time in Group 1 (172.4 min) and in Group 2 (129.5 min) was significantly different. Mean follow up in Group-1 and Group-2 was 14 and 6 months respectively. Utilisation of the "double hitch" manoeuvre in laparoscopic pyeloplasty reduces the operating time and probably makes it less laborious.

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.

Laparoscopic transperitoneal pyeloplasty in children from age of 3 years: our clinical outcomes compared with open surgery

OBJECTIVE

To report clinical outcomes for laparoscopic pyeloplasty (LP) in children compared with open pyeloplasty (OP) and literature findings.

PATIENTS AND METHODS

In a prospective study, the outcomes of 57 consecutive transperitoneal LP in children from the age of 3 years were analyzed and compared with a matched historic control group of OP and with series of LP in the literature. Successful result was defined as resolution of symptoms, no conversion or re-operation, improved hydronephrosis, and/or improved renographic drainage.

RESULTS

Mean operative time was 177 (SD 50.5)min in the LP group and 108 (SD 25.6)min in the OP group (p < 0.001). Mean hospital stay was 1.2 (SD 0.46) days in the LP and 6.7 (SD 1.2) days in the OP group. Improvement in renographic drainage was observed more often after LP than after OP (98% vs 83%; p = 0.010). A successful result was reported in 56 (98%) LP and 54 (95%) OP (p = 0.298) patients. Our LP series demonstrates a high success rate compared to literature data.

CONCLUSIONS

Our LP has a similar success rate and more often improved renographic drainage in comparison to OP. Furthermore, our LP demonstrates a shorter hospital stay and favorable outcomes compared to the literature. We thus regard LP as standard treatment for repair of ureteropelvic junction obstruction in children from the age of 3 years.

Transition from open to robotic-assisted pediatric pyeloplasty: a feasibility and outcome study

PURPOSE

Laparoscopic reconstructive procedures in the pediatric patient are associated with a steep learning curve. Outcomes from robotic-assisted pediatric urology have been reported by surgeons with known facility in laparoscopic surgery. We describe the experience of a single surgeon in transitioning from open to robotic-assisted laparoscopic pyeloplasty (RALP) without previous training in traditional laparoscopic pyeloplasty or intracorporeal suturing.

MATERIALS AND METHODS

We reviewed our experience with 20 (mean age 7.4 years) consecutive children undergoing RALP for ureteropelvic junction obstruction at our institution over 36 months. Additionally, a literature search was conducted to identify age-similar patient groups who underwent open and laparoscopic pyeloplasty.

RESULTS

Length of hospitalization and postoperative analgesia requirement were greater in the age-similar open pyeloplasty group compared to the other two groups. Intraoperative times were greater in the laparoscopic and RALP groups compared to the open pyeloplasty group.

CONCLUSIONS

Our experience confirms the feasibility of transitioning from open to robotic-assisted laparoscopic pediatric pyeloplasty without previous experience in conventional laparoscopy. Outcomes, analgesic requirement and hospitalization for the patients from our institution are comparable to the laparoscopy patient group and improved compared to open pyeloplasty patients from the literature.

Minimally invasive surgery in neonates and infants

Minimally invasive surgery (MIS) has significantly improved the field of surgery, with benefits including shorter operating time, improved recovery time, minimizing stress and pain due to smaller incisions, and even improving mortality. MIS procedures, including their indications, impact, limitations, and possible future evolution in neonates and infants, are discussed in this article.

Pediatric robotic surgery: early assessment

OBJECTIVES

This article reviews the evidence regarding the feasibility, safety, benefits, limitations, and costs of robotically assisted surgery in children, evaluates how the technology compares with other pediatric surgical techniques, and provides insights about the near and more-distant future of the technology.

METHODS

The peer-reviewed medical pediatric literature was searched for studies that provided evidence of the feasibility and safety of robotic surgery in children and for studies that compared pediatric robotic surgery with conventional laparoscopic surgery or open surgery.

RESULTS

A total of 8 case series and 5 studies comparing robotic surgery with open or conventional laparoscopic surgery met the selection criteria for review. A few small studies that focused on rare complex surgical procedures also were reviewed. All studies were designed to evaluate the feasibility and safety of robotic surgery in children. None of the studies was randomized, and some studies had a retrospective design. These studies demonstrated that a number of routine, robotically assisted, laparoscopic and thoracic procedures were feasible and safe when performed by surgeons experienced in the technique, although robotic surgery did not provide superior outcomes, compared with traditional laparoscopic and open surgery. The advantages of the robotic system were best seen in complex procedures that involved areas that were difficult to access and in procedures in which dissection of delicate, anatomic structures was required.

CONCLUSIONS

Robotic surgery is feasible and safe for a number of pediatric surgical procedures, but evidence that it offers better clinical outcomes than conventional open or laparoscopic techniques is lacking.

Complications of laparoscopic pyeloplasty in children

INTRODUCTION

Laparoscopic pyeloplasty in children has been proven to be safe and effective, with comparable results to open surgery. Due to the extension of laparoscopic indications from ablative to reconstructive procedures requiring endoscopic suturing, most centres have plateaued within their learning curve. Based on our own experience with a little more than 100 cases, we focus on the complications and the definitive learning curve of laparoscopic pyeloplasty in children.

MATERIALS AND METHODS

A total of 103 laparoscopic pyeloplasties were performed during the period January 2002 to June 2008. Of these, 102 underwent laparoscopic dismembered pyeloplasty and one underwent laparoscopic vascular hitch for crossing lower pole vessels. Intraoperative incidents/complications were analysed using the Satava classification, and the postoperative complications according to the Clavien classification.

RESULTS

Intraoperative incidents occurred in 2.91% of the cases, mostly without consequences for the child including faulty port placement needing placement of an extra port and umbilical port side bleed. Postoperative complications occurred in 11.65% children and included prolonged ileus, prolonged urinary leak, fever, haematuria and recurrent ureteropelvic junction (UPJ) stenosis. Recurrent UPJ stenosis occurred in 4.85% of children needing reoperation.

CONCLUSIONS

Laparoscopic pyeloplasty in children is not only feasible, but safe and effective. Intraoperative incidents occur in up to 3% of the cases, and complications in 12.9-15.8%. Increased experience, training and knowledge regarding the incidence and management of complications will be able to further reduce these in the future.