Combined treatment of ureteropelvic junction obstruction and renal calculi with robot‐assisted laparoscopic pyeloplasty and laser lithotripsy in children: Case report and non‐systematic review of the literature

Abstract

Objective(s) 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. Patient and Method(s) 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 48 h following surgery. At subsequent regular follow‐up examinations over a period of 24 months, no signs of recurrence were detected for both ureteropelvic junction obstruction and stone disease. Result(s) 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.

Comparison of the Safety and Efficacy of Laser Versus Pneumatic Intracorporeal Lithotripsy for Treatment of Bladder Stones in Children

“…Currently, pneumatic, laser and, to a lesser extent, electrohydraulic lithotripters are used to fragment stones in children [16]. Recent advances in robotic surgery will open the doors for even less invasive robotic-assisted removal of bladder stones in pediatric patients [12][13][14].…”

“…The superior advantage of MIS is the possibility of removing bladder stones through the navel, utilizing an endobag, without crushing them [11]. Moreover, robot-assisted laparoscopic surgery has demonstrated efficacy in the treatment of large-volume stones, especially in conditions requiring simultaneous reconstruction [12]. However, robotic surgery in pediatric bladder stones or urolithiasis still needs more evidence to be implemented within the practice [13,14].…”

Robotic Surgery: Is There a Possibility of Increasing Its Application in Pediatric Settings? A Single-Center Experience

“…Improved instruments, in fact, allow complex surgical procedures to be performed in low-weight children without additional difficulty. Other studies [ 14 , 15 ] have also reported case series demonstrating the safety and feasibility of the robot in pediatric surgery.…”

A combined approach of robot-assisted laparoscopic pyeloplasty and flexible endoscopy to treat concomitant ureteropelvic junction obstruction and calyceal stones in children: Technical considerations and review of the literature

“…A literature search was performed and five articles were identified which reported experience in using the combined approach of RALP and flexible endoscopy to treat concurrent UPJ obstruction and renal calculi in children ( Table 1 ). These include two multi-institutional case series ( 9 , 10 ), two single-institution case series ( 11 , 22 ), and one case report ( 23 ). Lee et al was the first to report the successful management of concomitant UPJ obstruction and renal stone in an adolescent by the combined approach of RALP with flexible nephroscopy ( 22 ).…”

“…The authors reported a 100% success rate in the concurrent correction of UPJ obstruction and stone extraction using the combined approach of RALP and flexible endoscopy ( 11 ). Two studies also reported using laser lithotripsy via flexible nephroscopy to fragment the stones where they were too big to be directly removed from the calyces ( 10 , 23 ). In the absence of concomitant UPJ obstruction, robot-assisted pyelolithotomy combined with flexible nephroscopy has been reported as a viable option to manage complex and challenging cases of nephrolithiasis in both adult ( 24 – 26 ) and pediatric populations ( 9 , 10 , 22 ) where other standard modalities may not be feasible due to altered anatomy, where the stone burden is large, or when multiple prior procedures have been attempted but failed.…”