ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY IN CHILDREN

This study aimed to compare the effects of various trocar placements in robot-assisted and laparoscopic pyeloplasty involving children diagnosed with obstruction of the ureteropelvic junction (OUPJ). We retrospectively collected the data on 74 patients under 14 years of age who had been diagnosed with OUPJ; these patients underwent either robot-assisted or laparoscopic pyeloplasty in our hospital between January 2015 and November 2021. There were four groups, as follows: •Laparoscopic multiport pyeloplasty (LMPY),•Laparoscopic single-port pyeloplasty (LSPY),•Robotic-assisted multiport pyeloplasty (RMPY),•Robotic-assisted single-port-plus-one pyeloplasty (RSPY).Patients' characteristics as well as their perioperative and follow-up data were collected and evaluated. There was no significant difference in the data regarding patients' characteristics. These data included the grade of hydronephrosis according to the Society of Fetal Urology (SFU grade), anterior and posterior diameter of the renal pelvis and ureter (APDRPU), and the differential degree of renal function (DRF) at following time points: preoperative, postoperative, and comparison of preoperative and postoperative. There was no difference among these groups. During surgery, the time of trocar placement, urethroplasty time, and total operative time in the robotic groups (RMPY and RSPY) were longer than those in the laparoscopic groups (LMPY and LSPY). However, the ratio of the urethroplasty time and full operative time (UT/WT) in the robotic groups (RMPY and RSPY) was lower than that in the laparoscopic groups (LMPY and LSPY) (P = 0.0075). Also, the volume of blood loss was lower in the robotic groups (RMPY and RSPY) than that in the laparoscopic groups (LMPY and LSPY), although there was no statistical difference (P = 0.11). There were, however, significant differences in hospitalization days (P < 0.0001) and parents' cosmetic satisfaction scores (P < 0.001). There were no differences in fasting time, the length of time that a ureteral catheter remained in place, or the number of postoperative complications. Our study shows that both robotic multiple-port and single-port-plus-one approaches are comparable, with laparoscopic multiple-port and single-port approaches equally effective in resolving OUPJ in children. Robotic and single-port-plus-one approaches may be associated with some advantages in hospitalization time and cosmetic outcomes; therefore, these approaches may be useful in urologic surgery that requires precise suturing, especially in pediatric patients.

Background: Historically open pyeloplasty has been regarded as the gold standard for the surgical management of ureteropelvic junction obstruction (UPJO). The treatment of this condition has evolved considerably over the past two decades resulting in new surgical approaches. One of these approaches is laparoscopic pyeloplasty,this technique aimed to achieve the same results as open surgery,with lower rates of morbidity and complications. Aim of the study: To compare the operative time,hospital stay,analgesic use,perioperative complications,and success rate between laparoscopic and open pyeloplasty in Al Diwaniya Teaching Hospital. Patients &amp; Methods: From October 2014 to October 2016,40 patients (26 males and 14 females) with Ureteropelvic junction obstruction who had been admitted to the urology unit of Al Diwaniya Teaching Hospital were enrolled in this study. Their ages ranged from 10 to 44 years with a mean age of 24 years. The patients were selected on the basis of standard indications for PUJO repair. The patients were assigned into two groups. Twenty patients underwent transperitoneal laparoscopic pyeloplasty and 20 patients underwent open surgery. The choice between the two types of operation was selected according to surgeon's preference (only surgeon who has enough experience with laparoscopic surgeries perform laparoscopic pyeloplasty,while the other performed open surgery). Preoperative evaluations were done using abdominal ultrasound and IVP. Laboratory tests included urinalysis,urine culture,blood urea,and serum creatinine. Blood group was determined. We compared the operative time,complications rates,hospital stay and success rate of the two groups.Mean operative time was 2 hours and 3 hours in open and laparoscopic pyeloplasty groups,respectively. Mean hospital stay was shorter (24 hours) in the laparoscopic group and (48 hours) in open group. Mean follow-up period was 9 months. Postoperative complication rates were 20 % and 30 % in laparoscopic and open pyeloplasty groups,respectively. Success rates were 95% and 90 % for open and laparoscopic pyeloplasty groups,respectively. Repeated surgery was performed in 2 patients of laparoscopy and 1 of open pyeloplasty groups due to recurrence of stricture.The safety and efficacy of laparoscopic pyeloplasty is comparable to that of open pyeloplasty,with better cosmetic results and shorter hospital stay,therefore laparoscopic pyeloplasty can replace open surgery and may be considered the gold standard technique for the treatment of ureteropelvic junction obstruction in expert hands.

Ureteropelvic junction obstruction (UPJO) is a common cause of hydronephrosis in children. We aimed to investigate the efficacy of robotic-assisted laparoscopic pyeloplasty (RALP) in newborns with UPJO compared to laparoscopic pyeloplasty (LP). We conducted a retrospective study of newborns aged ≤ 3 months who underwent RALP or LP from May 2018 to December 2023. Only primary pyeloplasty cases were included. Seventy-seven newborns (RALP = 46; LP = 31) were enrolled and no significant difference in the newborns’ demographics and pre-operative parameters was found. The mean operation time (OT) was 161.30 ± 29.07 min (RALP) and 200.60 ± 26.66 min (LP) (P < 0.0001), and the mean hospitalization stay was 7.80 ± 1.13 days (RALP) and 9.32 ± 1.19 days (LP) (P < 0.0001). RALP was associated with a higher hospitalization cost than LP (73449 ± 8513 yuan vs. 40152 ± 7555 yuan; P < 0.0001). The effectiveness and safety of RALP for treating UPJO in newborns is comparable to that of LP. In addition, RALP might have advantages over LP with its faster recovery and less trauma.

To compare the outcomes of Laparoscopic pyeloplasty (LP) with those of Robot-Assisted Laparoscopic pyeloplasty (RALP) in infants. A retrospective analysis of anteroposterior diameter, split renal function success rate, reoperation rate, and complication rate was done. A total of thirty-nine patients and 42 units of kidneys underwent LP, while thirteen patients and 14 units underwent RALP. There was a significant improvement in APD and SRF in both groups. However, the percentage changes in APD and SRF were not significantly different in the LP and RALP groups. The mean operative time in RALP (182 ± 14.8min) was significantly longer than the mean OT in the LP group (166 ± 21.5min), with a p-value of 0.005. The success rates of infant pyeloplasty were 95.3% in the laparoscopic group and 93% in the robotic-assisted group, which are comparable with each other. The success rates, outcomes, length of stay, and complication rates were similar between the two techniques, although robot-assisted pyeloplasty was associated with a longer operative time. Thus, the minimally invasive surgery, both LP and RALP, can be safely performed in infants with comparable complication and success rates.

Through the comparison with laparoscopic pyeloplasty, this paper discusses the clinical value of robot assisted laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction (UPJO). 82 patients with UPJO admitted to the First Affiliated Hospital of Medical College of Zhejiang University from January 2012 to December 2018 were retrospectively analyzed, including 43 patients who underwent robot assisted laparoscopic pyeloplasty (RALP group); Laparoscopic pyeloplasty was performed in 39 cases (LP group). The operation time, reconstruction suture time, intraoperative bleeding, postoperative drainage, postoperative intestinal recovery time, postoperative hospitalization time, hospitalization expenses, surgical complications and follow-up were compared and analyzed between the two groups. There was no significant difference between the two groups in operation time, renal pelvis reconstruction time, intraoperative bleeding, postoperative drainage tube stopping time, postoperative drainage volume and intestinal recovery time (P > 0.05); and the postoperative indwelling time of urinary catheter and postoperative hospital stay in RALP group were shorter than those in LP group (P < 0.05); The hospitalization cost in RALP group was significantly higher than that in LP group. Clavien Grade II complications occurred in 8 cases in LP group, Clavien Grade II complications occurred in 2 cases in RALP group, and there was 1 case of Grade III complications in both groups. The complication rate was 6.79% in RALP group and 23.07% in LP group. There was significant difference between the two groups (P < 0.05). During the postoperative follow-up, hydronephrosis was aggravated in 1 patient in RALP group half a year after operation, and hydronephrosis was aggravated in 1 patient in LP group due to ureteral stone obstruction. Another patient in LP group was found to have more hydronephrosis than before. The success rate was 97.7% in RALP group and 94.8% in LP group. There was no significant difference between the two groups (P > 0.05). Compared with laparoscopy, robot assisted laparoscopic pyeloplasty is a better surgical option. With the reduction of cost, it will gradually replace laparoscopic pyeloplasty.

Practice trends in contemporary management of adult ureteropelvic junction obstruction

Does the use of 5 mm instruments affect the outcomes of robot-assisted laparoscopic pyeloplasty in smaller working spaces? A comparative analysis of infants and older children

To investigate the technique of laparoscopic pyeloplasty in children with pelvi-ureteric junction (PUJ) obstruction. Six children, aged between 2.5 and 15 years, were treated by laparoscopic pyeloplasty in a prospective study. The outcome was assessed by post-operative isotopic renography. Four of the children underwent a Y/V plasty of the PUJ structure and one a Hynes-Anderson dismembered pyeloplasty. One case (the first in this series) was converted to open pyeloplasty due to adhesions around the PUJ from previous surgery. One patient developed an abdominal haematoma at the trocar site, which resolved without treatment. All anastomoses were completed without complication. Five of the children had normal or significantly improved drainage times on post-operative renography. In one patient, the drainage time deteriorated post-operatively, although differential function of the operated kidney improved. These early results suggest that laparoscopic pyeloplasty in children is feasible, safe and effective; a longer term follow-up is awaited.

Objective: To describe and analyze our experience with secondary robot-assisted laparoscopic pyeloplasty (RALP) and conventional laparoscopic pyeloplasty (LP) in treating recurrent ureteropelvic junction obstruction (UPJO) after primary pyeloplasty. Methods: Patients who underwent secondary RALP or LP for recurrent UPJO were retrospectively analyzed. Baseline characteristics, detailed history of previous pyeloplasty, operative profile and follow-up data were collected and analyzed. Results: Among 29 patients presented with recurrent UPJO, 15 patients underwent secondary RALP. Both groups (RALP or LP) were comparable in baseline characteristics and detailed history of previous pyeloplasty. The mean operative time, suturing time, and hospitalization time of patients in RALP group were significantly less than those in LP group. The mean operative time of RALP group was 2.1 h, while the mean operative time of LP group was 3.23 h. The average suturing time of LP (62.43 min) is about 3 times that of RALP (21.47 min). The overall mean follow-up data was 23 months. The success rate of the RALP group and LP group was 87.7 and 85.7% respectively. Conclusion: Compared to LP, RALP may be a better choice for the treatment of recurrent UPJO. Further high-quality clinical studies are needed to confirm the superior nature of RALP.

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.

Objective:To evaluate the role of nondismembered laparoscopic pyeloplasty and percutaneous endopyelotomy for ureteropelvic junction obstruction (UPJO) with low volume renal pelvis.Material and Methods:Retrospective acquired data of 34 patients of laparoscopic nondismembered pyeloplasty was compared with 26 patients of UPJO with pelvic volume less than 50 ml undergoing antegrade endopyelotomy and analyzed for clinical parameters, operative outcomes and success of procedures. All patients were followed up clinically and with diuretic renogram at regular intervals.Results:Mean age, renal pelvic volume and preoperative glomerular filtration rate (GFR) was 25 years, 43.6 ml and 42.5 ml/min, respectively in endopyelotomy group and 21 years, 34.4 ml and 39.9 ml/min, respectively in laparoscopic pyeloplasty group. Mean operative time, postoperative analgesic requirement and mean hospital stay was 100min, 250 mg and 4 days, respectively in endopyelotomy group and 210 min, 300 mg and 4 days, respectively in laparoscopic pyeloplasty group. Only operative time was significantly different between two groups (P < 0.05). Mean follow-up was 36 and 39 months and success rates were 91.2% and 88.8% in laparoscopy and endopyelotomy group, respectively (P < 0.05). No significant complication was seen in endopyelotomy group while two patients had hematuria (one requiring blood transfusion) and three had increased drain output for more than 3 days in laparoscopy group.Conclusion:Percutaneous endopyelotomy is associated with significantly less operative time and postoperative complication rate and provides equivalent success in comparison to nondismembered laparoscopic pyeloplasty in patients with UPJO and low volume pelvis. It can be a preferred minimally invasive treatment modality for such patients.

Background: Ureteropelvic junction obstruction can lead to symptoms such as hydronephrosis and progressive renal damage. Authors explain present primary experiences about laparoscopic pyeloplasty and open pyeloplasty in the treatment of UPJO.Methods: A bidirectional non-randomized study from March 2012 to April 2015 was conducted at a tertiary care centre in southern India. A Total 37 cases, 18 patients in laparoscopic pyeloplasty group and 19 patients in open pyeloplasty group were included.Results: A total of 37 patients were included in the study. 18 patients underwent laparoscopic Anderson-Hyne's pyeloplasty, 19 patients underwent open Anderson-Hyne's pyeloplasty patients. Outcomes were measured in terms of pain, surgery duration, postoperative pain, complications which were significant.Conclusions: Laparoscopic pyeloplasty was found to be better in terms of postoperative pain, hospital stay and complications.

To compare the postoperative outcomes including the cosmetic results of robotic-assisted laparoscopic pyeloplasty (RALP) performed with and without assistant port in pediatric population. 47 patients with ureteropelvic junction obstruction consecutively underwent RALPwere stratified as: three-port (Group 1, n = 26) and four-port (Group 2, n = 21). In Group 1, no assistant port was placed and double-J stent was introduced with the aid of an angiocatheter via the percutaneous route. In group 2, an assistant port was placed. The Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale(VSS), Satava, Clavien classification systems, and success rates were compared. We found similar success rates for both groups (group 1:96.2%, group 2:100%). Two groups were similar in terms of improvement in the postoperative anteroposterior diameter of the renal pelvis and parenchymal thickness. There was no difference in terms of perioperative and postoperative complication rates (group 1:19.2%, group 2:9.5%). The total PSAS was significantly lower in Group 1 (p < 0.008). No difference was observed for VSS and OSAS. Using an assistant port does not improve the success or complications of RALP, while the cosmetic outcomes are inferior to three-port RALP in children. We suggest avoiding the use of assistant port during RALP in children.

Laparoscopic Pyeloplasty for Secondary Ureteropelvic Junction Obstruction

The incidence of urinary tract stone disease is steadily increasing in both adult and paediatric populations. This condition develops due to different factors: dietary or metabolic alterations, infection, and congenital anatomic malformations. Standard indications and treatments for children are analogous to the ones indicated for adults. Extracorporeal shock wave lithotripsy, ureterorenoscopy and percutaneous nephrolithotomy (PCNL) should be preferred to more invasive techniques. Moreover, the introduction of laparoscopic and robot-assisted laparoscopic approaches have improved surgical outcomes, lowering the bleeding risk with higher stone-free rates, even in complicated cases. Despite these well-known improvements, there are few reports regarding laparoscopic robot-assisted management for urinary tract stone disease in paediatric patients under the age of 10, especially with concomitant treatment of ureteropelvic junction obstruction and multiple calyceal stones. A 4-year-old child was referred for recurrent right abdominal flank pain, macroscopic haematuria and a previous history of urinary tract infections. A computed tomography of the abdomen showed right ureteropelvic junction obstruction associated with multiple unilateral stones located in the renal pelvis and in the interpolar renal calyces. Due to its complexity, we held a multidisciplinary meeting with paediatric surgeons and nephrologists to determine optimal treatment. As a result, a combined robot-assisted laparoscopic pyeloplasty (LP) and renal calculi holmium laser lithotripsy using a digital flexible ureteroscope through an abdominal robotic trocar was performed. No post-surgical complications were recorded, and the patient was discharged within 48h following surgery. At subsequent regular follow-up examinations over a period of 24months, no signs of recurrence were detected for both ureteropelvic junction obstruction and stone disease. Robot-assisted LP with concomitant laser lithotripsy is a reasonable treatment option for designated young paediatric patients with challenging ureteropelvic junction obstruction complicated by urolithiasis, especially in cases where stones are not amenable with standard procedures.