Meta‐analysis of retroperitoneal vs transperitoneal laparoscopic and robot‐assisted pyeloplasty for the management of pelvi‐ureteric junction obstruction

Abstract

Objective To determine differences in perioperative outcomes between retroperitoneal and transperitoneal approaches for laparoscopic pyeloplasty (LP) to manage pelvi‐ureteric junction obstruction (PUJO) through a meta‐analysis of comparative studies. Methods A systematic search was performed in January 2020. Comparative studies were evaluated according to Cochrane Collaboration recommendations. Assessed outcomes included success and complication rates, conversion to open surgery, operative time (OT), length of hospital stay (LOS), estimated blood loss (EBL), analgesic requirements, regular diet resumption, and drain duration. Relative risk (RR) and standardised mean difference (SMD) with 95% confidence intervals (CIs) were extrapolated. Subgroup analyses were performed according to study design and techniques. International Prospective Register of Systematic Reviews (PROSPERO) number: CRD42020163303. Results A total of 18 studies describing 2007 cases were included. Overall pooled effect estimates did not show statistically significant differences between the approaches with regards to success rate (RR 0.99; 95% CI 0.97, 1.01), complications (RR 1.09; 95% CI 0.82, 1.45), OT (SMD 0.61; 95% CI −0.04, 1.26), LOS (SMD −0.30; 95% CI −0.63, 0.04), EBL (SMD −0.53; 95% CI −1.26, 0.21), or analgesic requirements (SMD −0.51; 95% CI −1.23, 0.21). Compared to the transperitoneal approach, retroperitoneal LP had a higher conversion rate (RR 2.40; 95% CI 1.23, 4.66); however, patients resumed diets earlier (SMD −2.49; 95% CI −4.17, −0.82) and had shorter drain duration (SMD −0.31; 95% CI −0.57, −0.05). Conclusion The evidence suggests that there are no significant differences in success rate, OT and complications between transperitoneal and retroperitoneal LP. Conversion rates are higher with the retroperitoneal approach; however, return to diet occurs faster and drain duration is shorter when compared to the transperitoneal approach.

Retroperitoneoscopy‐Assisted Dismembered Pyeloplasty With Single‐Site Plus One Port in Older Children With Congenital Hydronephrosis

“…Furthermore, it is possible to perform a precise ureteropelvic neoanastomosis under direct vison using a magnifier. The oral intake can be started earlier due to the minimum invasion for intraperitoneal organs 4,15 …”

“…The oral intake can be started earlier due to the minimum invasion for intraperitoneal organs. 4,15 If the accuracy of the ureteropelvic neoanastomosis is maintained, intraoperative DJ stent placement and an external stent are unnecessary. A network meta-analysis of the postoperative urinary drainage method after dismembered pyeloplasty in children showed no significant differences among DJ stent, external stent, and a stent-less procedure in operative time, operative success, hospital stay, improvement in renal functions, overall complications, or redo pyeloplasty, [16][17][18][19][20][21][22][23] concluding that each method has advantages and disadvantages.…”

“…procedure by Peters CA et al 2 In 2005, robot assisted dismembered pyeloplasty was reported by Atug F et al 3 A meta-analysis of retroperitoneal vs transperitoneal laparoscopic and robot-assisted pyeloplasty for the management of pelviureteric junction obstruction showed no significant differences in operative success rates, overall complications, operative time, use of analgesics, or hospital stay between the retroperitoneal approach and transperitoneal approach; however, the transperitoneal approach showed more urine leakage in the peritoneal space and delayed recovery of peristaltic activity than the retroperitoneal approach. 4 Therefore, we do not support the transperitoneal approach and prefer the retroperitoneal approach. In addition, it is challenging that the ureteropelvic neoanastomosis is associated with a longer learning curve in laparoscopic pyeloplasty than that in open surgery 5,6 ; and robotic surgery is expensive and not available in many institutions.…”

“…Dismembered pyeloplasty is the gold standard for surgical treatment of ureteropelvic junction obstruction (UPJO) in children 1 . In 1995, laparoscopic dismembered pyeloplasty was reported as a minimally invasive procedure by Peters CA et al 2 In 2005, robot assisted dismembered pyeloplasty was reported by Atug F et al 3 A meta‐analysis of retroperitoneal vs transperitoneal laparoscopic and robot‐assisted pyeloplasty for the management of pelviureteric junction obstruction showed no significant differences in operative success rates, overall complications, operative time, use of analgesics, or hospital stay between the retroperitoneal approach and transperitoneal approach; however, the transperitoneal approach showed more urine leakage in the peritoneal space and delayed recovery of peristaltic activity than the retroperitoneal approach 4 . Therefore, we do not support the transperitoneal approach and prefer the retroperitoneal approach.…”