Comparing Robot-Assisted Laparoscopic Pyeloplasty vs. Laparoscopic Pyeloplasty in Infants Aged 12 Months or Less

IntroductionThe historical gold standard treatment for ureteropelvic junction obstruction (UPJO) was the open Anderson–Hynes dismembered pyeloplasty (OP). Minimally invasive surgery (MIS) procedures, including laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP), have been reported to achieve better outcomes (i.e., decreased morbidity, reduced postoperative pain, superior esthetic results, and shortened length of hospital stay, LOS), with a success rate similar to OP. The main limitation of the MIS approach is the age and weight of patients, limiting these procedures to children >1 year. This study aims to evaluate the feasibility and benefits of MIS pyeloplasty compared to OP to surgically treat UPJO in children <1 year of age.Materials and methodsA systematic review was independently performed by two authors. Papers comparing both techniques (MIS pyeloplasty vs. OP) in infants were included in the meta-analysis. Data (mean ± DS or percentage) were analyzed using Rev.Man 5.4 A p < 0.05 was considered significant.ResultsNine studies (eight retrospective and one prospective) meet the inclusion criteria. A total of 3,145 pyeloplasties have been included, with 2,859 (90.9%) OP and 286 (9.1%) MIS. Age at operation was 4.9 ± 1.4 months in OP vs. 5.8 ± 2.2 months in MIS, p = ns. Weight at surgery was 6.4 ± 1.4 kg in OP vs. 6.9 ± 1.4 kg in MIS, p = ns. Operative time was 129.4 ± 24.1 min for OP vs. 144.0 ± 32.3 min for MIS, p < 0.001. LOS was 3.2 ± 1.9 days for OP vs. 2.2 ± 0.9 days for MIS, p < 0.01. Postoperative complications were present in 10.0 ± 12.9% of OP vs. 10.9 ± 11.6% in MIS, p = ns. Failure of surgery was 5.2 ± 3.5% for OP vs. 4.2 ± 3.3% for MIS, p = ns.ConclusionThe development of miniaturized instruments and technical modifications has made MIS feasible and safe in infants and small children. MIS presented a longer operative time than OP. However, MIS seemed effective for treating UPJO in infants, showing shortened LOS compared to OP. No differences have been reported with regard to the incidence of postoperative complications and failure of pyeloplasty. Given the low quality of evidence of the meta-analysis according to the GRADE methodology, we would suggest limiting MIS procedures in infants to only those high-volume centers with experienced surgeons.

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“…LAP + RALP ( 13 , 28 ); one was excluded ( 28 ) due to incomplete information. Two papers ( 23 , 29 ) treating RALP vs. LAP were excluded.…”

Section: Resultsmentioning

confidence: 99%

Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and meta-analysis

et al. 2022

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“…They reported success rate was 91% with LAP and 96% with RAP. Again no difference were identified between LAP and RAP but the authors refers a faster recovery and a shorter learning curve with RAP ( 12 ). Similarly, in our study we found that robotic assisted pyeloplasty (RAP) and laparoscopic pyeloplasty (LAP) are comparable in operative time, length of stay, success rate, and post-operative hydronephrosis grading.…”

Section: Discussionmentioning

confidence: 99%

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

Pérez-Marchán

Pérez-Brayfield

2022

Front. Pediatr.

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BackgroundUreteropelvic 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.MethodsWe 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.ResultsA 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.ConclusionBoth 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.

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“…The existing literature has illustrated the techniques of using four ports or four ports with an extra percutaneous liver retractor in the combined approach of robot-assisted laparoscopy and flexible nephroscopy in children ( 9 – 11 , 23 ). As we routinely perform RALP on infants to adolescents using three ports only ( 12 , 32 ), we decided to incorporate flexible nephroscopy into our standard techniques for pediatric RALP without adding extra ports. A complete and thorough examination of the entire calyceal system is critical to stone clearance.…”

Section: Discussionmentioning

confidence: 99%

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

Wong

Lo²,

Pang³

et al. 2022

Front. Pediatr.

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The management of children with concomitant ureteropelvic junction (UPJ) obstruction and calyceal stones remains challenging. The various treatment options available for pediatric nephrolithiasis may require multiple sessions, and the techniques by themselves are not designed for simultaneous correction of UPJ obstruction. Recently, success in combining robot-assisted laparoscopic pyeloplasty (RALP) and flexible endoscopy has been reported by multi-institutional studies to treat children with concomitant UPJ obstruction and renal stones. Given the paucity of technical details of this novel approach in the existing literature, we herein report our techniques to treat two girls aged 6 and 10 years who had concomitant UPJ obstruction and multiple stones in mid- and lower poles calyces. Three robotic ports were used without any assistant ports. A flexible endoscope, either a cystoscope or a single-use ureteroscope, was introduced via the undocked epigastric port to perform nephroscopy and stones removal after the renal pelvis was opened. The rest of the RALP was completed in the usual manner. Technical modifications were employed to facilitate the flexible endoscope to examine the entire calyceal system. Both patients underwent successful surgical procedures by the combined approach without any intra- or post-operative complications. Three and 14 stones were removed from each of the patients respectively. Postoperative investigations demonstrated successful correction of UPJ obstruction and complete stone clearance in both patients. A combined approach of RALP and flexible endoscopy is a safe and effective technique to treat concurrent UPJ obstruction and calyceal stones in children.

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Comparing Robot-Assisted Laparoscopic Pyeloplasty vs. Laparoscopic Pyeloplasty in Infants Aged 12 Months or Less

Cited by 10 publications

References 24 publications

Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and meta-analysis

Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and meta-analysis

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

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

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