Pyeloplasty In Infants Research Articles

A simple technique for percutaneous antegrade retrieval of proximally migrated double J stents after pyeloplasty in infants

Proximal migration of double J (DJ) stent after pyeloplasty poses a difficult problem in infants whose small ureter renders retrograde ureteroscopic retrieval difficult. Previously described antegrade techniques used large access sheaths or blind removal under fluoroscopic guidance. We describe a technique for antegrade retrieval of the stent under direct vision. A 8F vascular access sheath is placed into the renal pelvis under ultrasound guidance. A 6F nephroscope with 3F forceps placed through the sheath grasps and retrieves the stent under direct visualization. This technique is simple, quick, avoids radiation exposure and was used by us successfully in 2 small infants.

Does Age Influence the Functional Recovery after Infant Pyeloplasty?

The purpose was to study the correlation between age at surgery and functional recovery after infant pyeloplasty. All infants who underwent pyeloplasty were analyzed retrospectively in this multicenter study. Anteroposterior diameter (APD) >2 cm, split renal function (SRF) <40%, and Society of Fetal Urology (SFU) grade 3-4 were surgical indications. Based on the age at pyeloplasty, they were divided into Group 1 (1-3 months) and Group 2 (4-12 months). APD and SRF were compared before and after surgery in both groups. The fractional recoverable function (post-SRF-pre-SRF)/(50-pre-SRF) ×100 was correlated with age. Fifty-one infants underwent pyeloplasty (mean age: 1.6 months - Group 1 and 7.2 months - Group 2). The mean APD decreased from 3 cm to 1.2 cm in Group 1 while 2.8 cm to 2 cm in Group 2 (P = 0.001). The mean SRF increased from 32.28% to 42.81% in Group 1 while 31%-34.18% in Group 2. SRF recovery was significantly higher in Group 1 compared to Group 2 (P = 0.001). Regression analysis showed a weak negative correlation (r = -0.2792) between age at surgery and renal function improvement. Functional recovery after pyeloplasty is better when done earlier (1-3 months), as this gives the growing kidney the best opportunity to recover.

Pediatric Robot-Assisted Laparoscopic Pyeloplasty: Where Are We Now?

This review aims to provide an in-depth exploration of the recent advancements in robot-assisted laparoscopic pyeloplasty (RALP) and its evolving landscape in the context of infant pyeloplasty, complex genitourinary (GU) anatomy, recurrent ureteropelvic junction (UPJ) obstruction, cost considerations, and the learning curve. Recent literature highlights the safety and efficacy of RALP in treating the infant population, patients with complex GU anomalies, and recurrent UPJO which were all traditionally managed using the open approach. Cost considerations are evolving, with the potential for RALP to have a lesser financial burden. In addition, the learning curve for RALP is diminishing due to robust training programs and advances in research. RALP has become the gold standard in the treatment of UPJO in pediatric urology at many children's hospitals. Surgeon comfort and research in this space allow safe and successful reconstruction in the most challenging of cases.

Medullary pyramid thickness: The optimal cut-off value associated with the need for pyeloplasty in infants

The medullary pyramid compresses during the early phases of severe hydronephrosis and represents a promising ultrasound metric for the diagnosis and surveillance of PUJ obstruction. The aim of this study was to define the optimal cut-off value and utility of medullary pyramid thickness (MPT) associated with the need for pyeloplasty in infants being followed up for hydronephrosis. A retrospective review was performed over a five-year period to identify patients that were under surveillance for hydronephrosis during infancy and underwent a MAG3 to monitor the possible need for pyeloplasty. Ultrasound images were retrospectively reviewed to measure the MPT of the affected kidney in a blinded fashion. The primary outcome measure was subsequent requirement for pyeloplasty before three years of age. The Mann-Whitney U Test was used to determine statistically significant differences in the minimum MPT between the infant group requiring pyeloplasty and the non-operative group. Receiver operating characteristic analysis was performed to determine the optimal cut-off value associated with the requirement for pyeloplasty. A total of 63 patient cases were included, of which 45 underwent pyeloplasty (70%). A significant difference was found in the median MPT measurement between the pyeloplasty and non-operative groups (1.7mm vs. 3.8mm, p<0.001). The optimal cut-off value of MPT associated with pyeloplasty was 3.4mm. An MPT threshold of ≤3.4mm conferred a sensitivity of 98%, specificity of 63%, positive predictive value of 86%, and negative predictive value of 92%. Thinning of the medullary pyramid is an important ultrasound sign of parenchymal deterioration in high-grade hydronephrosis. An optimal MPT cut-off value of ≤3.4mm is associated with subsequent pyeloplasty in infants. MPT should be considered in future studies addressing the diagnosis and surveillance of PUJ obstruction.

Can pyeloplasty restore normal renal function in patients with severe unilateral ureteropelvic junction obstruction and DRF < 35 %

To assess the outcome of successful pyeloplasty in infants with Ureteropelvic Junction Obstruction (UPJO) and a differential renal function of (DRF)<35% whether they can attain normal postoperative renal function or not. All children who were diagnosed with antenatal hydronephrosis due to UPJO were presented to our institutions and were prospectively followed up. Pyeloplasty was performed based on predefined indications such as: initial DRF ≤40%, progression of hydronephrosis, and febrile urinary tract infection (UTI). A total of 173 children, who had successful surgical intervention due to impaired DFR, were divided according to their pre-intervention DRF value as follows: DRF <35% (group I) and DRF 35-40% (group II). The renal morphology and function changes were recorded and used for comparison between both groups. Group I was comprised of 79 patients, and group II included 94 patients. Pyeloplasty achieved significant improvement in the anatomical and functional indices in both groups (p-value <0.001). Thedegree of improvement in Anteroposterior diameter (APD) and cortical thickness was comparable in both groups (P-value, 0.64 and 0.44 respectively). While the improvement in the DRF was significantly higher in group I (16.06±6.6) than in group II (6.25±2.66) (P-value <0.001). Despite that, a significantly higher percentage of infants in group II (61.7%) achieved normal final DRF compared with only (10.1%) in group I (Figure). Even in severely impaired renal function (<35%), successful pyeloplasty can recover a significant part of lost renal function. However, most of these patients do not achieve normal postoperative renal function.

Open Pyeloplasty in Infants under 1 Year—Proven or Meaningless?

The use of minimally invasive surgery (MIS) to treat ureteropelvic junction obstruction (UPJO) in children has significantly increased. Nowadays, open pyeloplasty (OP) seems to lose importance. The aim of this study is to evaluate the safety and efficacy of OP in infants < 1 year. Medical records of patients < 1 year with UPJO who had undergone retroperitoneal OP (January 2008-February 2022) at our institution were retrospectively analyzed. Included patients were operated on according to a modified Anderson-Hynes technique. All clinical, operative, and postoperative (1 month-5 years' follow-up) data were collected. Additionally, a nonvalidated questionnaire was sent to the patients/parents. A total of 162 infants (124 boys) met the inclusion criteria. The median age at surgery was 3 months (range: 0-11 months). The median operation time was 106 min (range: 63-198 min). None of the patients had severe surgical complication (Clavien-Dindo > 3). The nonvalidated questionnaire showed a high impact of quality of life. Follow-up was in median 30.5 months (0-162 months). OP is still a reliable procedure with good long-term results especially in infants < 1 year of age, which can be performed in a variety of centers.

Effects Of Pyeloplasty in Infants with Failing Kidneys Over the Long Term

Objective: The most typical type of obstruction in the upper urinary tract is ureteropelvic junction obstruction or UPJO. The objective of this study was to assess the effectiveness and long-term results of pyeloplasty in children with poorly functioning kidneys. Method: Patients who underwent pyeloplasty at Department of Urology, Rajendra Institute of Medical Science, Ranchi for last twelve years were the subject of a retrospective data study. Postoperative outcome was the parameter under study. Success was measured by either symptom improvement or better drainage on postoperative Tc-99m DTPA renography, which was performed after two months and then yearly after that. Results: 60 individuals were enrolled in the study, with a mean age of 8.5 years (3 months to 12 years), a male-to-female ratio of 2:1, and poor function on the isotope renogram (31%). The ratio of left to right sides was 1.2:1. All patients had dismembered pyeloplasty procedures. 37 patients (66.8%) underwent laparoscopic pyeloplasty, whereas 23 (33.2%) underwent open surgery. 35 patients had follow-up renograms available; of these, 30 showed improved drainage and no further decline in renal function, while 5 displayed an obstructed pattern; of these, 3 patients had noticeably worsened split function, and the other two underwent a second open pyeloplasty. A mean follow-up of 21.5 months revealed a 91% overall success rate. Conclusion: In the pediatric age group, pyeloplasty provides satisfactory intermediate results in kidneys with inadequate function.

Open pyeloplasty in infants under 1 year – does it still have a raison d'être?

Open pyeloplasty in infants under 1 year – does it still have a raison d'être?

Safety and feasibility of performing robotic ureteroureterostomy and robotic pyeloplasty in infants

IntroductionOpen surgery is considered the standard of care for pediatric urological procedures. Nonetheless, Robotic Assisted Laparoscopic Surgeries (RALS) have become increasingly popular in pediatrics as they allow for quicker recovery times, lower narcotic use, better cosmesis, and better intraoperative visibility. However, there are concerns regarding the usefulness of RALS in the infant population, as operating on smaller patients limits mobility of the robotic arms and can result in arm collisions.ObjectiveThe aim of this study was to compare the clinical and postoperative outcomes of infants undergoing robotic vs open pyeloplasty or ureteroureterostomy.Materials and MethodsRetrospective study conducted between 2012 to 2022, 114 infants who underwent pyeloplasty (81 open pyeloplasty and 33 robotic pyeloplasty) and 21 who underwent ureteroureterostomy (9 open ureteroureterostomy and 12 robotic ureteroureterostomy) were included.ResultsMean age at surgery in the pyeloplasty cohort was 4.81 ± 3.1 months in the open group, and 6.24 ± 2.6 months in the robotic group (p=0.13), and in the ureteroureterostomy cohort was 7.67 ± 3.16 months in the open group and 7.58 ± 2.75 months in the robotic group (p=0.95). Operative time was found to be shorter in robotic pyeloplasty and robotic ureteroureterostomy, when compared to the open approaches. Postoperative complications, its severity, and the surgical success were comparable among the pyeloplasty and ureteroureterostomy groups. Only 1(3%) complication related to the robotic technique was reported in the pyeloplasty cohort. The length of hospital stay was found to be similar between the ureteroureterostomy groups, while in the pyeloplasty cohort the robotic group showed a significant shorter hospital stay than the open group. Overall, the mean follow-up was greater than 12 months.ConclusionOur results demonstrated that robotic pyeloplasty and ureteroureterostomy performed in infants are feasible, safe, and durable procedures, with an additional benefit of reducing duration of operative time and hospital stay.

Outcome analysis of immediate and delayed laparoscopic pyeloplasty in infants with severe ureteropelvic junction obstruction.

The treatment timing of ureteropelvic junction obstruction (UPJO) in infants remains controversial. This study aimed to compare the recovery effect of renal morphology of immediate and delayed laparoscopic pyeloplasty in infants with severe UPJO. The infants with severe UPJO-induced hydronephrosis who underwent laparoscopic pyeloplasty according to their age at the time of surgery [the immediate treatment (IT) group: ≤1 month of birth, the delayed treatment (LT) group: 3-6 months of birth] in our center between 2010 and 2019 were enrolled in this study. Ultrasonography was used to assess renal morphology, including anteroposterior diameter (APD) of a pelvic, parenchymal thickness (PT), polar length (PL), and Society of Fetal Urology (SFU) grade. Preoperative and postoperative renal morphological outcomes at 6, 12, and 24 months were measured and compared. During this period, a total of 135 patients were assigned to receive either IT (n = 73) or LT (n = 62) and were included for analysis. There were no significant differences in renal morphology indices at baseline between groups of IT and LT. The APD, PT, and PL in both groups all recovered to certain degrees compared with those at baseline, however, the IT group recovered more significantly than the LT group. Despite there being no significant difference in SFU grade between the two groups before and after surgery, the reduction of SFU grade in the IT group was more significant than that in the LT group during the 6-, 12- and 24-month follow-up periods. The PL, SFU, and APD were greater in the IT group than in the LT group at 6, 12, and 24 months of follow-up. At 6 months PL was not significantly higher between the two groups, while the outcome was significantly different at 12 months and 24 months. Immediate laparoscopic pyeloplasty for the infant with severe ureteropelvic junction obstruction is effective, and it can accelerate the recovery of renal morphological indices in infants with severe UPJO-induced hydronephrosis.

Laparoscopic versus robot-assisted pyeloplasty in infants and young children

To compare the characteristics of conventional laparoscopic pyeloplasty (LP) and robotic-assisted laparoscopic pyeloplasty (RALP) in infants and young children with ureteropelvic junction obstruction (UPJO). We performed a retrospective study of patients (age: 0-36 months) who underwent dismembered pyeloplasty (Anderson-Hynes) with the fourth-generation RALP or traditional LP between April 2020 and December 2020. A total of 33 patients with UPJO were enrolled: 12 underwent RALP (9 left side; 3 right side) and 21 underwent LP (18 left side; 3 right side). In the RALP group, the median patient age was 17 months (range: 5-36 months). In the LP group, the median patient age was 9 months (range: 2-36 months) (P=0.182). The mean operation times were 120.25±37.54min (RALP) and 156.10±51.11min (LP) (P=0.042), and the mean lengths of hospital stay were 6.42±1.62 days (RALP) and 8.19±2.25 days (LP) (P=0.023). Removal of the drainage tube was performed after 3.08±0.69 days (RALP) and after 4.76±1.81 days (LP) (P=0.001). The postoperative pain showed no significant difference. The mean hospitalization costs were 61464.75±2800.53 yuan (RALP) and 22169.52±3442.15 yuan (LP) (P<0.001). The mean follow-up time was 10-18 months. Significant improvements in the anteroposterior diameter and parenchymal thickness were observed after surgery. Conversion to laparotomy was not performed. No short-term complications occurred during postoperative hospitalization and follow-up. RALP has the advantages of less trauma and faster recovery. It can be safely and effectively performed in infants and young children, and its effectiveness is similar to that of traditional LP.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 Feb 2022This Month in Pediatric Urology Stacy T. Tanaka Stacy T. TanakaStacy T. Tanaka More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002330AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Safety and Efficacy of Robot-Assisted Laparoscopic Pyeloplasty Compared to Open Repair in Infants under 1 Year of Age Even as robotic pediatric urological procedures proliferated, open pyeloplasty continued to be standard of care in infants. The robotic assisted laparoscopic approach was ideal for older children, allowing for meticulous anastomotic repair of the ureteropelvic junction while decreasing recovery times and postoperative pain levels. For open infant pyeloplasty, multiple sites had already demonstrated short length of stay and pain management without opioids. Additionally, because of concerns of the decreased instrument working space in small infants, initial published studies on pediatric robotic pyeloplasty were limited to children weighing more than 10 kg. Increasingly, pediatric centers are offering a robot-assisted laparoscopic approach for these smaller infants as well. In this issue of The Journal, Rague et al (page 432) from Chicago compare outcomes from robotic assisted laparoscopic to open pyeloplasty in infants younger than 1 year of age and less than 10 kg.1 In this retrospective study, pyeloplasty was performed by robotic assisted laparoscopic approach in 83 infants and open approach in 121. Infants in the robotic group tended to be older and to weigh more. The authors did not demonstrate a significant difference in length of stay, postoperative radiographic improvement, 30-day complication rate or need for reoperative pyeloplasty. Currently, the robotic procedures required more hospital resources. The robotic procedures had longer operative times, and approximately a third of the robotic procedures had 2 attending co-surgeons. The dissemination of robotics has changed pediatric urology fellowship training much like it has changed general urology residency. The authors report that the robot-assisted laparoscopic approach has been the preferred method for correction of ureteropelvic junction obstruction in infants at their institution since 2017—so much so that no open infant pyeloplasty was performed from January to June 2020. Certainly, the needs of urology learners are ever changing, and pediatric urology educators should be vigilant. This study highlights that trainees may have limited exposure to open infant pyeloplasty in the near future unless it remains an educational priority. Reference 1. : Safety and efficacy of robot-assisted laparoscopic pyeloplasty compared to open repair in infants under 1 year of age. J Urol 2022; 207: 432. Link, Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue 2February 2022Page: 261-261 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stacy T. Tanaka More articles by this author Expand All Advertisement Advertisement Loading ...

Surgical simulation of pediatric laparoscopic dismembered pyeloplasty: Reproducible high-fidelity animal-tissue model

To provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of laparoscopic dismembered pyeloplasty in infants and children. A previously described animal tissue model using chicken crop was surgically modified and attached to piglet kidney specimens in order to provide organ model realistically resembling infant and children hydronephrosis for simulation of dismembered laparoscopic pyeloplasty. Dismembered pyeloplasty could then be carried out in a standard pelvi-trainer using a standard instrumentation as in a regular case. The model created could prove to be a high-fidelity, animal tissue model for the surgical simulation of dismembered pyeloplasty. The surgical modification of the used animal tissues of chicken crop and piglet kidney respectively used in this fusion model was able to provide a high grade of resembling a realistic organ situs for infant and pediatric pyeloplasty, respectively. The surgical procedure could be carried out as a simulation of a regular case while providing high-grade realistic anatomy, adequate sizes of a dilated renal pelvis and of the ureter, respectively. Biological as well as haptic conditions of the tissue were able to resemble human tissue in a high grade as well. Despite a live animal model has been described for dismembered pyeloplasty, its time-consuming creation and possible conflict concerning animal welfare cadaver models are more practicable for daily simulation. In literature so far animal-tissue models described range from folded chicken skin to a chicken crop model. While these types of models have its own advantages and disadvantages none of them provide adequate anatomical relations. By dissecting chicken crop and fixating it to a piglet's kidney this limitation could be overcome and furthermore will enable future modifications for a perfused model for laparoscopic dismembered pyeloplasty. The fusion of a previously described tissue model of chicken crop for simulation of pyeloplasty along with also previously used piglet kidneys for surgical simulation can provide a highly realistic model for surgical simulation of pediatric dismembered laparoscopic pyeloplasty. In addition, this model rules out the disadvantage of native animal kidney specimens which the lack of pathology of a dilated renal pelvis. Surgical modification is an established method to provide high-fidelity animal tissue models for surgical simulation and therefore training of complex procedures, respectively. For simulation purposes in pediatric laparoscopic urology, i.e., reconstructive procedures such as dismembered pyeloplasty this model appears to be promising in terms of providing realistic pathology in pediatric dimensions.

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

Objective: To investigate the outcomes of minimally invasive approach to infants with ureteropelvic junction (UPJ) obstruction by comparing the two surgical modalities of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP).Methods: We conducted a retrospective review of all consecutive infants aged ≤12 months who underwent either LP or RALP in a single institution over the period of 2008–Jul 2020. We included primary pyeloplasty cases that were performed by or under the supervision of the same surgeon.Results: Forty-six infants (LP = 22; RALP = 24) were included with medians of age and body weight at 6 months (2–12months) and 8.0 kg (5.4–10 kg), respectively. There was no difference between the two groups in the patients' demographics and pre-operative characteristics. All infants underwent LP or RALP successfully without conversion to open surgery. None had intraoperative complications. Operative time (OT) was 242 min (SD = 59) in LP, compared with 225 min (SD = 39) of RALP (p = 0.25). Linear regression analysis showed a significant trend of decrease in OT with increasing case experience of RALP(p = 0.005). No difference was noted in the post-operative analgesic requirement. RALP was associated with a shorter hospital length of stay than LP (3 vs. 3.8 days; p = 0.009). 4/22(18%) LP and 3/24(13%) RALP developed post-operative complications (p = 0.59), mostly minor and stent-related. The success rates were 20/22 (91%) in LP and 23/24 (96%) in RALP (p = 0.49).Conclusions: Pyeloplasty by minimally invasive approach is safe and effective in the infant population. RALP may have superiority over LP in infants with its faster recovery and a more manageable learning curve to acquire the skills.

Treatment of infants with ureteropelvic junction obstruction: findings from the PURSUIT network.

Studies based on administrative databases show that infant pyeloplasty is associated with minority race/ethnicity but lack clinical data that may influence treatment. Our objective was to identify clinical and demographic factors associated with pyeloplasty in infants from three large tertiary centers. We reviewed infants with unilateral Society for Fetal Urology (SFU) grade 3-4 hydronephrosis seen at three tertiary centers from 2/1/2018 to 9/30/2019. Patients were excluded if > 6months old or treated surgically prior to the initial visit. Outcomes were: pyeloplasty < age 1year and SFU grade on most recent ultrasound (US) within the first year. Covariables included: age at the initial visit, race/ethnicity, treating site, insurance type, febrile UTI, and initial imaging findings. Univariable and multivariable analyses were performed using log-rank tests and Cox proportional hazards models, respectively. 197 patients met study criteria; 19.3% underwent pyeloplasty. Pyeloplasty was associated with: treating site (p = 0.03), SFU 4 on initial US (p = 0.001), MAG-3 (p < 0.001), and T½ > 20min (p < 0.001) in patients undergoing a MAG-3 (n = 107). MAG-3 (p < 0.001) and location (p = 0.08) were associated with earlier time to pyeloplasty on multivariable Cox analysis. In infants with follow-up US (n = 115), initial SFU grade, MAG-3 evaluation or findings, and pyeloplasty were not associated with improvement of hydronephrosis. We found that infant pyeloplasty rates vary between sites. Prolonged T½ was associated with surgery despite prior studies suggesting this is a poor predictor of worsening dilation or function. These findings suggest the need to standardize evaluation and indications for intervention in infants with suspected UPJ obstruction.

Optimising working space for laparoscopic pyeloplasty in infants: Preliminary observations with the SGPGI Protocol.

Aims:This study aimed to test the efficacy of SGPGI protocol to minimise bowel distension and optimise working space for laparoscopic pyeloplasty in infants.Methodology:All infants who underwent laparoscopic pyeloplasty for unilateral pelvi-ureteric junction obstruction (PUJO) between January 2017 and March 2020 were included in the study. The patient cohort was divided into two groups: Group A and B. Group A included patients who underwent routine pre-operative preparation. Group B included patients wherein the SGPGI protocol was used. The key features of the protocol were fasting for 8 h, enemas, inserting a nasogastric tube in the pre-operative period and decompressing the colon on the operation table. Demographic features, pre-operative, intraoperative and post-operative parameters were compared between the two groups.Results:A total of 26 infants with unilateral PUJO underwent laparoscopic pyeloplasty during the study period. Group A included 12 patients and Group B included 14 patients. Both the groups were similar in age, weight and sex distribution. The median surgeon's rating score for suturing conditions was 2 for Group A and 5 for Group B patients (P > 0.05). The operating time was significantly longer in Group A (196 ± 21 min) as compared to Group B (114 ± 18 min) (P < 0.05). In Group A, intra-abdominal pressure (IAP) varied between 9 and 14 mmHg (median 12 mmHg), while in Group B, IAP varied between 6 and 9 mmHg (median 8 mmHg) (P < 0.05). In Group A, in 2/12 cases (16.7%), conversion to an open procedure was necessary because of inadequate working space owing to gross intestinal distension. Two patients in Group A also had intraoperative injuries to adjacent structures due to poor working space.Conclusions:Optimal working space is critical to the performance of advanced laparoscopic surgery like pyeloplasty in infants. SGPGI protocol significantly improves working space, which permits a faster and safer surgery with a lower intra-abdominal working pressure. This protocol is simple, safe and easy to replicate at most centres in our country.

A systematic review and meta-analysis of conventional laparoscopic versus robot-assisted laparoscopic pyeloplasty in infants

While there are several reports confirming the safety and efficacy of laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP) in children there have been none comparing LP and RALP specifically in infants. In this meta-analysis, we have compared the outcomes of LP and RALP in infants. Pubmed (Medline), Publon, Index Medicus and Embase were searched using the search terms: pyeloplasty (laparoscopic OR robot-assisted) AND (infant), to identify all papers pertaining to LP and RALP. Systematic review was performed to identify information regarding number of patients/renal units, age, body weight, operating time, hospital stay, success and complications. Meta-analysis of heterogeneity was reported with I2statistics. Once heterogeneity was found low, the pooled outcomes were compared with student's t test and Fishers exact test, wherever appropriate. After screening a total of 267 articles, 18 articles were included (10 articles on LP, 7 on RALP, 1 reporting both), comprising 323 renal units for LP and 173 renal units for RALP. With low heterogeneity (I2: 0%) both groups were considered to have been conducted under similar conditions for fixed effect model. There was no significant difference between the success rates of LP or RALP (97.5% vs 94.8%; p=0.21). The mean age at operation was significantly lower for LP (5.6±1.8 months) than RALP (7.2±1.2 months, P=0.0001). The duration of surgery was 137±45min for LP while significantly higher at 179±49min for RALP (p=0.0001). The mean (s.d) time to discharge was 2.0 (1.9) days for LP while 1.3 (0.4) days for RALP. The overall complication rate was significantly higher (summary table) for RALP than LP (p=0.03), mainly due to more port-site hernias in RALP. In the present study, we found that the success of LP and RALP in infants was similar. RALP in infants had longer duration of surgery, similar hospital stay and higher Clavien-3 complications than LP. While several studies have reported favorable outcomes for RALP over LP in children, this was not the case in infants. The smaller workspace, in an infant, can significantly limit the mobility of robotic instruments and increase the chance of port-site conflicts or trocar collisions. The use of larger robotic ports and instruments in the small space of infant abdomen might have been responsible for higher complications in RALP, including significantly larger number of port-site hernias. This meta-analysis represents the early experience of most RALP in infants, and it is possible that with experience RALP outcomes in infants also will catch up with LP. Miniaturization of robotic instruments might render RALP the future standard of care for pyeloplasty in infants.

Redo Laparoscopic Pyeloplasty in Infants and Children: Feasible and Effective.

Purpose: To determine the feasibility and effectiveness of redo laparoscopic pyeloplasty among patients with failed previous pyeloplasty, specifically examining rates of success and complications.Materials and Methods: We retrospectively reviewed the charts of all patients, who underwent redo laparoscopic pyeloplasty from 2006 to 2017. This included patients who underwent primary pyeloplasty at our institution and those referred for failures. Analysis included demographics, operative time, complications, length of hospital stay, complications, and success. Success was defined as improvement of symptoms and hydronephrosis and/or improvement in drainage demonstrated by diuretic renogram, especially in those with persistent hydronephrosis. Descriptive statistics are presented.Results: We identified 22 patients who underwent redo laparoscopic pyeloplasty. All had Anderson-Hynes technique except two cases in which ureterocalicostomy was performed. Median (IQR) follow-up was 29 (2–120) months, median time between primary pyeloplasty and redo laparoscopic pyeloplasty was 12 (7–49) months. The median operative time was 200 (50–250) min, and median length of hospital stay was 3 (2–10) days. The procedure was feasible in all cases without conversion. During follow-up, all but two patients demonstrated an improvement in the symptoms and the degree of hydronephrosis. Ninety-one percent of patients experienced success and no major complications were noted.Conclusions: Redo laparoscopic pyeloplasty is feasible and effective with a high success rate and low complication rate.

MORPHOFUNCTIONAL OUTCOMES OF LAPAROSCOPIC PYELOPLASTY IN INFANTS OF THE FIRST THREE MONTHS OF LIFE

Introduction. This study describes authors’ experience in performing laparoscopic pyeloplasty in infants whose age does not exceed 3 months of life, and compares pre- and postoperative results of these surgeries in order to answer the question - does the laparoscopic technology for the treatment of hydronephrosis in newborns and infants provide acceptable results based on improving kidney morphology and function? Material and methods. 105 children, aged 3 months, were enrolled into this retrospective study who for 8 years, since 2012, have been laparoscopically operated on for congenital hydronephrosis. Because of bilateral renal damage, a total of 110 surgeries were performed, including simultaneous pyeloplasty in 5 patients. All patients had dismembered pyeloplasty with the Anderson-Hynes technique via transparietal laparoscopic access. Indications for surgery were: decreased renal function with obstruction signs of urine outflow from the pelvis confirmed by radioisotope renography; a combination of reduction of parenchyma thickness and increase of pelvis diameter at serial ultrasound studies; or a combination of these pathologies with urinary tract infection. During the trial, the following parameters were recorded: demographic data, findings of perioperative diagnostic examinations, surgical details, recovery process after surgery and long-term consequences. Results. The average age of patients was 50.24 days. Of 105 patients, 60 (57.14%) were less than 1 month old, and the remaining 45 (42.86%) were 1-3 months old. Gender distribution in groups was as follows: m / f = 73:32. Unilateral operations on the left kidney were in 61.82% patients, on the right kidney - in 33.64% patients. 4.54% patients had bilateral pyeloplasty. Average duration of surgery was 73.07 minutes (40-120 minutes). The average length of hospital stay was 4.19 days (2-9 days). At the early postoperative period, 4 (3.6%) patients developed postoperative complications - urinoma formation. A comparison of pre- and postoperative renal morphometry findings by ultrasound and Doppler ultrasound examination showed a significant decrease of renal pelvis dimensions and improved renal blood flow. The pelvis size decreased in average from 23.5 to 5.5 mm (p = 0.001), and RI from 0.72 to 0.64 (p = 0.001). Functioning of the operated kidney, as showed by the radioisotope renography, improved from 34 to 45.27 (p = 0.001). Long-term follow-up observation revealed one relapse of the disease (0.9%) - stenosis of pyeloureteral anastomosis which required a repeated laparoscopic pyeloplasty. One patient (0.9%)/ who was under follow-up observation for 36 months, had deterioration and loss of kidney function without signs of renal obstruction at the level of pyeloureteral segment which required laparoscopic nephrectomy. Thus, taking into account one relapse and loss of kidney function in one patient, we can state that the effectiveness of laparoscopic pyeloplasty in our study was 98.2%. Conclusion. Summarizing results of the applied laparoscopic pyeloplasty in the youngest group of patients whose age does not exceed 3 months of life, it can be stated that the minimally invasive approach contributes to normalizing morphological and functional parameters of kidney.

Ultrasound-Based Scoring System for Indication of Pyeloplasty in Patients With UPJO-Like Hydronephrosis

Background: Previous scoring systems have used renal scan parameters to assess severity of ureteropelvic junction obstruction-like hydronephrosis (UPJO-like HN), however this information is not always reliable due to protocol variation across centers and renogram limitations. Therefore, we sought to evaluate the Pyeloplasty Prediction Score (PPS), which utilizes only baseline ultrasound measurements to predict the likelihood of pyeloplasty in infants with UPJO-like.Methods: PPS was developed using three ultrasound parameters, Society of Fetal Urology (SFU) grade, transverse anteroposterior (APD), and the absolute percentage difference of ipsilateral and contralateral renal lengths at baseline. PPS was evaluated using prospectively collected prenatal hydronephrosis data (n = 928) of patients with UPJO-HN. Children with vesicoureteral reflux. primary megaureter, other associated anomalies, bilateral HN and <3 months of follow-up were excluded. Scores were analyzed regarding its usefulness in predicting which patients would be more likely to undergo pyeloplasty. Sensitivity, specificity, likelihood ratios (LR) and receiver operating characteristic (ROC) curve were determined.Results: Of 353 patients, 275 (78%) were male, 268 (76%) had left UPJO-like HN, and 81 (23%) had a pyeloplasty. The median age at baseline was 3 months (IQR 1–5). The PPS system was highly accurate in distinguishing patients who underwent pyeloplasty using baseline ultrasound measurements (AUC: 0.902). PPS of 7 and 8 were found to have a sensitivity of 85 and 78%, and specificity of 81 and 90%, respectively. PPS of 8 was associated with a LR of 7.8, indicating that these patients were eight times more likely to undergo pyeloplasty.Conclusion: Overall, PPS could detect patients more likely to undergo pyeloplasty using baseline ultrasound measurements. Those with a PPS of eight or higher were eight times more likely to undergo pyeloplasty.