A comparative study of pediatric open pyeloplasty, laparoscopy-assisted extracorporeal pyeloplasty, and robot-assisted laparoscopic pyeloplasty

Analysis of risk factors for stenosis after laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction

BACKGROUND

Laparoscopic ureteroplasty is an effective method for managing ureteropelvic junction obstruction. Despite its high success rate, there remains a subset of patients who do not experience improvement in the hydrops.

METHODS

The study retrospectively analyzed the data of 143 patients with ureteropelvic junction obstruction (UPJO) who underwent laparoscopic pyeloplasty (LP) in our hospital from January 2015 to May 2022. Logistic regression was used to analyze the risk factors of recurrence stenosis after UPJO.

RESULTS

Out of these patients, 119 had complete clinical data and follow-up records. Among these patients, restenosis occurred in nine cases after the operation. There was a significant statistical difference in blood loss (P < 0.05). Univariate and multivariate logistic regression analysis revealed that the preoperative separation degree of the renal pelvis, cystatin C, and intraoperative blood loss were potential risk factors for recurrent stenosis after primary LP. When divided by split renal function (SRF), the odds ratio (OR) was 7.850 (P = 0.044), indicating that it was an independent risk factor for postoperative restenosis. Similarly, the OR for stenotic segment length was 0.025 (P = 0.011), also indicating it as an independent risk factor for restenosis. The areas under the receiver operating characteristic curve for stenotic segment length and SRF were 0.9056 and 0.7697, respectively.

CONCLUSION

In our study, we identified that preoperative renal pelvis separation, cystatin C, and intraoperative blood loss were potential risk factors for postoperative restenosis. SRF and stenosis segment length were independent risk factors for postoperative restenosis.

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.

Robot-assisted surgery versus laparoscopic surgery of ureteropelvic junction obstruction in children: a systematic review and meta-analysis

The clinical effectiveness and safety of robot-assisted laparoscopic pyeloplasty (RP) compared with laparoscopic pyeloplasty (LP) have not been clearly established in ureteropelvic junction obstruction (UPJO) children and require review. We searched in the Cochrane, MEDLINE, EMBASE, Web of Science, and CNKI database on 30 June 2022. This systematic review and meta-analysis were performed in RevMan 5.4 based on studies comparing RP versus LP in children with UPJO and subgroup analysis in children < 2 years of age has been performed. The Newcastle-Ottawa Scale was used to evaluate the studies. We included one RCT, and eighteen cohort studies, a total involving 3370 children. Compared with LP, RP showed higher surgical success rates (OR 2.57, 95%CI (1.24, 5.32), P < 0.05), lower postoperative complication rates (OR 0.61, 95%CI (0.38, 0.99), P < 0.05), shorter hospital stay (MD - 1.04, 95% CI (- 1.6, - 0.47), P < 0.05) as well as operative time (MD - 22.11, 95%CI (- 35.91, - 8.31), P < 0.05). No significant differences were detected for intraoperative complication rates or conversion to open surgery rates. RP is an alternative to UPJO with higher success rates, and less postoperative complications. Evidence on the effectiveness and safety of RP compared with LP for UPJO children is of low certainty. More quality evidence in the form of randomized controlled trials is needed to obtain more reliable analysis results.

The efficacy of robotic-assisted laparoscopic pyeloplasty for pediatric ureteropelvic junction obstruction: a systematic review and meta-analysis

To evaluate the safety and effectiveness of robotic-assisted laparoscopic pyeloplasty (RALP) for treating pediatric ureteropelvic junction obstruction through an extensive comparison of RALP, open pyeloplasty (OP) and laparoscopic pyeloplasty (LP). We conducted a comprehensive search of the following databases: PubMed, Excerpta Medica Database, Cochrane Library, Web of Science database, China National Knowledge Infrastructure, WanFang Data, and China Biology Medical Disc. Baseline data were compared, the sources of heterogeneity were assessed, and publication biases were detected. This study was registered with PROSPERO (CRD42023415667). 26 studies with 6074 cases performing pyeloplasty were included, and the overall data are comparable. Our analysis showed no significant difference in success rate and postoperative complications between RALP and OP, and RALP is associated with a shorter length of stay (LOS) (MD - 1.00 95%CI - 1.45 to - 0.55, p < 0.0001). In addition, compared to LP, RALP was associated with a shorter anastomosis time (MD - 18.35 95%CI - 29.88 to - 6.82, p = 0.002) and fewer postoperative analgesics (MD - 0.09 95% CI - 0.18 to - 0.01, p = 0.03); however, RALP has a longer operative time (OT) (MD 52.39, 95% CI 39.75-65.03, p < 0.00001) and higher cost. The heterogeneity of OT may be influenced by factors, such as age and region, while the heterogeneity of LOS primarily stems from regional differences. No significant publication bias was detected. Our meta-analysis shows that RALP can be an alternative to OP and LP with a high success rate, minimal postoperative complications, and shorter LOS. In addition, RALP contributes to reduce anastomosis time and postoperative analgesic drugs. However, further well-designed, large-scale, randomized controlled trials with additional parameters are needed to conduct a more comprehensive analysis of heterogeneity.

What credentials are required for robotic-assisted surgery in reconstructive and functional urology?

Introduction

The increasing popularity of robotic assisted surgery (RAS) as it is implemented in to sub specialities poses many challenges to ensuring standards in quality and safety. The area of Reconstructive and Functional Urology (RFU) has a wide range and largely complex heterogeneous procedures. In recent years RFU has started to incorporate RAS as the primary method to undertake these procedures due to improved vision, dexterity, and access to deep cavities. To ensure patient safety majority of institutions maintain minimal requirements to operate using RAS however across specialities and institutions these greatly vary.

Methods

A narrative review of all the relevant papers known to the author was conducted.

Results

Specific challenges facing RFU is the inability to rely on case numbers as a surrogate means to measure competency as well the ongoing consideration of how to differentiate between surgeons with robotic training and those with the clinical experience specific to RFU.

Conclusion

This review explores current models of training and credentialling and assess how it can be adapted to suggest a standardised guideline for RFU to ensure the highest standards of patient care.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Scarless laparoscopic incisions in Pfannenstiel (slip): the first 50 cases using an innovative approach in pediatric robotic surgery

Incisions in the supra-pubic region have been described robotic-assisted surgery to improve cosmetic results in adults, but seldom in children. We aimed to present an innovative trocar placement in the Pfannenstiel line, named Scarless Laparoscopic Incisions in Pfannenstiel (SLIP), and evaluate its feasibility for various intra-abdominal procedures and its cosmetic results in pediatric robotic surgery. We performed a monocentric prospective study, including children undergoing robotic-assisted surgeries using a SLIP approach (July 2019-September 2021). Data regarding demographics, surgery, and outcome were collected and reported as median (range), or number (percentage). Cosmetic results were evaluated with a questionnaire. A SLIP approach was performed in 50 children (24 cholecystectomies, 12 splenectomies, 2 cholecystectomies and splenectomies, 9 colonic resections, 2 choledochal cyst resections, and 1 pancreatic pseudocyst resection). Median age was 11 years (2-18) and median weight 35 kg (10.5-80). Conversion to laparoscopy occurred in two cases. Post-operative complications occurred in 5 patients (10%), after colectomies [intrabdominal abscess (n = 3), stoma dysfunction (n = 1), parietal abscess (n = 1)], of which 3 (6%) required reintervention (intrabdominal abscess n = 2, stoma dysfunction n = 1). Regarding scars, 68% (n = 28) of parents and patients reported the maximal score of 5/5 for global satisfaction and 63% (n = 26) had all scars hidden by underwear. SLIP approach is versatile and can be used in supra- and infra-mesocolic robotic-assisted procedures. The low complication rate shows its safety in both young children and teenagers and does not increase operative difficulties. It results in high patient satisfaction regarding scars, and a scarless abdomen.

Robot-assisted laparoscopic partial gastrectomy combined with endoscopy for gastrointestinal stromal tumors with intraluminal growth: a report of two cases

In cases of gastrointestinal stromal tumor (GIST) with intraluminal growth, determining the minimal resection line is difficult; however, the combined use of endoscopy can overcome this limitation. We performed robot-assisted partial gastrectomy with endoscopy for two cases of internally developed GISTs located on the posterior wall near the esophagogastric junction (EGJ). We confirmed the tumor location and determined minimal surgical margins using endoscopy. The double bipolar method (DBM), which is performed with Maryland bipolar forceps in the right hand and fenestrated bipolar forceps in the left hand, was used to reduce residual gastric damage and prevent tumor damage. The characteristics of robot-assisted surgery made it easier to precisely perform anastomosis of the upper part of the stomach, as compared with laparoscopic surgery, thus minimizing gastric deformity. Both patients were discharged without postoperative complications. In conclusion, robot-assisted partial gastrectomy using the DBM may represent a viable treatment option for gastric submucosal tumors close to the EGJ.

A Comparative Analysis of Robot-Assisted Laparoscopic Pyeloplasty in Pediatric and Adult Patients: Does Age Matter?

We investigated factors that affect the surgical outcomes of robotic pyeloplasty by comparing the surgical results of pediatric and adult patients with ureteropelvic junction stricture (UPJO). We retrospectively reviewed patients who underwent robotic pyeloplasty for UPJO between January 2013 and February 2022. The patients were categorized into two groups: the pediatric (≤18 years) and adult (>18 years) groups. The perioperative and postoperative outcomes and surgical complications were comparatively analyzed. Prognostic factors for predicting surgical failure were analyzed with multivariable logistic regression analysis. The pediatric group showed longer total operation and console times. The mean pain score was lower in the pediatric group than in the adult group on days 1 and 2 after surgery. The average amount of morphine used in the pediatric group was lower during postoperative days 0−2. No differences in the length of hospital stay, incidence of surgical failure, and incidence of urolithiasis requiring treatment after robotic pyeloplasty were observed between the groups. The only factor that predicted surgical failure was a history of urolithiasis before surgery. The results showed that age did not affect the surgical outcome.

Ten years of paediatric robotic surgery: Lessons learned

Background

Costs and a low total number of cases may be obstacles to the successful implementation of a paediatric robotic surgery programme. The aim of this study was to evaluate a decade of paediatric robotic surgery and to reflect upon factors for success and to consider obstacles.

Materials and Methods

All children operated on with robotic‐assisted laparoscopic surgery between 2006 and 2016 were included in a retrospective, single‐institutional study in Lund, Sweden.

Results

A total of 152 children underwent robotic surgery during the study time with the most frequent procedures being fundoplication (n = 55) and pyeloplasty (n = 53). Procedure times decreased significantly during the study period. Overall, 18 (12%) of the operations were converted to open surgery, and seven (5%) patients required a reoperation.

Conclusions

Despite a low volume of surgery, we have successfully introduced robotic paediatric surgery in our department. Our operative times and conversion rates are continuously decreasing.

Long Term Outcome of 112 Pediatric Patients With Ureteroplevic Junction Obstruction Treated by Endourologic Retrograde Balloon Dilatation

PURPOSE

To analyze the effectiveness, complications and long-term outcome of the patients with ureteropelvic junction obstruction (UPJO) treated by endoscopic retrograde balloon dilatation (ERBD) in the largest series reported.

MATERIALS AND METHODS

Between years 2004 and 2018, 112 patients with primary unilateral UPJO were treated by ERBD. Endoscopic treatment consisted on a retrograde balloon dilatation of the ureteropelvic junction (UPJ), through cystoscopy and under fluoroscopic guidance, using high-pressure balloon catheters. In case of persistence in the balloon notch, a Cutting Balloon™ catheter was used. Double-J stent was placed after dilatation.

RESULTS

Mean age at surgery was 13.1 ± 21.3 months, 92 cases being younger than 18 months. Mean operative time was 24.4 ± 10.3 min; hospital stay was 1 day in 82% of patients. No intraoperative complications occurred. UPJ was calibrated at time of stent removal with cystoscopy 39.1 ± 13.7 days after dilatation. ERBD was not possible in 11 cases. An additional procedure was needed in 24 cases: second ERBD (n = 11, seven during the stent withdrawal), a third dilatation (n = 3) due to persistent hydronephrosis, and percutaneous endopyelotomy (n = 3) or open pyeloplasty (n = 7) in cases of technical failure. Significant improvement in postoperative ultrasound measures were observed (p < 0.05, T-test). Long-term success rate was 76.8% after one dilatation, and 86.6% in those who required up to 2 dilatations. Mean follow-up was 66.7 ± 37.5 months.

CONCLUSIONS

ERBD is a feasible and safe option for the minimally invasive treatment of UPJ obstruction in infants. Long-term outcome is acceptable with a very low complication rate.

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.

Redo laparoscopic pyeloplasty for recurrent ureteropelvic junction obstruction: Propensity score matched analyses of a high-volume center

PURPOSE

Review the experience of redo laparoscopic pyeloplasty (RLP) in patients with recurrent ureteropelvic junction obstruction (UPJO) in comparison to primary laparoscopic pyeloplasty (PLP) and redo open pyeloplasty (ROP), and determine the feasibility and effectiveness of RLP for recurrent UPJO in children.

METHODS

We retrospectively reviewed the clinical data of patients treated with transperitoneal PLP, RLP, and ROP for UPJO from December 2015 to December 2022. The Propensity score matching (PSM) was used to balance confounding variables. RLP patients were 1:4 matched with PLP and 1:3 matched with ROP. The primary outcomes were failure and post-operative complications. Complications were classified according to the Clavien-Dindo grading system.

RESULTS

The study included ten patients who underwent RLP, 43 patients who underwent ROP, and 412 patients who underwent PLP. The follow-up time ranged from 6 to 36 months in the RLP group, 12 to 60 months in the PLP group, and 24 to 54 months in the ROP group. In the RLP group, no failure but three post-operative complications (Clavien grade II) were observed during the follow-up. Compared with the PLP group, the older age, higher weight, larger pre-operative anteroposterior diameter (APD) and APD/cortical thickness (P/C ratio), longer operation time, and post-operative length of stay (LOS) in the RLP group (P < 0.05). After PSM, longer operation time and post-operative LOS were observed in the RLP group (P < 0.05). Compared with the ROP group, the older age, higher weight, and longer post-operative LOS in the RLP group (P < 0.05). After PSM, longer post-operative LOS was observed in the ROP group (P < 0.05). The failure and complication rates were comparable between RLP and PLP or RLP and ROP (P > 0.05).

CONCLUSIONS

Our result demonstrated that RLP performed as well as PLP except for a longer operation time. Compared with ROP, RLP has the advantages of a clearer surgical view, sufficient exposure, clearer anatomical landmark position, and minor trauma with a comparable clinical outcome. On experienced hands, RLP for recurrent UPJO after is a safe and effective procedure and should be considered an excellent alternative to the more commonly recommended ROP in select patients.

Early outcome findings of treatment for transperitoneal laparoscopy-assisted pyeloplasty

Background

We retrospectively analyzed the initial results of laparoscopic pyeloplasty, among pediatric patients undergoing the procedure by transperitoneal access.

Methods

We retrospectively reviewed the medical records of patients who were operated with transperitoneal laparoscopy-assisted pyeloplasty at our institution between 2015 and 2020.

Results

The mean age of the 51 patients (M/F = 36/15) was 59 ± 49.8 months. The mean preoperative renal pelvis anterior–posterior diameter was 32.9 ± 13.4 mm, and the relative renal function was 42 ± 12.1% on the operation side. Forty-three (84.3%) patients had no excretion on MAG3 examination preop. The number of patients with no excretion decreased to 10 (19.7%) after surgery. One of them underwent a successful endopyelotomy; eight of them underwent a successful laparoscopic re-pyeloplasty. There was nothing to do in only one patient whose DRF decreased to 11%. The mean anterior posterior diameter decreased significantly to 16.7 ± 11.2 mm after surgery (p < 0.001).

Conclusion

Preoperative increased renal pelvis anterior–posterior diameter detected in our study was found to be a risk factor in the failure of transperitoneal laparoscopy-assisted pyeloplasty procedure.

Systematic Review and Meta-Analysis of Pediatric Robotic Assisted Laparoscopic Pyeloplasty (RALP)

INTRODUCTION

To perform a systematic review and meta-analysis of outcomes of robotic-assisted laparoscopic pyeloplasty for UPJ obstruction in children.

EVIDENCE ACQUISITION

A systematic review of the English-language literature on surgical techniques and perioperative outcomes of robotic-assisted laparoscopic pyeloplasty for UPJ obstruction in children was performed without time filters using the MEDLINE (via PubMed), EMBASE, and Cochrane databases in July 2020 according to the PRISMA statement recommendations.

EVIDENCE SYNTHESIS

Overall, 58 studies were selected for qualitative analysis, 46 of which were included in the meta-analysis. Nearly all studies included were observational and retrospective, either cohort or case-control. The quality of evidence was assessed using Modified Newcastle Ottawa Scoring, with the majority of studies scoring medium or high quality. The mean success rate was 95.4% (CI 91.0-99.3%), over a wide age range. There was a noticeable heterogeneity in reported follow up length and definitions of success rate. The majority of studies reported length of stay of ~1 day. The mean overall complication rate was 12%. For studies that reported complication rate by grade, the mean low Clavien grade (grade 2 or less) complication rate was 9.3% and the mean high Clavien grade (grade 3 or more) complication rate was 6.5%.

CONCLUSIONS

Robotic assisted surgery is technically feasible and has been shown to achieve very favorable outcomes for pyeloplasty in children. The evidence however is mostly retrospective and from single sites, which introduces potential biases. Further research is needed to further elucidate RALP benefits compared to the open and laparoscopic approach. As a RCT may not be practical in this space, perhaps a prospective multi-institutional design with a uniform reporting system of pediatric RALP is the next step to define its benefits and limits.

Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction

For ureteropelvic junction obstruction (UPJO), the standard of surgical care is dismembered pyeloplasty. This applies both for intrinsic but also for extrinsic etiology of the UPJO. When in 1995, Peters described for the first time laparoscopic pyeloplasty in children, the era of laparoscopic pediatric urological surgery began. Nowadays, laparoscopic dismembered pyeloplasty in children has evolved to become the gold standard. In this article, we report a standardized technique of laparoscopic transperitoneal dismembered pyeloplasty for infants and children. The described single steps of the procedure are reproducible regardless of age and weight and thus offer a high surgical success rate.

Renal Cortical Thickness After Pyeloplasty in Pediatric Ureteropelvic Junction Obstruction

Purpose

The main goal of pyeloplasty is to maintain or improve renal function. Diuretic renography is the gold standard for evaluating renal function after pyeloplasty. Renal ultrasonography (RUS) is commonly used to determine hydronephrosis in pediatric patients. We hypothesized that the change in the renal parenchymal cortex would predict pyeloplasty success. In this study, we aim to measure renal cortical thickness change after pyeloplasty in ureteropelvic junction obstruction patients.

Materials and Methods

We retrospectively reviewed 38 patients who underwent pyeloplasty between 2005 and 2019. We divided patients into three age groups and compared the difference of renal parenchymal thickness change by using generalized estimating equations to identify associated factors for renal cortical thickness change after pyeloplasty.

Results

Thirty-nine kidney units were identified. The median age at the time of surgery was 41.61±40.99 months. Generalized estimating equations showed significant change of renal parenchymal thickness over the period of follow-up (p=0.02). The estimate of thickness change was 0.0373 mm/month. Age at the time of surgery was not associated with significant renal cortical thickness over the period of follow-up. The positive predictive factors for renal cortical thickness were creatinine clearance, pre-operative anteroposterior diameter and pre-operative renal differential function. The negative factors for decrease of renal cortical thickness were body weight, presentation with abdominal mass, and history of infection.

Conclusion

Renal cortical thickness after pyeloplasty was improved over the period of follow-up. Age at surgery was not associated with improvement of renal parenchymal thickness.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Surgery of uretero-pelvic junction obstruction (UPJO)

Uretero-pelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in infants and children. Historically, this condition has been approached surgically through a retroperitoneal approach as described by Anderson and Hynes aiming for an open dismembered pyeloplasty. A true evolution of laparoscopy in pediatric urology took place within the last 30 years. Laparoscopy developed from a merely diagnostic tool for non-palpable testes to "interventional" laparoscopy for extirpative surgery. Finally the era of reconstructive pediatric laparoscopic urology started, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic dismembered pyeloplasty now has become the preferred surgical treatment of UPJO. It offers excellent visualization of the anatomy, accurate anastomotic suturing, thus the precise reconstruction of the UPJ along with good functional outcome. This article aims to provide the current status, indication and operative technique of laparoscopic dismembered pyeloplasty for UPJO in infants and children.

Anaesthesia management during paediatric robotic surgery: preliminary results from a single centre multidisciplinary experience

INTRODUCTION

Paediatric robotic surgery is gaining popularity across multiple disciplines and offers technical advantages in complex procedures requiring delicate dissection. To date, limited publications describe its perioperative management in children.

MATERIAL & METHODS

We retrospectively analysed the prospectively collected anaesthetic data of the first 200 robotic-assisted surgery procedures in our paediatric university hospital as part of a multidisciplinary program from October of 2016 to February of 2019. Anaesthetic technique and monitoring were based on guidelines initially derived from adult data. We examined adverse events and particular outcomes including blood loss and analgesic requirements.

RESULTS

Fifty-one different surgical procedures were performed in patients aged 4 months to 18 years (weight 5-144 kg). Operative times averaged 4 h and conversion rate was 3%. Neither robotic arm nor positional injury occurred. Limited access to the patient did not lead to any complication. Hypothermia was frequent and mostly self-limiting. Negative physiological effects due to positioning, body cavity insufflation or surgery manifesting as significant respiratory and haemodynamic changes occurred in 14% and 11% of patients, respectively. Overt haemorrhage complicated one case. Eighty per cent of 170 patients did not require level 3 analgesics postoperatively, while thoracic and certain tumour cases had greater analgesic requirements.

CONCLUSION

These preliminary results show that paediatric robotic surgery is well tolerated with a low bleeding risk and that major intraoperative events are uncommon. A consistent anaesthetic approach is effective across a broad range of procedures. Analgesic requirements are low excluding thoracic and some complex abdominal cases. Future studies should focus on the rehabilitative aspects of robotic surgery technique.

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 for Primary Pelvic Ureteric Junction Obstruction: A Prospective Single Centre Study

Introduction

The aim of the study was to compare the clinical and patient-reported outcomes among open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) patients.

Materials and methods

This was a prospective single centre, case-cohort study conducted in a tertiary care hospital with 62 patients. In both techniques, dismembered Anderson-Hynes pyeloplasty were undertaken. Post-operatively patients underwent visual analogue scale (VAS) assessment for pain, days to ambulation and comparison of the short- and long-term outcomes of the two procedures.

Results

There was no difference in the physical and functional outcomes between the two surgical approaches at 12 months period after surgery. However, patients in the laparoscopic group did report a higher rate of satisfaction at six weeks and six months’ postoperatively.

Likewise, patients in LP experienced less pain during the postoperative period (p-value <0.001), with decreased analgesic requirements. This translated into an early patient ambulation in the laparoscopic group (p-value <0.001), and a shorter hospital stay for the LP group (p-value <0.001). Moreover, follow-up ultrasound showed equal improvement of hydronephrosis among the two groups.

Conclusion

Laparoscopic and open pyeloplasty are equally effective in treating pelvic ureteric junction obstruction (PUJO), with comparable patient-reported outcomes at 12-month follow-up. However, the laparoscopic technique merits over open surgery with faster rehabilitation, a decreased postoperative pain experience and shorter hospital stay.

Roboterassistierte (RA-)Kinderchirurgie: Nierenbeckenplastiken mit dem Da-Vinci-Roboter

Hintergrund

Im Ausland stellt die roboterassistierte (RA-)Chirurgie und hier besonders die RA-Urologie in der Kinderchirurgie bereits eine wichtige Alternative zu konventionellen Eingriffen (offen, laparoskopisch, laparoskopisch-assistiert) dar. Für Deutschland wurden dazu erst wenige Untersuchungen publiziert.

Ziel der Arbeit (Fragestellung)

Im Sinne einer vergleichenden Serie sollten die ersten Fälle von RA-Nierenbecken-Plastiken der Kinderchirurgie der Universitätsmedizin Göttingen im Vergleich zu konventionell laparoskopisch-assistierten (LAA) vor dem Hintergrund der internationalen Literatur evaluiert werden.

Material und Methoden

Es werden retrospektiv die ersten 13 RA und 14, unter Berücksichtigung des Patientenalters ausgewählte, konventionell LAA Anderson-Hynes-Plastiken hinsichtlich Operationsdauer, Krankenhausverweildauer, Alter der Patienten, Komplikationen und Rezidiven untersucht. Laparoskopisch-assistierte Operationen werden laparoskopisch durchgeführt, lediglich die Anlage der Anastomose erfolgt über einen kleinen Flankenschnitt extrakorporal. Roboterassistierte Eingriffe verlaufen gänzlich laparoskopisch.

Ergebnisse

Für die Operationsdauer ergab sich kein signifikanter Unterschied (111,54 min vs. 117,64 min). Die Liegezeit fiel für RA-Eingriffe signifikant kürzer aus (5,85 Tage vs. 10,0 Tage). Die Altersverteilung ergab für die RA-Kohorte ein Mittel von 52,23 Monaten und für die LAA 30,29 Monate. Die Komplikationsrate betrug 15,38 % (Harntransportstörung, paralytischer Ileus und Dislokation des PDK sowie Omentumprolaps), die Rezidivrate 7,69 % für die RA Eingriffe. Für die LAA operierten Patienten und Patientinnen lagen die Werte bei 7,14 % (Dislokation der Doppel-J-Schiene nach kranial) und 14,28 %.

Diskussion

Die ersten RA-Nierenbecken-Plastiken unserer Klinik wiesen im internationalen Vergleich ähnliche Werte für Operationsdauer, Komplikations- sowie Rezidivrate auf. Es zeigten sich ein ähnliches Outcome für beide Operationsverfahren und keine signifikante Zeitersparnis durch Verwendung des OP-Roboters. Im Gegensatz dazu fiel die Krankenhausverweildauer nach RA-Eingriffen signifikant kürzer aus als nach LAA-Operationen. In der internationalen Literatur finden sich jedoch auch insgesamt kürzere Liegezeiten. Insgesamt stellen RA-Nierenbecken-Plastiken eine wertvolle Alterative zu LAA-Verfahren dar.

Best ultrasound parameter for prediction of adverse renal function outcome after pyeloplasty

OBJECTIVE

To evaluate the clinical value of preoperative ultrasound parameters for post-pyeloplasty outcomes in pediatric patients with ureteropelvic junction obstruction.

METHODS

The medical records of 187 pediatric and adolescent patients who underwent pyeloplasty as a result of ureteropelvic junction obstruction between 2010 and 2016 were retrospectively reviewed. The severity of hydronephrosis was measured by the Society for Fetal Urology grade, anteroposterior pelvic diameter, urinary tract dilation, hydronephrosis index, and the hydronephrosis area to renal parenchyma ratio at 3, 6 and 12 months. Adverse renal function outcome was defined as ≥10% decrease in postoperative differential renal function compared with preoperative values.

RESULTS

Of the 187 patients, preoperative hydronephrosis was categorized as Society for Fetal Urology grade 3 in 26 patients (13.9%) and grade 4 in 161 patients (86.1%). No surgical failures, defined as requirement of repeat surgery or deterioration of hydronephrosis grade, were noted. The mean changes in Society for Fetal Urology grade, anteroposterior pelvic diameter, urinary tract dilation and hydronephrosis area to renal parenchyma ratio showed similar trends of recovery during the follow-up period. In total, 19 patients (10.2%) showed >10% decrease in differential renal function during follow up (mean 42 months). Multivariate logistic regression analysis showed that the hydronephrosis area-to-renal parenchyma ratio was the only significant prognostic factor for adverse renal function outcome (hazard ratio 1.806, 95% confidence interval 1.210-2.859, P = 0.005). Receiver operating characteristic analysis showed that the hydronephrosis area-to-renal parenchyma ratio was the most significant predictive value (area under the curve 0.711, 95% confidence interval 0.618-0.804, P = 0.006).

CONCLUSIONS

Pediatric patients with high hydronephrosis area-to-renal parenchyma ratio values before surgery are more likely to show renal function decline after pyeloplasty.

Lumboscopic-Assisted Pyeloplasty: A Single-Port, Retroperitoneoscopic Approach for Children with Pelvi-Ureteric Junction Obstruction

Introduction:

Pelvi-ureteric junction obstruction (PUJO) is one of the most common conditions presenting to a pediatric urologist. As laparoscopic or robotic-assisted pyeloplasty, either transperitoneal or retroperitoneal, involves intracorporeal suturing skills and has a long learning curve, they have not gained popularity among beginners in laparoscopy.

Objective:

We conducted a study to assess the results of a single-port, retroperitoneoscopic approach to renal access, i.e. lumboscopic-assisted pyeloplasty (LAP), by single surgeon at our institute.

Materials and Methods:

A retrospective review of all children who underwent LAP from July 2013 to March 2018 was conducted. Patients who presented with PUJO and required surgical treatment were included. A single-port lumboscopy using coaxial telescope was performed in prone position in all patients. The renal pelvis was dissected and retrieved through the port site followed by extracorporeal hand-sewn pyeloplasty over a double–J stent or a nephrostent. The operative time, postoperative pain, surgical complications, duration of hospital stay, follow-up, and cosmesis at 6 months postsurgery were evaluated.

Results:

A total of 96 children were included (72 males and 24 females), with the age at operation ranging from 3 months to 10 years (mean = 4.9 years). All patients had an uneventful postoperative recovery. Two patients had a superficial wound infection, and one patient was converted to open approach due to excessive bleeding. The average operating time was 80 ± 22.5 min, the median duration of hospital stay was 3 days, and the average scar length at 3 months was 15.6 ± 0.4 mm. Follow-up renogram (diethylenetriamine pentaacetic acid) showed satisfactory postpyeloplasty drainage pattern in 93 children while three showed obstructive drainage curves.

Conclusion:

LAP can be performed safely with minimal retroperitoneal dissection, excellent cosmetic results, and minimal postoperative pain in children with PUJO. It has a shorter learning curve as compared to laparoscopic pyeloplasty as it involves time tested extracorporeal hand-sewn anastomosis.

Minimally invasive open pyeloplasty in children: Long-term follow-up

OBJECTIVE

Our aim was to report the long-term follow-up for minimally invasive open pyeloplasty in children.

MATERIAL AND METHODS

A total of 213 children with a mean age 16.33 months underwent miniature open pyeloplasty for ureteropelvic junction obstruction between January 2010 and May 2016. Anderson-Hynes dismembered pyeloplasty was performed through a subcostal miniature incision. The intraoperative and postoperative parameters including surgical operative time, incision size, intraoperative blood loss volume, postoperative analgesic use, hospital stay, complications, and success rate were documented.

RESULTS

The mean surgery time was 65 min (50-85 min), and incision size was 16.99 mm (12-36 mm). None of the patients required blood transfusion or narcotic analgesics in the postoperative period. The mean hospital stay was 21.97 h (10-48 h). Minor side effects included urinary tract infection (3.8%) and urinary leakage in one case (0.004%). Major complications were not observed. The mean antero-posterior pelvic diameter before and after surgery was 28.69 ± 11.54 mm and 15.89 ± 9.29 mm, respectively with a mean difference of 12.78 mm, which shows a significant decrease (P value = 0.001). The success rate was 98.1% with a mean follow-up of 21.43 months (3-56 months). Two of the recurrences occurred in the first postoperative year, another one after 1.5 years, and the last one after 4 years.

CONCLUSION

Our study confirms minimally invasive open pyeloplasty in children as a safe and efficient procedure with the least complication and hospital stay rate in comparison with other minimally invasive techniques. Moreover, long-term follow-up is a requirement in pyeloplasty surgery.

Redo Laparoscopic Pyeloplasty in Infants and Children: Feasible and Effective

Purpose: To determine the feasibility and effectiveness of redo laparoscopic pyeloplasty among patients with failed previous pyeloplasty, specifically examining rates of success and complications. Materials and Methods: We retrospectively reviewed the charts of all patients, who underwent redo laparoscopic pyeloplasty from 2006 to 2017. This included patients who underwent primary pyeloplasty at our institution and those referred for failures. Analysis included demographics, operative time, complications, length of hospital stay, complications, and success. Success was defined as improvement of symptoms and hydronephrosis and/or improvement in drainage demonstrated by diuretic renogram, especially in those with persistent hydronephrosis. Descriptive statistics are presented. Results: We identified 22 patients who underwent redo laparoscopic pyeloplasty. All had Anderson-Hynes technique except two cases in which ureterocalicostomy was performed. Median (IQR) follow-up was 29 (2-120) months, median time between primary pyeloplasty and redo laparoscopic pyeloplasty was 12 (7-49) months. The median operative time was 200 (50-250) min, and median length of hospital stay was 3 (2-10) days. The procedure was feasible in all cases without conversion. During follow-up, all but two patients demonstrated an improvement in the symptoms and the degree of hydronephrosis. Ninety-one percent of patients experienced success and no major complications were noted. Conclusions: Redo laparoscopic pyeloplasty is feasible and effective with a high success rate and low complication rate.

Comparison Between Robotic and Laparoscopic or Open Anastomoses: A Systematic Review and Meta-Analysis

INTRODUCTION

Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.

METHODS

A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.

RESULTS

We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).

CONCLUSION

Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.

Laparoscopic hybrid pyloromyotomy for infantile hypertrophic pyloric stenosis: A simplified technique

Introduction:

Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric has advantage of smaller incisions, faster recovery, reduction in wound-related complications and better cosmesis. Various laparoscopic knives and spreaders have been used for LP, but they do not provide the depth and tissue perception as in open surgery. We describe the laparoscopic hybrid pyloromyotomy (LHP) which makes procedure simple and safe without the requirement of any special instrument.

Materials and Methods:

This retrospective and prospective comparative study was conducted over a period of 4.5 years in a tertiary teaching hospital in central India. All patients with infantile hypertrophic pyloric stenosis diagnosed on the basis of clinical history, examination and ultrasonography were included in the study. Retrospective data of three-port conventional LP (CLP) using monopolar diathermy hook for incision was used as control group against prospective data of 25 patients undergoing LHP. After a proper layout, LHP was done using one umbilical optical port, right paraumbilical grasper of holding the pyloric olive and an epigastric incision for hybrid pyloromyotomy using 11 no blade and blunt-tipped mosquito artery forceps.

Results:

Prospective group of LHP included 25 patients which were compared with a retrospective group of CLP consisting of 25 patients. On comparison of two groups, it was found that LHP reduces operative duration significantly. The outcome in terms of complications and recovery was comparable in two groups. None of the patients developed recurrence and required any redo surgery.

Conclusion:

LHP is a simplified approach which is easy to learn and teach, improves safety and accuracy of the procedure.

Lessons learned from a single-surgeon series of paediatric robot-assisted laparoscopic urological procedures: predictors of high-grade postoperative complications

OBJECTIVES

To describe postoperative complications after robot-assisted laparoscopic urological surgery in children, and identify potential predictors of these complications by analysing the outcomes of a large-volume single-surgeon experience.

PATIENTS AND METHODS

We reviewed our institutional database to identify all robot-assisted laparoscopy (RAL) cases performed between December 2007 and December 2017. Patients were grouped into three cohorts based on the anatomical location of the procedure: upper urinary tract (kidney and renal pelvis); lower urinary tract (ureter); and lower urinary tract reconstruction with bowel (bladder reconstruction). A descriptive analysis of baseline characteristics, intra-operative variables and postoperative outcomes was carried out. All complications were graded using the Clavien-Dindo scale, and grouped based on type and time of occurrence (<30, 30-90, >90 days). Multivariable logistic regression analysis was performed to identify predictors of high-grade complications (Clavien-Dindo grade ≥ III). We also measured complication rates based on year of surgery and surgical caseload.

RESULTS

Our database included a total of 326 patients, of whom 57% (n = 186) underwent upper urinary tract procedures, 30% (n = 97) ureteric procedures, and 13% bladder reconstruction. The median follow-up for each procedure was 13, 11 and 57 months, respectively. Of the total, 10 cases were converted to an open approach and excluded from further analysis. The most common types of complication in all groups were infections (urinary tract infections) and urinary complications (urine leaks and urolithiasis). Bladder reconstructive procedures, which require the use of bowel, presented the highest rate of high-grade complications (32%). Length of hospital stay (LOS; odds ratio [OR] 1.33, confidence interval [CI] 1.16-1.53), estimated blood loss (EBL) in surgery (OR 1.01, CI 1.002-1.019) and operating time (OR 1.004, CI 1.002-1.006) were all associated with increased odds of high-grade complications on multivariate analysis (P < 0.05).

CONCLUSIONS

In this single-surgeon series, we have described the most commonly encountered complications after RAL in paediatric urology, finding rates similar to the complication rates reported in the current literature on other surgical approaches. In addition, LOS, operating time and EBL, which are probable surrogates of case complexity, were associated with increased odds of high-grade complications.

Robot-assisted laparoscopic pyeloplasty in infants and children: is it superior to conventional laparoscopy?

INTRODUCTION

Open pyeloplasty (OP) has been the first-line treatment for ureteropelvic junction obstruction (UPJO) since it was first described by Anderson and Hynes. The use of minimally invasive surgery (MIS) to treat UPJO in the pediatric population has increased in recent years, due to decreased morbidity and shorter recovery times. Recently, robot-assisted laparoscopic pyeloplasty (RALP) has seen a steady expansion. Unlike laparoscopic pyeloplasty (LP), RALP comes with a more manageable learning curve aided by specialized technological advantages such as high-resolution three-dimensional view, tremor filtration with motion scaling, and highly dexterous wrist-like instruments. With this review, we aim to highlight the trend toward robotic pyeloplasty over laparoscopy and current available evidence on outcomes.

METHODS

We systematically searched the PubMed and EMBASE databases, and we critically reviewed the available literature on the use of laparoscopy and robotic technology in pediatric patients with UPJO.

RESULTS

Overall, we selected 19 original articles and 5 meta-analyses. The available literature showed that the robotic approach to the UPJO allowed for decreased operative times, shorter length of hospital stay, lower complication rates, with success rates comparable to LP. Conflicting results persist regarding robotic platform and equipment costs.

CONCLUSION

While laparoscopy requires advanced skills for complex reconstructive procedures, such as pyeloplasty, robot-assisted surgery offers the valuable potential of making MIS more accessible to these types of procedure. Robotic technology has contributed to shortening the learning curve by acting as a bridge between open and endoscopic approach. There is still a strong need for higher quality evidence in the form of prospective observational studies and clinical trials, as well as further cost-effectiveness analyses. As robotic surgical technology spreads, future systems will be developed, offering smaller and more flexible tools, allowing enhanced applications on pediatric patients.

Low Weight Child: Can It Be Considered a Limit of Robotic Surgery? Experience of Two Centers

Purpose: Robotic surgery should be considered a technical opportunity for many procedures in pediatric age. The purpose of this study is to verify the correlation between robotic procedures and low weight. Materials and Methods: It is a retrospective study (2013-2017). We included all patients who underwent robotic assisted surgery for major procedures in two Italian centers for pediatric surgery. All patients were divided into two groups (group A ≤15 kg and group B > 15 kg). Parameters considered were as follows: time to console, average time procedures, time of hospitalization, and minor/major complications. Statistical test used was Wilcoxon-Mann-Whitney test. Results: We enrolled 83 patients. Group A: 28 patients, medium weight 11.2 kg (range: 7-15 kg). Group B: 55 patients, average weight 40.8 kg (range: 15.2-120 kg). In relation to the outcomes considered, we found statistical significance in relation to surgical time and time at the console. Conclusions: The retrospective analysis of our case found that body weight cannot be considered an absolute contraindication for the execution of surgical procedures in robotics. The improvement of instruments permits to perform complex surgical procedures in low-weight children without additional difficulties. However, it is important to point out that the youngest child of our case had a weight of 7 kg.

Robot-assisted laparoscopic pyeloplasty versus laparoscopic pyeloplasty for pelvi-ureteric junction obstruction in the paediatric population: a systematic review and meta-analysis

Background

Owing to the improved vision and instrument manipulation in robot-assisted procedures, we sought to evaluate the comparative outcomes of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) in a paediatric patients with pelvi-ureteric junction obstruction (PUJO).

Methods

We conducted a systemic literature search of online sources, including PubMed, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials, and respective bibliographic reference lists. Success rate, operative time, hospital length of stay, postoperative complication rate and re-intervention rate were our primary outcomes. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

Results

We identified 14 observational studies reporting a total of 2254 paediatric patients with PUJO, who underwent LP (n = 1021) or RALP (n = 1233). Our analysis demonstrated that RALP was associated with a significantly higher success rate [odds ratio (OR) 2.51; 95% confidence interval (CI) 1.08-5.83, p = 0.03] and shorter length of hospital stay [mean difference (MD) -1.49; 95% CI -2.22 to -077; p < 0.0001] compared with LP. Moreover, nonsignificant reductions in postoperative complications (OR 0.61; 95% CI 0.36-1.02; p = 0.06) and re-intervention (OR 0.43; 95% CI 0.15-1.21; p = 0.11) were found in favour of RALP. There was no difference in procedure time between the two approaches (MD -0.15; 95% CI -30.22 to 29.93, p = 0.99).

Conclusions

Our meta-analysis of observational studies demonstrated that RALP is safe and may have higher success rate compared with the more traditional laparoscopic approach in a paediatric population. Moreover, it may be associated with lower postoperative complications and re-intervention rates. Evidence from randomized trials is required.

Current Concepts in Pediatric Robotic Assisted Pyeloplasty

Robotic surgery in pediatric urology has been gaining popularity since its introduction almost two decades ago. Robotic assisted pyeloplasty is the most common robotic procedure performed in pediatric urology. Advances in robotic technology, instrumentation, patient care and surgical expertise have allowed the correction of ureteropelvic junction (UPJ) obstruction in most patients using this minimally invasive technique. The excellent experience with robotic assisted pyeloplasty has challenged other approaches as a new standard for the treatment of UPJ obstruction. In this review, we will describe the technique as it relates to the different robotic platforms, review the surgical experience and compare its results to other surgical approaches. Also, we will discuss patient and parent satisfaction, cost and financial considerations, along with evaluating the future of robotic surgery in the treatment of UPJ obstruction.

Applications of Laparoscopic Transperitoneal Surgery of the Pediatric Urinary Tract

Application of laparoscopy in pediatric urology has evolved over more than 30 years coming from a merely diagnostic use for non-palpable testes to "interventional" laparoscopy to extirpative surgery and finally to the era of reconstructive pediatric laparoscopic urology, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic surgery in pediatric urology became implemented increasingly in the twenty-first century with now present-day applications including the complete variety of all kind of indications for surgery for pediatric urological pathology. This article aims to provide a comprehensive overview of current indications, techniques, and outcomes of laparoscopic transperitoneal surgery of the upper as well as of the lower urinary tract for urological pathology in the pediatric patient population.

Laparoscopic renal surgery is here to stay

Objectives

To review the current literature comparing the outcomes of renal surgery via open, laparoscopic and robotic approaches.

Materials and methods

A comprehensive literature search was performed on PubMed, MEDLINE and Ovid, to look for studies comparing outcomes of renal surgery via open, laparoscopic, and robotic approaches.

Results

Limited good-quality evidence suggests that all three approaches result in largely comparable functional and oncological outcomes. Both laparoscopic and robotic approaches result in less blood loss, analgesia requirement, with a shorter hospital stay and recovery time, with similar complication rates when compared with the open approach. Robotic renal surgeries have not shown any significant clinical benefit over a laparoscopic approach, whilst the associated cost is significantly higher.

Conclusion

With the high cost and lack of overt clinical benefit of the robotic approach, laparoscopic renal surgery will likely continue to remain relevant in treating various urological pathologies.

Redo laparoscopic pyeloplasty among children: A systematic review and meta-analysis

Laparoscopic pyeloplasty (LP) is more beneficial than open procedures. However, studies on laparoscopic management of cases with secondary ureteropelvic junction obstruction (SUPJO) after previous failed pyeloplasty in the pediatric population are lacking. This meta-analysis aimed to assess the difference between redo LP (RLP) and redo open pyeloplasty (ROP) for children with SUPJO, focusing on certain criteria. All recent studies on RLP and ROP in children with SUPJO were searched. Search engines such as Medline, PubMed, and The Cochrane Library of Systematic Reviews were used. Sixty citations were specified. Two reviewers extracted data independently, screened the titles, and assessed the quality of each citation. Continuous data reported as a weighted mean difference (WMD) (95% confidence interval) and dichotomous data reported as relative risk were used. We measured the length of hospital stay (LOS) and operative time using weighted mean and success and complication rates using risk difference and odds ratio (OR). A random effects model was used to pool OR that was tested for heterogeneity. We specified six publications that minutely met our eligibility standards. Meta-analysis of given data resulted in the following: ROP showed reduction in operative time by 12 min (WMD: 12.7 min; P = 0.14). RLP had shorter LOS than ROP (WMD: 0.6 days; P < 0.01). No difference was observed in complication and success rates (OR: 0.8; P = 0.50 and OR: 1.2; P = 0.51, respectively). In conclusion, RLP seems to be better than ROP in terms of LOS reduction; however, both are comparable with respect to success and complication rates, especially postoperative urine leakage.

Simultaneous Robot-assisted Laparoscopic Excision of Pre-pyloric Gastrointestinal Stromal Tumor and Cholecystectomy

Operating on more than a single procedure in a same surgical intervention saves time, anesthesia duration and can increase the overall quality of life by lowering the duration of hospital stay and minimizing patient anxiety. But such interventions require expertise, high surgical performance, and precision in anatomical manipulation. We present a case of an outstanding performance of a unique minimally invasive simultaneous approach of removing a pre-pyloric gastrointestinal stromal tumor (GIST) along with a cholecystectomy by a robot-assisted laparascopic surgical system.

So far, only 33 cases of GIST have been reported in literature that were managed by robot-assistance, and this case is the first of its kind. This is the case of a 60-year-old overweight female who presented for a follow-up for chest discomfort, shortness of breath, chronic gastric reflux and classical features of cholecystitis along with diarrheal and constipation episodes. A gastroduodenoscopy showed a mass in the pre-pyloric area that extended in the luminal cavity. A robot-assisted laparascopic approach was planned, and with precision and surgical expertise the mass was removed along with a cholecystectomy. The surgical specimen were confirmed on histopathology.

Optimal Length of Follow-up for the Detection of Unsuccessful Pediatric Pyeloplasty: A Single-Center Experience

OBJECTIVES

To assess the optimal length of follow-up for patients undergoing both open and minimally invasive pyeloplasties to ensure prompt detection of a recurrent obstruction. There are no standard guidelines on ideal follow-up and imaging post-pediatric pyeloplasty currently.

METHODS

A retrospective chart review identified 264 patients (<18 years old) who underwent pyeloplasty for ureteropelvic junction obstruction between April 2002 and December 2014. Ultrasound was obtained every 3-4 months for the first year following pyeloplasty and thereafter at discretion of treating physician. Patient characteristics including symptoms and imaging were reviewed.

RESULTS

Of the 264 patients, 72% were male with mean age of 51 months and follow-up of 26.8 months. Approximately 73% followed up to 3 years. Fourteen patients (5.3%) had a recurrent obstruction. Among the failures, 85% were diagnosed and underwent successful redo pyeloplasty within 3 years. Six infants had a recurrence (43% of all unsuccessful surgeries) and were diagnosed within 3 years of the initial surgery. Patients undergoing a minimally invasive procedure were less likely to be followed for more than 3 years compared to an open procedure (p < 0.001). Patients with severe hydronephrosis preoperatively were followed longer (p = 0.031). Age at surgery and type of surgical approach (p < 0.01) were significant predictors of length of follow-up in a negative binomial regression.

CONCLUSION

Based on the results, a minimum of 3 years of follow-up is necessary to detect the majority of recurrent obstructions. Those patients who have higher than average lengths of follow-up tend to be younger and/or underwent an open surgical approach.