Pyeloplasty In Infants Research Articles

Safety and Efficiency of Pyeloplasty in The First Six Weeks of Infants' Life.

The aim of this study was to assess the safety and the efficiency of pyeloplasty in infants with ureteropelvic junction obstruction (UPJO) in the first six weeks of their life. Clinical records of the patients who had surgery during first six weeks of life for UPJO between June 2009 and June 2014 were analysed retrospectively. In this period, twenty-six dismembered pyeloplasties were performed in twenty-four patients on mean operation age of 27.3 ± 10.2 days (range 8-42 days). On the first postnatal ultrasound all twenty-six renal units had SFU-4 hydronephrosis. Mean preoperative and postoperative anterior-posterior pelvic diameter and parenchymal thickness were 33.1 ± 8.9mm (range 14-49mm), 3.2 ± 1mm (range 1-4,6mm) and 14.7 ± 6.6mm (range 6-27mm) and 7.8 ± 1.9mm (range 3.0-10.4mm), respectively. The differences between preoperative and postoperative parenchymal thickness and anterior-posterior pelvic diameter were statistically significant (P ˂ 0.0001). Preoperative MAG3 dynamic renal scintigraphy showed obstructive pattern on the diuretic renogram in 26 units. Mean preoperative and postoperative differential renal function on dynamic renal scintigraphy of the affected renal units were 46 ± 15 and 44 ± 15, respectively. Postoperative drainage was normal on dynamic renal scintigraphy in 25 (96.2%) of the 26 units, redo-pyeloplasty was needed in only one unit (3.8%). In conclusion, patient selection and timing of surgery are very important in the protection of renal function in newborn with UPJO. In our opinion, if there is indication for surgery, early surgical intervention should not postpone in this period. Surgical treatment of UPJO during first six weeks of life is safe and effective.

MP71-05 PYELOPLASTY IN INFANTS: DOES THE TYPE OF SURGICAL MODALITY (OPEN, ROBOTIC) AND POSTOPERATIVE DRAINAGE TYPE AFFECT THE NUMBER OF POSTOPERATIVE PHONE CALLS BY PARENTS?

You have accessJournal of UrologyPediatrics: Upper Urinary Tract Disorders and Fetal Urology (MP71)1 Apr 2020MP71-05 PYELOPLASTY IN INFANTS: DOES THE TYPE OF SURGICAL MODALITY (OPEN, ROBOTIC) AND POSTOPERATIVE DRAINAGE TYPE AFFECT THE NUMBER OF POSTOPERATIVE PHONE CALLS BY PARENTS? Kathleen Puttmann*, Sang Hoon Song, Vinaya Bhatia, Jonathan Gerber, Rodolfo A. Elizondo, Duong Tu, Gene Huang, Huirong Zhu, Nicolette Janzen, Abhishek Seth, David Roth, Edmond Gonzales, and Chester Koh Kathleen Puttmann*Kathleen Puttmann* More articles by this author , Sang Hoon SongSang Hoon Song More articles by this author , Vinaya BhatiaVinaya Bhatia More articles by this author , Jonathan GerberJonathan Gerber More articles by this author , Rodolfo A. ElizondoRodolfo A. Elizondo More articles by this author , Duong TuDuong Tu More articles by this author , Gene HuangGene Huang More articles by this author , Huirong ZhuHuirong Zhu More articles by this author , Nicolette JanzenNicolette Janzen More articles by this author , Abhishek SethAbhishek Seth More articles by this author , David RothDavid Roth More articles by this author , Edmond GonzalesEdmond Gonzales More articles by this author , and Chester KohChester Koh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000951.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We hypothesize that drainage type influenced the number of post-operative calls by parents in infants undergoing open pyeloplasty and RALP. METHODS: We reviewed the perioperative information for all infants who underwent open or robotic pyeloplasty from 2011 – 2017. Demographic information was collected for each group as well as surgery length, intraoperative complications, estimated blood loss, hydronephrosis grade, drain type, parent phone calls 30 days postoperatively, analgesic use postoperatively, 30-day postoperative complications and Clavien grade, and reoperations. Means were compared using Fisher’s exact test for categorical variables and the Mann Whitney test for continuous variables. RESULTS: During the study period, 104 infant cases (69 open / 35 RALP) were completed by 7 surgeons. Drains were classified as external (Penrose) (50), nephroureteral catheter (16), or internal double J ureteral stents (38) with 8 patients having an additional external drain (Table 1). All 35 infant RALP cases (100%) received internal double J stents versus 3 (4%) of the infant open cases. While 40% of nephroureteral catheter cases were associated with documented parent phone calls, only 7.7% of external drain cases and 2.7% of double J stent cases had parent phone calls for drain/stent concerns. Nephroureteral catheters were also associated with higher pain control requirements in infants than with ureteral stents or external drains. Using multivariate logistic regression to adjust for patient age and weight, nephroureteral catheters in infants had a significantly higher likelihood of a parent phone call when compared with external drains or ureteral stents (p = 0.025 and p = 0.010). When compared to nephroureteral catheters, the odds of a documented parent phone call device was 95% lower with a ureteral stent and 85% lower with an external drain. CONCLUSIONS: Nephroureteral catheters were also associated with higher documented call rates and higher pain control requirements in infants than with ureteral stents or external drains. Avoidance of drains, catheters, or stents remains an option in this population as well. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1065-e1066 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kathleen Puttmann* More articles by this author Sang Hoon Song More articles by this author Vinaya Bhatia More articles by this author Jonathan Gerber More articles by this author Rodolfo A. Elizondo More articles by this author Duong Tu More articles by this author Gene Huang More articles by this author Huirong Zhu More articles by this author Nicolette Janzen More articles by this author Abhishek Seth More articles by this author David Roth More articles by this author Edmond Gonzales More articles by this author Chester Koh More articles by this author Expand All Advertisement PDF downloadLoading ...

Changes in differential renal function after pyeloplasty in infants and children

Ureteropelvic junction obstruction (UPJO) is one of the most common causes of hydronephrosis in pediatric populations. Many need surgical intervention. The aim of surgery is preserving renal function and reducing symptoms such as urinary tract infections and pain. The objectives were to evaluate differential renal function (DRF) in infants and children after surgery for UPJO and to identify factors predicting postoperative improvement. The difference in outcomes between patients with antenatal hydronephrosis and those diagnosed later was evaluated. A total of 85 children (63 boys and 22 girls) aged 0-16 years, treated for UPJO with dismembered pyeloplasty, were followed up as per a structured protocol including ultrasounds and renal scans (MAG-3) pre-operatively and three and 18 months postoperatively. Five children with bilateral or single kidney UPJO were excluded. Patient records were retrospectively reviewed, and the patients were grouped as per prenatal (group 1, n=23) or postnatal (group 2, n=57) diagnosis. Univariable and multivariable logistic regression analyses searching for factors predicting >5% postoperative improvement in DRF on the obstructed side were performed. Factors included in analyses were age at diagnosis and surgery, sex, type of presentation, cause of obstruction, estimated glomerular filtration rate, pre-operative DRF, anteroposterior diameter (APD), APD/renal parenchymal thickness, and grade of hydronephrosis as per the Onen alternative grading system (grade 1-4). Pre-operative DRF on the obstructed side was a mean of 42% (standard deviation, 12), with no difference between the groups. The median age at surgery was 0.9 (0.2-10) and 8.1 (0.6-16) years in groups 1 and 2, respectively (P<0.001). The majority had unchanged DRF 18 months postoperatively, 19 (27%) patients improved by >5%, and one deteriorated. The proportion of patients with improved DRF was higher in group 1 (n=10; 45%, P=0.026). Anteroposterior diameter, APD/parenchymal thickness, pre-operative DRF, and antenatal diagnosis were predictors in the univariable analyses, and high APD (odds ratio [OR] = 1.1, P=0.0023), antenatal diagnosis (OR = 0.23, P=0.048), and low pre-operative DRF (OR = 0.90, P=0.0045) built the best model of independent factors predicting improvement in DRF in multivariable analyses (Summary Figure). The limitation of the study is that it is retrospective, but it has the advantage of auniform follow-up protocol, including patients from a five-year period, with few lost to follow-up. The results can be of interest in evaluating factors of importance for predicting recovery of function in obstructive uropathies in children. The majority of children had preserved or improved function after surgery for UPJO. Those with an antenatal diagnosis displayed a greater ability to catch up in DRF, and high APD, antenatal diagnosis, and low pre-operative DRF were independent predictive factors of an improvement in renal function after pyeloplasty.

Robotic Pyeloplasty in Infants: A Review of Safety and Outcomes

Robotic Pyeloplasty in Infants: A Review of Safety and Outcomes

Inpatient interventions that may preclude outpatient open pyeloplasty in infants.

ABSTRACTObjective:In the majority of published series, children undergoing open pyeloplasty are admitted for at least one night. We hypothesized that it would be possible in the majority of infants to perform open pyeloplasty as an outpatient procedure.Materials and Methods:All patients who underwent open pyeloplasty by a single surgeon between 2008 and 2016 were retrospectively reviewed. Demographic data (age at surgery, gender, pre- and postoperative imaging studies, laterality, type of local anesthesia), operative time, duration of hospital stay, need for narcotic analgesics, complications, readmission within 1-month after surgery and need for additional procedures were abstracted.Results:A total of 18 infants underwent open pyeloplasty by single surgeon. Mean age at time of surgery was 19 months (range 3-23 months). There were 8 girls and 10 boys. In addition to general anesthesia, all of the patients received regional anesthesia (caudal block 8, epidural block 8, subcutaneous nerve block 2). Median operative time was 135 minutes (range 81-166). Median hospital stay was 1 day (range 1 to 2). Two patients required iv narcotics for pain management. None of the patients required parenteral administration of other medications during the short hospitalization. No patients required any additional procedures or hospital readmissions within 1 month from surgery.Conclusions:In appropriately selected patients, outpatient pyeloplasty appears to be feasible with an oral postoperative analgesia plan to be administered at home.

Does the use of 5 mm instruments affect the outcomes of robot-assisted laparoscopic pyeloplasty in smaller working spaces? A comparative analysis of infants and older children

Pediatric robot-assisted laparoscopic (RAL) pyeloplasty has become a viable minimally invasive surgical option for ureteropelvic junction obstruction (UPJO) based on its efficacy and safety. However, RAL pyeloplasty in infants can be a challenging procedure because of the smaller working spaces. The use of the larger 8mm instruments for these patients instead of the 5mm instruments is common because of the shorter wrist lengths. We hypothesized that the use of 5mm instruments for RAL pyeloplasty in infants with smaller working spaces will have comparable perioperative parameters and surgical outcomes in comparison with older children with larger working spaces. We compared the perioperative parameters and surgical outcomes of RAL pyeloplasties performed by a single surgeon in infants and non-infant pediatric patients over a 2 year period. All of the procedures were performed using an 8.5mm camera and 5mm robotic instruments. Patient demographics, operative times, perioperative complications, hospital pain medication usage, hospital length of stay, and treatment success rates were compared between the two groups. A total of 65 pediatric RAL pyeloplasties were included in the study (16 infants and 49 non-infants, Table). There were no significant differences in gender, laterality, proportion of re-do pyeloplasty, or preoperative hydronephrosis grade between the two groups. All procedures were performed without conversion to open surgery or significant perioperative complications. There were no differences in segmental operative times (total operative time, console time, port placement time, time for dissection to UPJO, and anastomosis time), hospital pain medication usage, and hospital length of stay between the two groups (p>0.05 for all comparisons). The treatment success rates were 93.8% (15/16) and 100% (49/49), respectively (p=0.08). We present the first comparative study of infant and non-infant pediatric RAL pyeloplasty using 5mm robotic instruments. An advantage of the current study is the use of a single surgeon's experience to compare RAL pyeloplasty outcomes in infants with those of older children, a group in which RAL pyeloplasty has already been shown to be efficacious and safe. Operative tips for infant RAL pyeloplasty are also provided. RAL pyeloplasty is a safe and effective surgical modality even in infants, with comparable perioperative parameters and outcomes as those in older children. The use of 5mm instruments in infants does not affect outcomes and offers the potential for improved cosmesis.

V09-05 SIX-WEEK-OLD INFANT ROBOTIC PYELOPLASTY: KEY POINTS FOR SAFETY AND PROFICIENCY

You have accessJournal of UrologyPediatric Urology1 Apr 2018V09-05 SIX-WEEK-OLD INFANT ROBOTIC PYELOPLASTY: KEY POINTS FOR SAFETY AND PROFICIENCY Maria Veronica Rodriguez, Nimrod Barashi, Joseph Rodriguez, and Mohan S Gundeti Maria Veronica RodriguezMaria Veronica Rodriguez More articles by this author , Nimrod BarashiNimrod Barashi More articles by this author , Joseph RodriguezJoseph Rodriguez More articles by this author , and Mohan S GundetiMohan S Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2177AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteropelvic junction obstruction (UPJO) is one of the most common pediatric urologic congenital anomalies. Anderson-Hynes dismembered pyeloplasty has been the gold standard for the intervention of this pathology. Nowadays, robotic surgery has provided a safe alternative to manage these patients with minimally invasive surgery and, even though the procedure is frequently performed by pediatric urologists across the US, there is still a steep learning curve to perform infant robotic pyeloplasty. We aim to describe a robotic-assisted laparoscopic pyeloplasty in a 6-week-old patient with grade 4 hydronephrosis and UPJO in addition to key technical points for safety and proficiency. METHODS The crucial points are patient positioning, proper port placement; particularly the inferior working ports, given the close proximity to the bladder, instrumentation and docking and the inherent bowel distension that children usually have. We present a robotic pyeloplasty in a 6-week old infant with UPJO. The patient was placed in a lateral position, close to the edge of the table. With an open Hassan technique approach, a 12-mm umbilical camera port and two 8-mm ports were placed in the midline in addition to a 5-mm assistant port that was positioned on the lower midclavicular line. There was a distended bowel, therefore an orogastric tube was placed to improve visualization and avoid bowel injury. The Gerota's fascia was incised and the pelvis was hitched with a subcutaneous suture. Then, the narrow ureteropelvic junction was recognized and the pelvis was transected just below the renal hilum vessels, which was followed by ureter spatulation. Ultimately, the anastomosis of the posterior wall with the spatulated ureter was performed in a continuous fashion and subsequently, a double J stent was placed percutaneously to complete the anterior wall anastomosis. RESULTS The patient tolerated the procedure well and was discharged on postoperative day 2 without any complications. Operative time was 143 minutes and, estimated blood loss was found to be less than 5 mL. The Foley catheter was removed prior to discharge. At 1 month follow-up, the patient had well healed abdominal surgical incisions, the double J stent was removed and, his renal bladder ultrasound scan showed improvement of the hydronephrosis. CONCLUSIONS We emphasize the key points for safety and proficiency when performing a robotic infant pyeloplasty, given our long-term institutional experience doing robotic surgery in such young patients to optimize outcomes and prevent complications. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e904 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Maria Veronica Rodriguez More articles by this author Nimrod Barashi More articles by this author Joseph Rodriguez More articles by this author Mohan S Gundeti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison of Robotic Pyeloplasty and Standard Laparoscopic Pyeloplasty in Infants: A Bi-Institutional Study.

To compare outcomes between robotic pyeloplasty (RP) and standard laparoscopic pyeloplasty (LP) in the infant population for the treatment of ureteropelvic junction (UPJ) obstruction. We performed a retrospective cohort study of all children under 1 year of age who underwent RP or LP at two different medical centers between October 2009 and February 2016. Patient demographics, perioperative data, complications, and results were reviewed. Thirteen patients underwent standard LP, and 21 patients underwent RP during the study period. Median age and median weight at time of operation for the whole cohort were 6.1 months and 7.9 kg. Surgery success rates were similar with 95% and 92% in RP and LP, respectively. There was no statistically significant difference in operating time between the 2 groups, with a median time of 156 minutes in RP (range 125-249) and 192 minutes (range 98-229) in standard LP (P = .35). Median length of hospital stay was significantly shorter in the robotic group with a median stay of 1 day (range 1-3) and 7 days (range 7-12) in the standard LP group.(P < .0001) Drains or nephrostomy tubes were used more often in the laparoscopic group (100%, 13/13) as opposed to RP (9.5%, 2/21, P < .0001) There was a comparable complication rate between the 2 groups, 30.8% for LP and 23.8% for RP (P = .65). The minimally invasive dismembered pyeloplasty is safe and effective in the infant population and produces high success rates. The results, complication rates, and operative time were comparable between the two surgical methods while the standard LP demonstrated longer hospital stay. Both the robotic approach and the LP can be successfully utilized for the benefit of infants with UPJ obstruction.

Robot-assisted laparoscopic pyeloplasty in the pediatric population: a review of technique, outcomes, complications, and special considerations in infants.

Ureteropelvic junction obstruction is a common condition encountered by the pediatric urologist, and treated with pyeloplasty when indicated. Recent technological advancements and a shift across all surgical fields to embrace minimally invasive surgery have led to increased utilization of minimally invasive pyeloplasty. Conventional laparoscopy is a reasonable choice, but its use is limited by the technical challenges of precise suturing in a confined space and the associated considerable learning curve. Robotic technology has simplified the minimally invasive approach to pyeloplasty, offering enhanced visualization and improved dexterity with a fairly short learning curve. As utilization of robotic pyeloplasty continues to increase, we sought to critically assess the literature on this approach. We begin with a review of the technical aspects of robot-assisted laparoscopic pyeloplasty including tips for surgical proficiency and patient safety. Outcomes and complications from the contemporary literature are reviewed, as well as special considerations in the pediatric population including infant pyeloplasty, cost concerns, training, and postoperative diversion/drainage.

Dismembered Pyeloplasty in Infants 6 Months Old or Younger With and Without External Trans-anastomotic Nephrostent: A Prospective Randomized Study

To compare the outcome of dismembered pyeloplasty in infants with and without external nephro-ureteric stent (ENUS) for treatment of congenital ureteropelvic junction obstruction. This is a parallel, randomized comparative study between October 2013 and September 2014. Thirty infants ≤6 months old with ureteropelvic junction obstruction indicated for dismembered pyeloplasty were randomly assigned (block randomization, closed envelope method) into two groups: group A (stentless) and group B (ENUS). Infants with solitary kidney, gross pyuria, huge pelvis, vesicoureteric reflux, or other renal anomalies were excluded. Operative data, complications, and ultrasonographic and nuclear scintigraphy criteria were compared after at least 18 months of follow-up using Student t, Mann-Whitney U, Kruskal-Wallis, chi-square, and Fisher exact tests when appropriate. Occurrence of urinary leakage was the primary outcome. Included patients completed the study with intention-to-treat analysis. All children had normal renal function. The mean operative time was 85.3 ± 6.3 (60-90) minutes in group A and 92.6 ± 15.3 (70-120) minutes in group B (P = .2). Although there was a significant postoperative improvement in each group in split renal function and anterior-posterior renal pelvis diameter, there was no significant difference between both groups. The mean hospital stay for group A and group B was 5.9 ± 2 (4-10) days versus 3.5 ± 0.8 (2-5) days, respectively (P < .001). Postoperative urinary leakage was reported only in group A (40%). All complications were managed by double J insertion. Auxiliary interventions were higher in group A. The overall success rate was 93.4%. Redo pyeloplasty was performed in one case in each group. ENUS significantly reduces hospital stay and complications. It saves the infant hazards of auxiliary interventions under general anesthesia for management of leakage or double J removal if placed at time of pyeloplasty.

The BULT Method for Pediatric Minilaparoscopic Pyeloplasty in Infants: Technique and Results.

We reviewed retrospectively the results of transperitoneal minilaparoscopic pyeloplasty in children younger than 2 years. The surgical technique utilized as well as the retrograde placement of the stent is described in detail. Twenty-four consecutive children with a mean age of 7.9 months (range 1–23), a mean weight of 7.4 kg (range 4–12), and a mean follow-up of 18 months (range 3–59) are included. Preoperative grade of dilatation was 3.8 (SFU scale) and postoperatively improved to 1.5. The AP diameter of the pelvis decreased from a mean of 28–9 mm. In 83% of cases, there was complete resolution of hydronephrosis (grades 0–2) and the rest showed improvement. There was one conversion to open surgery in a child with a horseshoe kidney. There was one omental prolapse though a port site in a child in whom an inappropriate drain was used. There were no stent-related complications and no reinterventions for persistent or recurrent obstruction. Given these outcomes, low complication rate and excellent cosmetic results, we recommend transperitoneal minilaparoscopy with a double J stent and a perirenal drain for infants requiring pyeloplasty.

Outcomes of Re-Intervention for Laparoscopic Transperitoneal Pyeloplasty in Children.

There is no consensus for the management of failed laparoscopic pyeloplasty in pediatric surgical patients, and only limited publications are available. We evaluated here the clinical outcomes of re-intervention for failed laparoscopic transperitoneal pyeloplasty in infants and children. Retrospective review of all children who had undergone laparoscopic transperitoneal dismembered Anderson-Hynes pyeloplasty for ureteropelvic junction obstruction from 2002 to 2013 was performed. Patients' demographics, indications, operative details, and outcomes for primary operation as well as re-intervention were studied. There were 42 patients with a median age of 20 months (range, 3-192 months) and a median body weight of 12 kg (range, 6-56 kg) who underwent a total of 46 laparoscopic transperitoneal pyeloplasties during the study period. The median operative time and blood loss were 193 minutes (range, 115-480 minutes) and trace amount (range, trace amount to 400 mL), respectively. No conversion was reported. Ten cases (22%) required re-intervention. No statistically significant risk factor for failed pyeloplasty was identified. Indications for re-intervention included deterioration of differential renal function (n = 6), progressive hydronephrosis (n = 1), urinary ascites (n = 2), and urosepsis (n = 1). Median time of re-intervention was 6.5 ± 38 months postpyeloplasty. Re-intervention was categorized into the redo pyeloplasty group (n = 6) and the urinary diversion group (n = 4) (insertion of double-J ureteral stent or endopyelotomy) with success rates of 50% and 25%, respectively. Among the redo pyeloplasty group, 3 patients underwent redo laparoscopic pyeloplasty, and all of them had drainage restored with a median improvement in differential renal function of 11%. The mean follow-up duration was 77 ± 38 months. Laparoscopic transperitoneal pyeloplasty is safe and feasible in children. Redo pyeloplasty is a more favorable re-intervention compared with urinary diversion in our series. Redo laparoscopic pyeloplasty has been shown to improve differential renal function.

A Modified Antegrade Stenting Technique for Laparoscopic Pyeloplasty in Infants and Children

Objective: There are 2 critical steps of stent placement during laparoscopic pyeloplasty (LP) in children. Introduction to the ureteropelvic junction and passing through the ureterovesical junction. We aimed at overcoming those 2 steps by creating a modified technique. Methods: Consecutive 27 children undergoing transperitoneal laparoscopic dismembered pyeloplasty by a single surgeon were prospectively enrolled into this study. The modifications of our technique are using an Amplatz dilator and a closed tip stent. Results: The mean age of the children was 6.7 (range 4 months-17 years). The mean time of stent insertion was 2.7 ± 2.0 (2-6) min and the operative time was 128.3 ± 17.6 (90-180) min. The mean number of days of hospital stay was 2.0 ± 0.4 (1-3). After a mean follow-up period of 20.3 ± 4.2 (14-30) months, no operative failure was detected. Conclusion: Our modified technique is a completion of the current armamentarium for stent placement during LP in infants and children.

Laparoscopic pyeloplasty in infants: Single-surgeon experience

Although laparoscopic pyeloplasty (LP) is popular in children, its role in infants is less well defined. It is presumed that infant LP is technically challenging, with a higher failure rate. To consider the hypothesis that LP can be safely and successfully performed in infants. The records of 111 infants that underwent LP from March 2009 to December 2013 with at least 1 year of follow-up, were retrospectively reviewed. The results of pre- and postoperative imaging studies (ultrasound (US) and diuretic renogram (DR)), operative details and complications were noted. Pre- and postoperative parameters were compared using statistical software. The details are given in the Table. Laparoscopic pyleoplasty was successfully completed using three ports in all children without any open conversions. There were complications in 14 children (12%); 13 did not require a second intervention and the final outcome was not affected. One child (1%) had a re-obstruction with worsening hydronephrosis (HDN) 2 months after stent removal; she underwent successful redo LP. Median follow-up was 2 years; LP was successful in relieving the obstruction in 115 kidneys (99%); all had follow-up US, while 76 children had follow-up DR. The tests showed significant reduction in HDN (mean pre-operative anteroposterior diameter (APD) of renal pelvis, 34.4 mm (SD 13.4) versus mean post-operative APD 10.6 mm (SD 5.7), p < 0.001) and improved drainage in all kidneys. In unilateral cases, there was significant improvement in mean split renal function (SRF) of the operated kidneys (pre-operative 22.1% (SD 8.6) versus post-operative 35.6% (SD 11.4), p < 0.001). Over the past 6 years, all pyeloplasties at our unit have been performed by laparoscopy, irrespective of the age or weight of the child. In this large retrospective series, it is demonstrated that infant LP is a safe and successful operation; pyeloplasty in this age group not only resulted in significant reduction of hydronephrosis, but also in significant functional improvement. The results are comparable to published series comparing open pyeloplasty to laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70 to 96%, and complication rates ranging from 0 to 24% for open pyeloplasty.

Robot-assisted laparoscopic pyeloplasty: Multi-institutional experience in infants

Robot-assisted laparoscopic pyeloplasty (RALP) has been gaining acceptance among pediatric urologists. Over 300 have been described in the literature, but few studies have evaluated the role of RALP in infants alone. We sought to examine the operative experience and outcomes of RALP in a cohort of infants treated at multiple institutions across the United States. Our primary aim was to describe the safety and efficacy of RALP within this cohort. We recognize the challenges of performing minimally invasive surgery in small patients. In our paper, we address some technical considerations for the infant population. This multi-centered observational study collected data on subjects one year of age or less who underwent RALP between April 2006 and July 2012 at five institutions. The primary outcome was resolution of hydronephrosis, and secondary outcomes included surgical time and complications. A total of 60 patients (62 procedures) underwent RALP by six surgeons during the study period. All surgeons had > 5 years of experience beyond fellowship training. Mean surgical age was 7.3 months (SD ± 1.7 mo), 56 patients (95%) were diagnosed prenatally, and 59 patients (95%) had follow up imaging. Of these patients, 91% showed resolution or improvement of hydronephrosis. Two patients had recurrent obstruction and required additional surgery. Mean surgical time was 3 hours 52 minutes (SD ± 43 minutes). Seven (11%) patients reported intra-operative or immediate post-operative complications. This series found a 91% success rate for reduction or resolution of hydronephrosis, and an 11% complication rate. This is equivalent to modern series comparing open pyeloplasty to pure laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70-96%, and complication rates ranging from 0-24% for open pyeloplasty. We lacked a standardized technique amongst institutions. This was not surprising since there are not established technical benchmarks for this surgery. However, we specified multiple technical considerations for this unique patient population. The advantages of using robot-assistance to perform pyeloplasty in infants remain to be defined. This study cannot make that assessment due to small sample size. Nonetheless, this cohort is the largest robotic pyeloplasty series in infants to date. Seeing an excellent success rate and a low complication rate in this infant cohort is encouraging.

Double J or Transrenal Transanastomotic Stent in Laparoscopic Pyeloplasty in Infants and Children: A Comparative Study and Our Technique

We compared our experience with intra- and extracorporeal stenting in laparoscopic transabdominal pyeloplasty in children and adolescents. As the placement of transanastomotic stents during laparoscopy can be difficult, we developed a technique for laparoscopic transrenal stent placement. Eighty-six consecutive patients who underwent laparoscopic transabdominal pyeloplasty in our institution from December 2003 to November 2012 were retrospectively analyzed. Initially we antegradely placed the double J catheter (n=48), whereas in later patients transrenal/transcutaneous stents were inserted (n=38), either via a cannula from the flank (n=33) or from the inside-out by transrenal puncture using a specially constructed spear (n=5). End points of the analysis were stent-related technical problems and complications and the need for reoperation. Sixty-two boys and 24 girls with a mean age of 5.6 years (range, 78 days-17.3 years) and mean weight of 22.1 kg (range, 5.5-71 kg) underwent laparoscopic transabdominal pyeloplasty. The most common technical problem in the double J group was inability to place the double J catheter in 9 of the 48 patients. In combination with other complications such as dislocations, urinary tract infections, or catheter occlusions, this led to an overall complication rate of 35% in the group that underwent double J catheter insertion versus 13% in the group with transrenal stenting (P<.05). In the whole series, 4 patients required a redo pyeloplasty, all of them in the double J group. We recommend transrenal stents to facilitate stent removal without general anesthesia and to minimize complications such as stent dislocation. The initial experience with our simple device for transrenal puncture and stent placement is promising.

Ultrasound-guided transversus abdominis plane block versus caudal block for postoperative pain relief in infants and children undergoing surgical pyeloplasty

Background Caudal block is the most frequently used regional anesthetic technique for pediatric analgesia, with the disadvantage of limited duration of action. Transversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing caudal block with ultrasound-guided TAP block in pediatric patients undergoing surgical pyeloplasty. Patients and methods Thirty-nine patients (6 months to 6 years) scheduled for elective surgical pyeloplasty were divided into two groups in a double-blinded randomized manner. After sevoflurane in oxygen anesthesia, patients were assigned to one of the two groups: group A (caudal; n = 19 patients) received a single caudal dose of isobaric bupivacaine 0.25% (1.25 ml/kg) and group B (TAP block; n = 20 patients) received isobaric bupivacaine 0.25% (0.3 ml/kg). The primary outcomes were the time to first analgesia in minutes and the analgesic doses (oral acetaminophen and rectal diclofenac) required during the first 24 h postoperatively. The secondary outcome measures included FLACC pain scale score and intraoperative hemodynamic variables. Results Group B had a significantly longer time to first analgesia (602, 705, 748 vs. 250, 280, 365 min) and required significantly lower doses of acetaminophen (301.9 ± 161.26 vs. 635.05 ± 205.42) and rectal diclofenac (0, 0, 0 vs. 0, 0, 12.5 mg) than group A. FLACC pain scale score was significantly lower in group B than in group A ( P < 0.05) at 2, 4, 6, 8, 10, 12, 16, 18, 20, and 24 h postoperatively. There was no significant difference between both groups with respect to intraoperative hemodynamic variables. Conclusion Unilateral TAP block provided superior analgesia compared with single caudal block injection in the first 24 postoperative hours after surgical pyeloplasty in infants and children aged 6 months to 6 years.

Hybrid procedure for pyeloplasty in infants and young children with ureteropelvic junction obstruction is a safe and effective alternative

Ureteropelvic junction obstruction (UPJO) is a common congenital urinary tract anomaly causing hydronephrosis in children. Laparoscopic pyeloplasty has become a popular and effective method to treat UPJO both in children and adults, but seems controversial in neonates or infants. From January 2007 to May 2012, patients with UPJO aged <18 years undergoing operations at our institute were included in this study. By retrospectively reviewing medical charts, the demographic data, presentation, laterality, etiology, operative time, length of hospital stay, stents, drainage tubes, and postoperative complications were recorded. Surgical outcomes were evaluated based on renal sonography and Lasix diuretic renography. A total of 47 patients (40 boys and 7 girls) were enrolled initially, but seven patients who were complicated with other congenital anomalies of the urinary system or who underwent surgery at other hospitals were excluded. Among these 40 patients, 21 had open pyeloplasty (Group I), eight who were younger than 1 year old or weighed <10 kg had a hybrid procedure (Group II), and 19 had laparoscopic surgery (Group III). The mean age was younger in Groups I and II because the selected procedure was nonrandomized. The operative time and the duration of perianastomotic drainage were longer in Groups II and III. There was no significant difference with regard to successful resolution of UPJO among the three groups. In infants or young children (<1 year old or weighing <10 kg) with UPJO, the hybrid procedure of pyeloplasty may be considered as a safe, effective, and less time-consuming alternative to laparoscopic surgery, and most importantly, confirms the security of the anastomosis.

Infant robotic pyeloplasty: Comparison with an open cohort

ObjectiveTo present our experience with infant pyeloplasty, comparing outcomes between robotic-assisted laparoscopic pyeloplasty (RALP) and open pyeloplasty (OP). Materials and methodsA retrospective review was performed of all children <1 year of age who underwent unilateral dismembered pyeloplasty at a single pediatric institution since January 2007. Patients with standard laparoscopic pyeloplasty were excluded. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed. ResultsA total of 70 infants (51 boys and 19 girls) were identified, with nine RALP and 61 OP performed. Median age was 9.2 months (range, 3.7–11.9 months) for RALP and 4.1 months (range, 1.0–11.6 months) for OP (p = 0.005). Median weight was 8 kg (range, 5.8–10.9 kg) for RALP and 7 kg (range, 4–14 kg) for OP (p = 0.163). Median operative time was 115 min (range, 95–205 min) for RALP and 166 min (range, 79–300 min) for OP (p = 0.028). Median hospital stay was 1 day (range, 1–2 days) for RALP and 3 days (range, 1–7 days) for OP (p < 0.001). Median postoperative narcotic use of morphine equivalent was <0.01 mg/kg/day (range, 0–0.1 mg/kg/day) for RALP and 0.05 mg/kg/day (range, 0–2.2 mg/kg/day) for OP (p < 0.001). Median follow-up was 10 months (range, 7.2–17.8 months) for RALP and 43.6 months (3.4–73.8 months) for OP (p < 0.001). The success rate was 100% for RALP and 98% for OP. ConclusionsInfant RALP was observed to be feasible and efficacious with shorter operative time, hospital stay, and narcotic utilization than OP.

Outcomes of Infants Undergoing Robot-Assisted Laparoscopic Pyeloplasty Compared to Open Repair

Robotic surgery has evolved from simple extirpative surgery to complex reconstructions even in infants. Data are lacking comparing surgical and direct costs to open approaches. We describe the feasibility, salient tips and outcomes of robot-assisted laparoscopic pyeloplasty compared to an open approach. We evaluated patients undergoing open pyeloplasty or robot-assisted laparoscopic pyeloplasty. Ten patients in each group met inclusion criteria. Mean patient age was 3.31 months in the open group and 7.3 months in the robotic group (p=0.02). Postoperative outcomes including length of stay (2.2 vs 2.1 days), estimated blood loss (6.5 vs 7.6 ml), days to regular diet (1 vs 1.1) and days to Foley catheter removal (1.3 vs 1.3) were similar between the open and robotic groups. Total operating time (199 vs 242 minutes) was significantly longer in the robotic group. Postoperative improvement in hydronephrosis was identical in both groups. Direct costs, excluding amortization, robotic cost, maintenance and depreciation, were $4,410 in the open group and $4,979 in the robotic group (p=0.10). In our preliminary experience robotic pyeloplasty in infants is feasible and safe. The immediate outcomes are similar to those of an open approach. The robotic technique in infants currently has the benefits of improved esthetic appearance, improved pain control and similar direct costs compared to the traditional open approach.