Pyeloplasty For Ureteropelvic Junction Obstruction Research Articles

Single-port robot-assisted pyeloplasty using the da vinci SP system versus multiport pyeloplasty: Comparison of outcomes and costs

To investigate the feasibility of single-port (SP) robotic pyeloplasty by comparing perioperative outcomes with those of multiport (MP) robotic pyeloplasty. We reviewed the data from patients who underwent robot-assisted pyeloplasty for ureteropelvic junction obstruction (UPJO) at a single tertiary institution between March 2016 and May 2022. Radiographic and symptomatic improvements were assessed 3 months postoperatively. Propensity score matching was performed for age, sex, body mass index, and hydronephrosis grade. Of the 15SP-pyeloplasty and 28MP-pyeloplasty cases, 14 from each group were matched using 1:1 matching. The SP group had shorter console and operative times without significant differences. Blood loss was lower in the SP group than in the MP group (p=0.019). The length of hospital stay, opioid use on the operative day, and pain score at discharge did not differ between the two groups. The mean cost for surgery was higher in the SP group than in the MP group (p<0.001). The mean cost of hospitalization was comparable between the two groups (p=0.083). The cosmetic numerical rating scale scores were significantly higher in the SP group (p=0.014). Symptoms improved in all patients, and the radiographic improvement rates were 92.9% in the SP group and 100% in the MP group. SP-pyeloplasty showed cosmetic benefits, lower blood loss, operative time, and console time compared with MP-pyeloplasty. In patients who underwent surgery for UPJO for the first time, SP surgery can show comparable outcomes when compared to MP surgery.

Robotic-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction A retrospective review of a high-volume Canadian center.

At present, there is no literature on the outcomes of robotic-assisted laparoscopic pyeloplasty (RALPyelo) in a Canadian context. Our objective was to perform a retrospective review of RALPyelo cases at a high-volume Canadian center. We performed a retrospective review of patients who underwent RALPyelo at St. Michael's Hospital, between January 2012 and May 2019. Demographics, operative details, and pre- and postoperative imaging results (ultrasounds, computed tomography [CT] scans, and diuretic renal scan [DRS ]) were recorded. Patients were excluded if at least one-year followup data was unavailable. Our primary outcome was clinical and radiologic improvement defined as 1) symptom improvement; 2) stable/improved split renal function on DRS ; and 3) either improvement in the degree of hydronephrosis on ultrasound or CT, or improved drainage time on DRS. Secondary outcomes included postoperative complications, need for diagnostic intervention, and reintervention for recurrent UPJO. A total of 156 patients underwent RALPyelo after exclusions. The median age was 42 and 66% were female. Mean followup was 2.5 years. For our primary outcome, 87% had clinical and radiologic improvement. Diagnostic investigation for possible recurrent/persistent obstruction, based on symptoms and/or imaging results, was required in 17% of cases, but only 3% required reintervention for recurrent UPJO. Accordingly, the overall treatment success was 97%. The most common postoperative complication was urinary tract infection (18%), and urine leak was seen in only 2% of patients. The results of our study compare favorably with currently reported outcomes in the literature and demonstrate the safety and high level of success of RALPyelo at a high-volume Canadian center.

Minimally invasive pyeloplasty versus open pyeloplasty for ureteropelvic junction obstruction in infants: a systematic review and meta-analysis.

To compare the perioperative outcomes and success rates of minimally invasive pyeloplasty (MIP), including laparoscopic and robotic-assisted laparoscopic pyeloplasty, with open pyeloplasty (OP) in infants. In September 2022, a systematic search of PubMed, EMBASE, and the Cochrane Library databases was undertaken. The systematic review and meta-analysis were conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with the study registered prospectively in the PROSPERO database (CRD42022359475). Eleven studies were included. Dichotomous and continuous variables were presented as odds ratios (OR) and standard mean differences (SMD), respectively, with their 95% confidence intervals (CI). Compared to OP, a longer operation time and shorter length of stay were associated with MIP (SMD: 0.96,95% CI: 0.30 to 1.62, p=0.004, and SMD: -1.12, 95% CI: -1.82 to -0.43, p=0.002, respectively). No significant differences were found between the MIP and OP in terms of overall postoperative complications (OR:0.84, 95% CI: 0.52 to 1.35, p=0.47), minor complications (OR: 0.76, 95% CI: 0.40 to 1.42, p=0.39), or major complications (OR: 1.10, 95% CI: 0.49 to 2.50, p=0.81). In addition, a lower stent placement rate was related to MIP (OR: 0.09, 95% CI: 0.02 to 0.47, p=0.004). There was no statistical difference for success rate between the MIP and OP (OR: 1.35, 95% CI: 0.59 to 3.07, p=0.47). Finally, the results of subgroup analysis were consistent with the above. Our meta-analysis demonstrates that MIP is a feasible and safe alternative to OP for infants, presenting comparable perioperative outcomes and similar success rates, albeit requiring longer operation times. However, it is essential to consider the limitations of our study, including the inclusion of studies with small sample sizes and the combination of both prospective and retrospective research designs.

Robot-assisted pyeloplasty for ureteropelvic junction obstruction: initial experience with the novel avatera system.

This pilot study was designed to interpret the technically specific features of the avatera robotic system and present our initial experience with this novel platform in robot-assisted pyeloplasty (RAP). A single-center prospective study was conducted including all patients who underwent RAP with the avatera robotic system from June 2022 to October 2022 in our Department. Transperitoneal robot-assisted dismembered pyeloplasty was performed in all cases. The trocar placement and the surgical technique were similar in all patients. The successful completion of the procedures, operation time (including draping, docking and console time), decrease in hemoglobin postoperatively, and presence of any complications were the study's primary endpoints. In total, nine patients underwent RAP using the avatera system. All procedures were successfully completed. The draping of the robotic unit was completed in a median time of 10min (range 7-15), while the median docking time was 17min (range 10-24). The median console time was 88min (range 78-116) and no complications were noticed. The median hemoglobin drop was calculated to 0.7g/dL (range 0.4-1). During the mean follow-up of 9.33 ± 2.78months, no late postoperative complications were noticed. The early outcomes of the use of the novel avatera system in RAP are presented. All operations were successfully completed with safety and efficacy, without complications or significant blood loss.

Robot-assisted pyeloplasty for ureteropelvic junction obstruction in renal anomalies

The surgical video demonstrates the technical nuances of performing pyeloplasties on complex renal anomalies, including duplex, horseshoe, malrotated, and ectopic kidneys. The video also highlights the anatomic relationships of the affected kidney for proper port placement and positioning during the procedure.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children: Value of Robotic Assistance

AimRetroperitoneal pyeloplasty (RP) for pediatric ureteropelvic junction obstruction (UPJO) performed using retroperitoneoscopy (retro-RP) or robotic assistance (robo-RP) were compared. MethodsAll subjects were Japanese, matched for age, weight, and RP diameters. All RP were performed in the lateral decubitus position at a single institute by the same team using identical protocols. Five independent surgeons were asked to score intraoperative video recordings for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and rank RP as +1 if robo-RP appeared to be superior, 0 if they appeared to be the same, and −1 if robo-RP appeared to be inferior. ResultsRobo-RP performed 2018-2022 (n = 22) were matched with retro-RP performed 2011-2019 (n = 34). Mean overall operative times were similar (robo-RP: 305.2 ± 57.8 min versus retro-RP: 340.0 ± 117.9 min; p = 0.19), but securing the larger retroperitoneal space required for robo-RP took significantly longer; 50.8 ± 13.9 min versus 24.3 ± 9.6 min; p < 0.0001. Total anastomotic time (TAT) and TAT per suture were both significantly shorter for robo-RP (p < 0.0001). The coefficient of variation for time taken to place one suture was smaller for robo-RP than for retro-RP. DOS was lower for robo-RP with less variance (p < 0.01). Robo-RP had shorter drainage tube insertion, ambulated quicker postoperatively, and shorter hospitalization. Retro-RP had anastomotic complications; leaks (n = 2) and strictures (n = 2, requiring conventional open re-pyeloplasty). Robo-RP had no anastomotic complications and was ranked +1 unanimously. ConclusionsThe RP anastomosis was quicker with less complications and more precise with robotic assistance in matched patients under similar circumstances. Should RP be indicated, robo-RP is recommended. Level of evidenceIII.

Robotic-assisted surgery in pediatrics: what is evidence-based?-a literature review.

The use of robotic-assisted surgery (RAS) has increased more slowly in pediatrics than in the adult population. Despite the many advantages of robotic instruments, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) still presents some limitations for use in pediatric surgery. This study aims to examine evidence-based indications for RAS in the different fields of pediatric surgery according to the published literature. A database search (MEDLINE, Scopus, Web of Science) was performed to identify articles covering any aspect of RAS in the pediatric population. Using Boolean operators AND/OR, all possible combinations of the following search terms were used: robotic surgery, pediatrics, neonatal surgery, thoracic surgery, abdominal surgery, urologic surgery, hepatobiliary surgery, and surgical oncology. The selection criteria were limited to the English language, pediatric patients (under 18 years of age), and articles published after 2010. A total of 239 abstracts were reviewed. Of these, 10 published articles met the purposes of our study with the highest level of evidence and therefore were analyzed. Notably, most of the articles included in this review reported evidence-based indications in urological surgery. According to this study, the exclusive indications for RAS in the pediatric population are pyeloplasty for ureteropelvic junction obstruction in older children and ureteral reimplantation according to the Lich-Gregoire technique in selected cases for the need to access the pelvis with a narrow anatomical and working space. All other indications for RAS in pediatric surgery are still under discussion to date, and cannot be supported by papers with a high level of evidence. However, RAS is certainly a promising technology. Further evidence is strongly encouraged in the future.

Laparoscopic Transperitoneal Pyeloplasty for Ureteropelvic Junction Obstruction: Preliminary Results from 26 Cases

Laparoscopic Transperitoneal Pyeloplasty for Ureteropelvic Junction Obstruction: Preliminary Results from 26 Cases

Evaluation of Early and Late Clinical, Radiological and Scintigraphic Datas After Laparoscopic Pyeloplasty in Ureteropelvic Junction Obstruction

Ureteropelvic junction obstruction(UPJO) causes inadequate transport of urine from the renal pelvis to the ureter. Laparoscopic pyeloplasty(LP) is increasingly preferred in patients with UPJO. We aimed to compare the clinical, radiological and scintigraphic findings before the treatment and the early and late progress of the patients underwent LP for UPJO. Sixty-eight cases underwent LP for UPJO(January 2010-May 2016) were included. Demographic characteristics, clinical findings, intraoperative characteristics, data on preoperative and postoperative clinical, radiological and scintigraphic follow-ups of the cases were evaluated retrospectively. LP was performed in 68 patients(51 males, 17 females) for UPJO. Twenty-four patients with antenatal hydronephrosis, 46 patients with abdominal pain, hematuria and urinary tract infection(UTI) findings were diagnosed with UPJO. Patients were preoperatively followed up by USG and DTPA-MAG3 imaging. During surgery, aberrant vessel in 13(19.1%) patients, malrotation in 4(5.8%) and polyp in one(1.4%) patient were detected. Thirteen patients(19.1%) underwent surgery with the transmesoolic approach, 55 patients(80.8%) underwent retrocolic surgery, 33 patients underwent laparoscopy-assisted extracorporeal pyeloplasty. In postoperative period, patients were followed up at 1st, 3rd, 6th months and in the first year with USG and at 6th months with DTPA-MAG3 imaging. Postoperative USG follow up showed a decrease in hydronephrosis(p&amp;lt;0.001), an increase in parenchymal thickness(p&amp;lt;0.001), and a decrease in caliceal dilatation(p&amp;lt;0.001). In scintigraphic data, renal function was increased but it is not statistically significant(p&amp;gt;0.05) and activated half-time was decreased(p&amp;lt;0.05) in postoperative period. LP is a surgical treatment method with successful results when performed with appropriate indications in experienced clinics.

Application of three-dimensional visualization technology in laparoscopic pyeloplasty for ureteropelvic junction obstruction caused by crossing vessels: a retrospective comparative cohort study.

Ureteropelvic junction obstruction (UPJO) caused by crossing vessels is a common upper urinary tract abnormal development in which the vessels compress the upper segment of the ureter leading to different grades of hydronephrosis. Compared with routine computed tomography (CT) examination, three-dimensional visualization technology (3DVT) can help surgeons better understand the anatomical structure of the target surgical area. The aim of this study was to investigate the clinical value of 3DVT for the diagnosis, preoperative surgical planning, perioperative outcomes, and patient education of UPJO caused by crossing vessels. In this study, we retrospectively analyzed the clinical data of 28 patients who were admitted to the Department of Urology in Xiangya Hospital between January 2016 and December 2021 presenting with UPJO caused by crossing vessel compression. Among the 28 patients included, 13 patients underwent preoperative 3DVT and 15 patients underwent routine computed tomography (CT) scans. After the initial evaluation, all patients received standardized dismembered LP. The 2 groups of patients were compared in terms of demographic parameters, intraoperative data, and perioperative results. After surgery, all patients were asked to complete a Likert scale questionnaire to gain insight into their understanding of the disease and surgery, as well as their satisfaction with the use of different imaging techniques. There were no statistically significant differences in age, gender, body mass index (BMI), side of obstruction, blood vessel compressing the ureteropelvic junction (UPJ), mean duration of hospitalization, and surgical efficacy between the 2 groups. However, the 3DVT group experienced a significant reduction in operation duration (120.8±7.0 versus 144.0±7.9 min, P=0.039), time required for dismemberment of the UPJ (14.8±1.7 versus 24.0±2.2 min, P=0.004), and the amount of intraoperative blood loss (60.8±10.5 versus 95.3±11.9 mL, P=0.041). The 3DVT group was also notably superior to the conventional CT group in terms of the overall levels of patient satisfaction and understanding of the disease and surgery. 3DVT is a helpful preoperative examination tool which can clearly show the anatomical relationship between crossing vessels and the UPJ. In addition, 3DVT can also help patients better understand their conditions and surgical plans, thereby improving patient satisfaction.

Impact of drainage technique on surgical treatment of ureteropelvic junction obstruction in adults

Introduction. Urinary drainage is a key part of ureteropelvic junction obstruction treatment. Both external and internal drainage methods have been widely used for many years, but there is now relevant research comparing these methods and their impact on surgical outcomes in adults. The aim of the current research was to assess the efficacy and safety of two different types of urinary drainage on adult pyeloplasty. Material and methods. We conducted a retrospective and prospective clinical controlled study in the Department of Urology at the Republican Clinical Hospital from Chisinau. We reviewed 118 consecutive adult pyeloplasties for ureteropelvic junction obstruction. In 62 (52.54%) patients, we used double-J ureteral stent insertion (DJ); in another 56 (47.46%) patients, we used different types of external drainage (ED): uretero-pyelo-nephrostomy, nephrostomy, or a combination of both. Operative time, hospital stay, use of analgesics, overall complications, type of complications, and success rates were compared between the two groups. Results. The mean operative time in the DJ group was 93.52±18.10 min. vs. 95.77±20.48 min. in the ED group (p = 0.001). The average postoperative hospital stay in the DJ group was 8.45±2.02 days vs. 14.71±3.45 days in the ED group (p=0.000). The DJ group used 7.77±3.48 analgesics on average, while the ED group used 9.86±4.64 (p = 0.006). Overall complication rate was 9.68% in the DJ group and 32.14% in the ED group (p = 0.002). The most frequent complication for all patients was acute pyelonephritis (12.71%): 4.84% in the DJ group vs. 21.43% in the ED group (p = 0.007). The success rate was 96.77% in the DJ group and 92.86% in the ED group. Conclusions. Both urinary drainage methods appear equivalent concerning overall success rates, but double-J ureteral stents are associated with a shorter operating time, fewer postoperative pain medications, a shorter postoperative hospital stay, and a lower number of postoperative complications compared with external urinary drainage methods.

Robotic-assisted pyeloplasty for ureteropelvic junction obstruction

Robotic-assisted pyeloplasty for ureteropelvic junction obstruction

Outcome Analysis of Reduction and Nonreduction Dismembered Pyeloplasty in Ureteropelvic Junction Obstruction: A Randomized, Prospective, Comparative Study.

Objectives:The objective of this study is to compare the changes in renal function and drainage following open dismembered pyeloplasty with and without renal pelvis reduction.Materials and Methods:Randomized prospective study of children with ureteropelvic junction obstruction undergoing pyeloplasty with (Group 1) and without (Group 2) pelvis reduction over an 18-month period. Postoperative function and drainage were assessed by ethylene dicysteine (EC) scan and intravenous urography (IVU) and renal pelvis size by ultrasonography.Results:Forty-two patients (2 months-11 years) participated. The mean preoperative EC scan function was Group 1: 45.88% ± 14.42% (5%–80%) and Group 2: 39.22% ± 9.75% (21%–53%). (P = 0.117). The mean postoperative EC scan function of Group 1 was 42.64% ± 9.62% (17%–54%) and 43.75% ± 9.88% (17%–58%) and of Group 2 was 44.77% ± 12.82% (20%–68%) and 42.25% ± 8.56% (23%–58%) at 3 months (P = 0.584) and ≥ 1year (P = 0.385), respectively, with no significant difference. None required re-do pyeloplasty. The number of patients with slow drainage, especially at 3 months and also at ≥1-year postoperative period on EC scan was slightly higher in Group 2 compared to Group 1 but did not attain statistical significance. There was postoperative improvement in function and drainage on IVU with no significant difference between the two groups, (P = 0.214; P = 0.99, respectively). At a mean follow-up of 45.5 months, Group 2 also showed significant reduction in pelvis size on ultrasound (P = 0.011).Conclusion:Postoperative function remained stable in both groups. More number of patients achieved unobstructed drainage by 3 mo postoperative after reduction pyeloplasty but drainage patterns were mostly similar between reduction and nonreduction of pelvis group in late follow-up.

Initial experiences with preoperative three-dimensional image reconstruction technology in laparoscopic pyeloplasty for ureteropelvic junction obstruction.

BackgroundTo explore the clinical value of three-dimensional image reconstruction technology (3DIT) on preoperative surgical planning and perioperative outcomes in laparoscopic pyeloplasty (LP).MethodsData of 25 patients with ureteropelvic junction obstruction (UPJO) admitted to our hospital from January 2018 to January 2019 was analyzed retrospectively. All patients underwent preoperative enhanced computed tomography (CT) scanning. In the 12 cases in the 3DIT group, preoperative planning involved the use of virtual operation and morphometry based on reconstruction of the CT data into three-dimensional (3D) images. Surgery in the other 13 cases was performed with traditional CT examination. Demographic, surgical outcome, and postoperative parameters were compared between these two groups.ResultsReconstructed 3D images clearly showed the spatial structural relationships between the UPJO and surrounding blood vessels. In all 25 cases surgery was completed with no conversion to open surgery. Preoperative 3DIT analyses resulted in significant improvements to mean operation time (107.76 vs. 141.58 min, P=0.024), mean time of dissociating ureteropelvic junction (UPJ) (11.26 vs. 19.40 min, P=0.020), and mean estimated blood loss volume (23.84 vs. 49.16 mL, P=0.028). There were no statistically significant differences in perioperative complications, postoperative hospital stays or postoperative drainage time.Conclusions3DIT based on enhanced CT scans is of clinical value in the treatment of UPJO, as it can provide accurate anatomical information and reliable guidance for preoperative operation planning, and it facilitates image-guided LP.

Long term outcomes following pyeloplasty for unilateral pelviureteric junction obstruction in paediatric patients

Background: Pelviureteric junction obstruction (PUJO) is the most common cause of pediatric hydronephrosis. The gold standard treatment for PUJO is Anderson hynes (AH) dismembered pyeloplasty. The parameters to assess the post-operative outcomes of pyeloplasty include reduction in the AP diameter of the pelvis and increase in parenchymal thickness. The aim of the study was to find out the long-term outcomes following pyeloplasty for Ureteropelvic junction obstruction (UPJO) in paediatric patients.Methods: A prospective study was done from September, 2014 to January, 2019. All children above the age of 2 months who presented with unilateral PUJO were included in the study. All patients underwent ultrasound of the kidneys and diuretic renogram. All patients underwent AH dismembered pyeloplasty. Success was defined as both symptomatic relief and radiographic resolution of obstruction at the last follow-up visit.Results: 60 patients with unilateral intrinsic PUJO were included in this study. Post-operatively split renal function (SRF) improved in 42 patients, remained stable in 13, and deteriorated in 5 cases. Post-operative renal drainage improved in 40 patients, remained stable in 15 and deteriorated in 5. The degree of hydronephrosis deteriorated in 5 cases but improved or was preserved in 55 cases. The renal parenchyma deteriorated in 7 cases. Overall success rate of AH dismembered pyeloplasty was 92%.Conclusions: Dismembered pyeloplasty is a safe and effective treatment of PUJO in the pediatric population. Majority of the patients had an improved split renal function, renal drainage, cortical thickness, and decreased degree of hydronephrosis.

Renal Cortical Thickness After Pyeloplasty in Pediatric Ureteropelvic Junction Obstruction.

PurposeThe main goal of pyeloplasty is to maintain or improve renal function. Diuretic renography is the gold standard for evaluating renal function after pyeloplasty. Renal ultrasonography (RUS) is commonly used to determine hydronephrosis in pediatric patients. We hypothesized that the change in the renal parenchymal cortex would predict pyeloplasty success. In this study, we aim to measure renal cortical thickness change after pyeloplasty in ureteropelvic junction obstruction patients.Materials and MethodsWe retrospectively reviewed 38 patients who underwent pyeloplasty between 2005 and 2019. We divided patients into three age groups and compared the difference of renal parenchymal thickness change by using generalized estimating equations to identify associated factors for renal cortical thickness change after pyeloplasty.ResultsThirty-nine kidney units were identified. The median age at the time of surgery was 41.61±40.99 months. Generalized estimating equations showed significant change of renal parenchymal thickness over the period of follow-up (p=0.02). The estimate of thickness change was 0.0373 mm/month. Age at the time of surgery was not associated with significant renal cortical thickness over the period of follow-up. The positive predictive factors for renal cortical thickness were creatinine clearance, pre-operative anteroposterior diameter and pre-operative renal differential function. The negative factors for decrease of renal cortical thickness were body weight, presentation with abdominal mass, and history of infection.ConclusionRenal cortical thickness after pyeloplasty was improved over the period of follow-up. Age at surgery was not associated with improvement of renal parenchymal thickness.

V03-05 ROBOT-ASSISTED LAPAROSCOPIC PYELOPLASTY FOR URETEROPELVIC JUNCTION OBSTRUCTION IN A Y-TYPE DUPLICATED COLLECTING SYSTEM

You have accessJournal of UrologyPediatrics (V03)1 Sep 2021V03-05 ROBOT-ASSISTED LAPAROSCOPIC PYELOPLASTY FOR URETEROPELVIC JUNCTION OBSTRUCTION IN A Y-TYPE DUPLICATED COLLECTING SYSTEM Zoe Gan, Katherine Fischer, and Aseem Shukla Zoe GanZoe Gan More articles by this author , Katherine FischerKatherine Fischer More articles by this author , and Aseem ShuklaAseem Shukla More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001991.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal duplication anomalies may present with a ureteropelvic junction obstruction (UPJO) affecting the lower moiety. A proximal partial ureteral duplication (Y-type ureter) is a rare associated finding and can render surgical repair more challenging. We present our technique for robot-assisted left lower pole pyeloplasty in the setting of a Y-type ureter demonstrating the anatomical considerations relevant for the adjacent upper pole ureter. METHODS: Cystoscopy and retrograde pyelogram were performed, and an open-ended catheter was placed across the lower pole UPJO for identification. The daVinci® robot platform was docked. The left colon and renal pelvis were mobilized medially to visualize the Y-type duplication and dilated lower pole. The lower pole ureter was dismembered and spatulated past the area of obstruction until unaffected normal ureter was reached. A stent was placed antegrade into the lower pole ureter, the anastomosis between the lower pole ureter and renal pelvis was performed, and excess renal pelvis was trimmed. A feeding tube was passed retrograde to identify and protect the upper pole ureter during the anastamosis, and minor spatulation was performed on the upper pole ureter to avoid compromising the insertion of the upper pole ureter into the renal pelvis. RESULTS: The patient was discharged on postoperative day 1. One month postoperatively, a renal bladder ultrasound showed resolved dilation of the lower pole, and the upper pole remained non-dilated. The stent was removed 2 months postoperatively. CONCLUSIONS: A lower pole UPJO in a Y-type duplex system may be repaired with a modified Anderson Hines dismembered pyeloplasty using a robot surgery platform. Additional consideration is given to maintain the patency and continuity of the adjacent unobstructed ureter. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e223-e223 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zoe Gan More articles by this author Katherine Fischer More articles by this author Aseem Shukla More articles by this author Expand All Advertisement Loading ...

Robotics and future technical developments in pediatric urology

Minimally invasive surgery (MIS) has represented the main innovation in the field of pediatric surgery and urology over the last 30 years. Pediatric MIS is a wide field, ranging from the standard laparoscopic surgery using 3-mm ports to robotics mainly adopted for pediatric urology indications. The aim of this paper was to summarize the current status of robotic surgery in pediatric urology and to evaluate possible future technical developments for this technique. In pediatric urology, many procedures are challenged by the narrow working space available in smaller children, the difficulty to perform complex and long suture lines to repair complex urinary malformations, and the challenge to remove renal or adrenal tumors. The main characteristic of robotic surgery is that the robotic instruments inserted into the abdominal cavity are remotely controlled by the surgeon, who is sitting at a console next to the patient or even far away, avoiding human tremor during complex suturing. Due to the magnification of the operative field view and the six degrees of freedom of the robotic instruments compared to conventional laparoscopic instruments, providing enhanced 3D vision and improved surgeon ergonomics, robot-assisted surgery appears to be beneficial over conventional MIS, especially in complex reconstructive procedures. Currently, there are two robotic systems available on the market and certified for robotic surgery in children: the DaVinci (Intuitive Surgical, since 2001) and Senhance (Transenterix, since 2020). However, almost the totality of papers published in the international literature are focused on robotic procedures using the DaVinci platform. Analyzing the current literature, there is no evidence about the indications where robotics are preferable to conventional MIS approaches. Currently, the main indications of robotic surgery in pediatric urology are: pyeloplasty for ureteropelvic junction obstruction (UPJO), ureteral reimplantation according to Lich Gregoire technique, Mitrofanoff procedure, nephrectomy or partial nephrectomy for oncological indications, removal of renal cysts, bladder neck reconstruction or removal of urinary tract stones. The future developments in this field are certainly represented by intraoperative use of indocyanine green (ICG) fluorescence imaging that permits to have a better vision of vascular anatomy or clearly identify nodes in case of tumors, and by development of 5G technology. The main limitation of robotic surgery today remains the excessive cost of the machine itself and the limited lifespan of robotic instruments. We believe that robotic surgery will surely represent the new field of development in pediatric surgery, but its widespread application will depend on the introduction of new robotic platforms in the market, that will certainly low the costs, and also to the development of smaller size instruments more suitable for pediatric use.

Comparative analysis of suturing technique in pediatric pyeloplasty on surgical outcomes.

Pyeloplasty for ureteropelvic junction obstruction is the gold standard for surgical repair. There are currently no reports outlining optimal suturing technique. This paper compares the effect of suturing technique in dismembered pediatric pyeloplasty (open and laparoscopic) on post-operative outcomes. A non-concurrent cohort study assessed different suturing techniques in both open and laparoscopic dismembered pyeloplasty performed two senior urologists at a tertiary referral pediatric center. Cases were stratified according to different suturing techniques for ureteropelvic anastomosis and subgroup analysis was performed according to open or laparoscopic approach. A total of 185 renal units were evaluated. The overall comparative analysis of different anastomotic suturing techniques and clustered analysis according to open and laparoscopic approach showed no significant differences on post-operative complication rate, leakage, stenosis, redo-pyeloplasties, operative time and hospital stay. There was a significant difference between suturing techniques on stent duration, age and weight of the patient. There was no effect of suture type or size on post-operative complication rate, leakage, UPJ stenosis and redo pyeloplasty rates, however, sample sizes were small. Suturing technique has no significant effect on the surgical outcomes assessed regardless of open or laparoscopic technique.

Renal functional improvement after pediatric pyeloplasty in kidneys with split renal function less than 20%: a single institute experience

BackgroundPediatric pyeloplasty in ureteropelvic junction obstruction (UPJO) is indicated in renal impaired drainage or renal function deterioration. The improvement of renal function after pediatric pyeloplasty is still controversial in poorly functioning kidneys. Past studies on poorly functioning kidneys had a variable SRF specification, and these studies often had a limited number of patients so that they did not achieve statistical significance. The study aims to detect the renal functional improvement after pediatric Anderson-Hynes pyeloplasty (AHP) with split renal function (SRF) less than 20% (poor renal function).ResultsA retrospective study included 46 pediatric patients with unilateral UPJO who underwent open AHP with SRF < 20% on a renal isotope scan from August 2012 to October 2018. Success was defined based on either improvement in symptoms, improvement in drainage on postoperative renography, and/or improvement or stability in SRF on the renal scan done 6 months postoperatively and yearly thereafter. Deterioration of SRF by more than 5% was deemed to be deterioration. An increase in SRF of more than 5% was deemed to be an improvement.A total of 46 patients with a mean age of 32 months with poor renal function on isotope renogram (SRF < 20%) were included. All patients had an obstructive pattern on the preoperative radionuclide scans. The median preoperative SRF was 9.26%. The mean (range) follow-up was 30 months. The success rate was 91.3%. Three patients underwent redo pyeloplasty, whereas a secondary nephrectomy was necessary for one. The remaining (42) patients showed stability or improvement of SRF with no further symptoms. Renal scintigraphy at 6 and 12 months after surgery revealed significantly increased SRF compared to preoperative one.ConclusionPoorly functioning renal unit with SRF < 20% can show functional improvement and recoverability after pediatric pyeloplasty.