Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes.

Marco Castagnetti,Massimo Iafrate,Ciro Esposito,Ramnath Subramaniam

doi:10.3389/fped.2020.00252

Abstract

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances.Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures.Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame.Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

Highlights

To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances
Multiple reports coming for different institutions prove that open pyeloplasty is safe and duplicable in the widespread use, and duplicability of the minimally invasive pyeloplasty (MIP) procedure is more controversial as the skills necessary to perform the procedure can be hard to achieve and maintain [5]
Gatte et al performing a randomized, prospective, controlled trial comparing laparoscopic vs. open pyeloplasty concluded that both approaches are comparable and effective methods for repair of pyelo-ureteric junction (PUJ) obstruction

Summary

Introduction

To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances. Open pyeloplasty has been for ages considered the gold standard treatment of pyelo-ureteric junction (PUJ) obstruction, and the standards of open pyeloplasty were set back in 1998 by Gerard Monfort [1]. The potential advantages of a minimally invasive approach for the dissection have never been questioned; the main hurdle lies with the accomplishment of the pyelo-ureteral anastomosis that can require advanced suturing skills and can be time-consuming even in experienced hands, a fact true with laparoscopic techniques [3]. In a systematic review and meta-analysis of open vs minimally invasive pyeloplasty (MIP) performed in 2014, Autorino et al observed that MIP procedures can achieve complication and success rates comparable to open surgery, the operating time still largely favors open pyeloplasty [4]. The most complex scenario is clearly that of a pyeloplasty performed in an infant [6], which is not an uncommon scenario with prenatal diagnosis, the most common presentation of PUJ obstruction, and most of these patients who require surgery do so in infancy [7]

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