Redo Pyeloplasty Research Articles

Outcomes of robot-assisted laparoscopic pyeloplasty among pediatric patients with complex renal anatomy: A retrospective comparative study

Robot-assisted laparoscopic pyeloplasty (RALP) has been increasingly utilized in the treatment of pediatric ureteropelvic junction obstruction (UPJO) with reported success rates of >95%. Complex renal anatomy can make some cases challenging to reconstruct. To evaluate outcomes of children undergoing RALP with aberrant renal anatomy and compare it to those with simple renal anatomy. An IRB approved prospective registry was queried to retrospectively identify all patients who underwent robotic pyeloplasty at our institution from 2012 to 2022. Patients undergoing re-do pyeloplasty were excluded. Complex anatomy was defined as horseshoe kidney, ectopic/pelvic kidney, duplex collecting system, fully bifid renal pelvis and severe malrotation (≥180°). A comparative analysis of baseline demographics, pre-operative clinical/radiological characteristics, intra and post-operative details, and long-term success was performed between those patients with complex anatomy and those without. Of 405 total robotic pyeloplasty's, 375 patients (378 total pyeloplasty; 353 simple, 22 complex) met inclusion criteria. 27 re-do were excluded from analysis. The complex pyeloplasty cohort included 9 horseshoe kidneys, 8 duplex collecting systems, 3 ectopic/pelvic kidneys and 2 kidneys with severe malrotation. There was no difference in age (58 vs 31 months; p=0.38), procedure time (203 vs 207min; p=0.06), length of stay (1.4 vs 1.3 days; p=0.99), or success (91.6% vs 100%; p=0.24) between the simple and complex groups. Etiology of obstruction differed significantly between groups - high insertion was more common (3.9% vs 18.2%, p=0.02) and intrinsic narrowing was less common (60.1% vs 36.4%, p=0.04) in patients with complex anatomy. A multivariate logistic regression was adjusted for age, gender, etiology of obstruction, preoperative differential renal function and post-operative complications and found no difference in success between complex and simple RALP. The findings showed no significant differences in age, procedure time, length of hospital stay, or success rates between the two groups. Specifically, the success rates were 91.6% for the complex group and 100% for the simple group (p=0.24), indicating comparable efficacy. However, the etiology of obstruction varied significantly, with high ureteral insertion more common in the complex anatomy group (18.2% vs. 3.9%, p=0.02) and intrinsic narrowing less common (36.4% vs. 60.1%, p=0.04). Despite these differences, multivariate logistic regression, adjusted for confounders, confirmed no difference in success rates between the groups. RALP is a safe and efficacious approach in patients with complex anatomy with success rates comparable to index patients. High ureteral insertion does appear to be more common in patients with complex anatomy undergoing pyeloplasty.

The missed crossing vessel during open pyeloplasty: a potential advantage of the robot-assisted approach in children

ObjectiveTo investigate whether the panoramic view offered by robot-assisted laparoscopic pyeloplasty (RALP) reduces the likelihood of missing a crossing vessel compared to open pyeloplasty in cases where initial pyeloplasty fails.MethodsA single institution redo-pyeloplasty database was reviewed for children treated between January 2012 to July 2023. Clinical history, imaging and operative details were reviewed to identify the etiology for the redo procedure.ResultsCohort consisted of 45 patients undergoing a redo RALP during the study period. 29 of 45 patients had an initial open surgical approach, whereas 16 had an initial RALP. 10 patients were noted to have a missed crossing vessel on redo pyeloplasty – 9 had an initial open approach whereas 1 had an initial RALP (p<0.0001).ConclusionsRALP may reduce the risk of missing a crossing vessel due to the panoramic view of the surgical field intrinsic to an intraperitoneal RALP approach.

Analysis of outcomes of robot-assisted laparoscopic pyeloplasty in children from a tertiary pediatric center in South India.

This study aims to analyze the outcomes of robot-assisted laparoscopic pyeloplasty (RALP) in children with pelvi-ureteric junction obstruction (PUJO) over a 10-year period at a tertiary care center in South India. This study provides a detailed analysis of prospectively acquired data from 2013 to 2023 of all children who underwent RALP at our institution. Pre- and post-operative renal ultrasound and isotope renography were used to assess outcomes. Detailed information on patient demographics, procedural duration, post-operative pain relief, operation steps, and post-surgical follow-up protocols has been provided. The analysis included all patients who completed a 1-year follow-up. Between 2013 and 2023, 201 children underwent RALP. Of these, 185 children completed at least 1 year of follow-up and were included in the analysis. The mean age of the cohort was 4.9 years (1 month to 17 years), with males comprising the majority (77.3%). Twenty-five children (13.5%) were younger than 1 year of age. Left-sided PUJO was found to be more common. The mean console time was 76.5 min (40-180 min), and the average hospital stay was 2.8 days (2-5). After surgery, the mean reduction in antero-posterior diameter of the renal pelvis was more than 50% of its pre-operative value and statistically significant (3.3 ± 0.3 to 1.9 ± 0.9 cm). At the end of 1 year, the overall reduction in renal size was also significant (9.7 ± 2.3 cm pre-operative to 8.9 ± 1.8 cm post-operative). The pre-operative Society of Fetal Urology (SFU) grade of hydronephrosis was compared to the post-operative SFU grade, and the improvement (resolution/downgrading) was found to be statistically significant. The median split renal function in this series was 39% pre-operative and 43% post-operative, and the overall functional improvement after RALP was significant. A successful outcome was observed in 181 children (97.8%). Four children experienced persistent severe hydronephrosis and underwent redo stenting and/or redo pyeloplasty (2.1% failure rate). Post-operative complications, according to the Clavien-Dindo classification, were classified as type 1 in three children and type 3b in two children. There were no conversions to open surgery in the series. RALP emerges as the minimally invasive procedure of choice for children with PUJO at our institution. It is safe, delivering consistently excellent results and minimal complications. Our outcomes are comparable to those of previously published series. We trust that our experience will serve as a roadmap for those centers (especially in South Asia) embarking on a pediatric robotic program.

Feasibility and Effectiveness of Repeat Laparoscopic Pyeloplasty for Recurrent Ureteropelvic Junction Obstruction in Pediatric Patients.

Objective: To assess the outcomes of redo laparoscopic pyeloplasty (RLP) in pediatric patients with recurrent ureteropelvic junction obstruction (UPJO) in contrast to redo open pyeloplasty (ROP). In addition, evaluate the feasibility and efficacy of RLP as a treatment modality for recurrent UPJO in children. Materials and Methods: The data of 44 patients from March 2012 to March 2022, who underwent redo pyeloplasty, were retrospectively reviewed. In Group RLP, the children underwent RLP, whereas ROP was attempted in Group ROP. Demographics, clinical manifestations, surgical duration, hospitalization duration, complication rates, and treatment success were examined within the respective groups. Moreover, preoperative and postoperative measurements of anterior-posterior diameter of the renal pelvis (APD), preoperative assessment of differential renal function (DRF), and the percentage of improvement in DRF (PI-DRF) were subject to analysis. Results: The study included 28 patients who underwent RLP (Group RLP), and 16 patients who underwent ROP (Group ROP). In all cases, the Anderson-Hynes technique was employed. There was no significant difference between the two groups regarding age, body mass index, gender distribution, affected side, preoperative APD, postoperative APD, and preoperative DRF. In comparison to Group ROP, Group RLP exhibited a shorter hospitalization duration, a longer surgical procedure duration, and a higher percentage improvement in PI-DRF. The median follow-up period for Group RLP was 25 months, whereas it was 25.5 months for Group ROP. Notably, the success rates were similar between the two groups, with a success rate of 89.2% in RLP and 87.5% in ROP (p = 0.634). Conclusion: RLP has a comparable success rate to ROP and is a safe, effective, and feasible procedure for the treatment of failed pyeloplasty in children.

Can urinary caspase-3 and cytochrome c levels be used as predictive biomarkers in the management of unilateral antenatal hydronephrosis?

We aimed to investigate the urinary caspase-3 and cytochrome c levels in patients with unilateral antenatal hydronephrosis and to determine whether changes in urinary biomarker levels could be useful for both predicting the need for surgical intervention due to ureteropelvic junction obstruction (UPJO) and postoperative surgical success. Sixty-five children with a history of unilateral antenatal hydronephrosis and postnatal anteroposterior diameter ≥ 10mm were included in this prospective case-control study between January 2013 and December 2021. The obstruction group consisted of 33 patients (28 boys, 84.8%) who underwent open dismembered pyeloplasty due to UPJO. The non-obstructive dilatation (NOD) group consisted of 32 patients (27 boys, 84.4%) with stable or improving hydronephrosis and no significant reduction in ipsilateral split renal function during follow-up, whereas 34 healthy children were enrolled in the study as a control group. Urinary urinary caspase-3 and cytochrome c levels using ELISA were measured. The median preoperative urinary caspase-3 level was significantly higher in the obstruction group when compared to the NOD group (4.82ng/mgCr vs. 2.61ng/mgCr, p = 0.013) as well as the control group (4.82ng/mgCr vs. 1.72ng/mgCr, p = 0.002). In the postoperative period, urinary caspase-3 levels significantly decreased compared to preoperative measurements (4.82ng/mgCr vs. 2.51ng/mgCr, p = 0.006) and became similar to the control group (2.51ng/mgCr vs. 1.72ng/mgCr, p = 0.422). On the other hand, no significant differences were observed in urinary cytochrome c levels between the groups. All patients who underwent pyeloplasty achieved postoperative resolution in hydronephrosis and improved drainage on MAG-3, so none of the patients required re-do pyeloplasty. Postoperative decrease in caspase-3 level was found to be compatible with adequate urine drainage on MAG-3 scan. The cut-off value of urinary caspase-3 to predict patients requiring pyeloplasty was found to be 3.31ng/mg creatinine with 63.6% sensitivity, 62.5% specificity (AUC = 0.679). In the multivariable analysis, urinary caspase-3 level (OR: 1.653, p = 0.019), anteroposterior pelvic diameter (OR: 1.401, p = 0.001), and split renal function on MAG-3 (OR: 1.277, p = 0.011) were found to be independent factors in determining patients who require surgery. Based on our preliminary findings, urinary caspase-3 levels could be a useful biomarker not only for predicting the need for surgical intervention but also for determining the postoperative surgical success in children with UPJO.

What to Expect on the Long-term Follow-up of Pediatric Pyeloplasty: Critical Time Intervals and Risk Factors

BackgroundStandard protocol for post-pyeloplasty monitoring in children and natural course of hydronephrosis resolution have not been well defined. We aimed to analyze critical time intervals and risk factors in the long-term clinical outcomes of children who were operated for ureteropelvic junction obstruction. MethodsFiles of patients who underwent open dismembered pyeloplasty between January 2000 and December 2012 and had a ≥10 years follow-up were retrospectively reviewed. Changes in SFU hydronephrosis grade, pelvis anteroposterior diameter (APD), renal parenchymal thickness, split renal functions (SRF) on MAG-3 scan as well as development of hypertension and proteinuria were noted. Complete resolution was defined as SFU grade 0–1 or APD≤10 mm or ≥50 % APD decrease. ResultsOverall, 223 patients (161 boys, 72.1 %) with a median age of 9 (range 1–185) months underwent unilateral pyeloplasty, whereas 14 patients (13 boys, 92.8 %) with a median age of 4 (range 2–39) months underwent bilateral pyeloplasty. Median follow-up was 13 (range 10–22) years. Complete resolution was observed in 190 patients (85.2 %). None of the cases required re-do pyeloplasty. Regarding unilateral cases, postoperative changes in hydronephrosis reached a plateau at the 60th month. Also, there was no significant difference regarding SRF between the 12th month and the 60th month (p > 0.05). Hypertension developed after a median period of 12 years in 13 (5.4 %) of the patients, while proteinuria developed in four (1.6 %) patients. Bilateral disease (HR: 2.518, p = 0.034) was found to be a significant determinant for development of hypertension and/or proteinuria. ConclusionsOur results indicated that ultrasonographic findings stabilized after the 60th month postoperatively, and SRF remained stable between the postoperative 12th and the 60th months. The risk of developing hypertension and/or proteinuria was 2.5 times greater in bilateral cases. Level of EvidenceLevel II.

Laparoscopic pyeloplasty proficiency during a residency program after adoption of a standardized simulation training program is maintained during the COVID pandemic despite reduced surgery volume.

To evaluate the effect of the standardized laparoscopic simulation training program in pyeloplasty, following its implementation and during the COVID-19 pandemic. A retrospective chart review was performed at Hospital de Clínicas de Porto Alegre, a tertiary referral center in south Brazil, in which 151 patients underwent laparoscopic pyeloplasty performed by residents between 2006-2021. They were divided into three groups: before and after adoption of a standardized laparoscopic simulation training program and during the COVID-19 pandemic. The main outcome was a combined negative outcome of conversion to open surgery, major postoperative complications (Clavien-Dindo III or higher) or unsuccessful procedure, defined as need for redo pyeloplasty. There was a significant reduction in the combined negative outcome (21.1% vs 6.3%), surgical time (mean 200.0 min vs 177.4 min) and length of stay (median 5 days vs 3 days) after the adoption of simulation training program. These results were maintained during the COVID-19 pandemic (combined negative outcome of 6.3%, mean surgical time of 160.1 min and median length of stay of 3 days) despite a reduction in 55.4% of the surgical volume. A structured laparoscopic simulation program can improve outcomes of laparoscopic pyeloplasty during the learning curve.

Latitudes and attitudes: A multinational study of laparoscopic pyeloplasty in children

The Anderson-Hynes technique has been the treatment of choice for primary ureteropelvic junction obstruction in children. Laparoscopic approach has shown similar outcomes to open, with advantages of shorter hospital stay and less pain. We reviewed the experience of 11 geographically diverse, tertiary pediatric urology institutions focusing on the outcomes and complications of laparoscopic pyeloplasty. A descriptive, retrospective study was conducted evaluating patients undergoing Anderson-Hynes dismembered laparoscopic pyeloplasty. Centers from four different continents participated. Demographic data, perioperative management, results, and complications are described. Over a 9-year period, 744 laparoscopic pyeloplasties were performed in 743 patients. Mean follow-up was 31 months (6-120m). Mean age at surgery was 82 months (1 w-19y). Median operative time was 177min. An internal stent was placed in 648 patients (87%). A catheter was placed for bladder drainage in 702 patients (94%). Conversion to open pyeloplasty was necessary in seven patients. Average length of hospital stay was 2.8 days. Mean time of analgesic requirement was 3.2 days. Complications, according to Clavien-Dindo classification, were observed in 56 patients (7.5%); 10 (1%) were Clavien-Dindo IIIb. Treatment failure occurred in 35 cases with 30 requiring redo pyeloplasty (4%) and 5 cases requiring nephrectomy (0.6%). We have described the laparoscopic pyeloplasty experience of institutions with diverse cultural and economic backgrounds. They had very similar outcomes, in agreement with previously published data. Based on these findings, we conclude that laparoscopic pyeloplasty is safe and successful in diverse geographics areas of the world.

V08-09 SERIES OF MISSED FIBROEPITHELIAL POLYPS IN THE PEDIATRIC POPULATION

You have accessJournal of UrologyCME1 May 2022V08-09 SERIES OF MISSED FIBROEPITHELIAL POLYPS IN THE PEDIATRIC POPULATION Aznive Aghababian, John Weaver, Sahar Eftekharzadeh, Sonam Saxena, Iqra Nadeem, Pooja Unadkat, Katherine Fischer, Karl Godlewski, Sameer Mittal, Christopher Long, Dana Weiss, Arun Srinivasan, and Aseem Shukla Aznive AghababianAznive Aghababian More articles by this author , John WeaverJohn Weaver More articles by this author , Sahar EftekharzadehSahar Eftekharzadeh More articles by this author , Sonam SaxenaSonam Saxena More articles by this author , Iqra NadeemIqra Nadeem More articles by this author , Pooja UnadkatPooja Unadkat More articles by this author , Katherine FischerKatherine Fischer More articles by this author , Karl GodlewskiKarl Godlewski More articles by this author , Sameer MittalSameer Mittal More articles by this author , Christopher LongChristopher Long More articles by this author , Dana WeissDana Weiss More articles by this author , Arun SrinivasanArun Srinivasan More articles by this author , and Aseem ShuklaAseem Shukla More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002606.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fibroepithelial polyps in the urinary tract are a rare cause of obstructive uropathy. We hypothesized that the presence of polyps should be considered as a potential cause of ureteral obstruction during ureteral spatulation at the time of reconstruction in older children. METHODS: We queried our institution’s prospectively managed pyeloplasty and ureteroureterostomy databases to identify patients with findings of fibroepithelial polyps between 2008-2021. Baseline demographics, clinical presentation, imaging details, and post-operative details including resolution of symptoms/hydronephrosis or need for further intervention were aggregated. RESULTS: We identified 7 patients (all male) with fibroepithelial polyps who presented at a median age of 10.4 years (IQR: 9.1, 12.9) [Table 1]. All patients underwent cross-sectional imaging with no polyps visualized. There was a possible crossing vessel visualized in 2 patients who underwent magnetic resonance urography (MRU). 6/7 patients underwent pyeloplasty for presumptive ureteropelvic junction obstruction (UPJO), while one patient underwent an upper to lower pole ureteroureterostomy (UU) following a ureteroscopy that revealed polyps in the distal upper pole ureter of a duplicated system. The median age at surgery was 10.5 years (IQR: 9.5, 13.1). During surgery, retrograde pyelogram (RPG) was performed in 3/7 patients and polyps were visualized in 2 cases. During the median follow-up duration of 27.4 months (IQR: 6.3, 43.6), 2 patients required further intervention: 1 patient required 2 endoscopic interventions for persistent polyps, and 1 patient required 6 endoscopic interventions for persistent polyps/recurrent stones, ultimately requiring a redo pyeloplasty 5.9 years after the index procedure. CONCLUSIONS: In our series, polyps were missed on preoperative imaging (including cross-sectional imaging) in all cases. It is critical for urologists to be aware of polyps as a potential source of obstruction as they can increase the complexity of a reconstruction and, if missed, may result in a failed repair. Performing a RPG prior to upper tract reconstruction can potentially reveal the diagnosis and more clearly delineate the extent of the polyps. Failure to adequately spatulate the ureter and remove all the polyps can result in recurrence which is why we advocate for longer post-operative follow up in these patients. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e716 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aznive Aghababian More articles by this author John Weaver More articles by this author Sahar Eftekharzadeh More articles by this author Sonam Saxena More articles by this author Iqra Nadeem More articles by this author Pooja Unadkat More articles by this author Katherine Fischer More articles by this author Karl Godlewski More articles by this author Sameer Mittal More articles by this author Christopher Long More articles by this author Dana Weiss More articles by this author Arun Srinivasan More articles by this author Aseem Shukla More articles by this author Expand All Advertisement PDF DownloadLoading ...

Retrograde stent with external string for pediatric robotic pyeloplasty: does it reduce cost and complications?

Robotic-assisted pyeloplasty (RAP) is a mainstay in the treatment of ureteropelvic junction obstruction (UPJO) in children. At our institution, to limit planned operating rooms visits we have placed a ureteral stent with an external string (SWES) immediately prior to RAP. In this study, we sought to quantify the operative time, complications, and costs associated with this approach compared to the traditional approach, requiring subsequent stent removal in the operating room. We hypothesized the SWES cohort would have decreased cost, yet with similar operative time and complications. We retrospectively collected all RAPs performed at our institution using the SWES approach (Aug 2012-July 2017). We excluded those with a redo pyeloplasty, and/or a percutaneous nephrostomy tube for post-operative drainage. We collected 30-day costs linked to the patients' MRN using the Pediatric Health Information System (PHIS) database. We compared 30-day healthare costs for all patients following RAP. We compared our SWES group to a national cohort of all pediatric RAP during the same time period. Lastly, we sent an anonymous, electronic survey to urologists of all PHIS institutions to identify the predominant postoperative drainage, nationally. Within our institution, we reviewed all those treated with SWES (n = 85) (Table 1). The median 30-day cost was $10,548 among those with SWES (Table 2). This was significantly less than the overall, national cohort of all pediatric RAP during the same period ($14,119, p < 0.001). There was a 15.5 % rate of unplanned return to the hospital in the SWES group. Of those unplanned returns, 8.2 % (7/85) had unplanned return for a procedure (3 for unplanned stent removal, 2 for nephrostomy tube for persistent obstruction, 1 for omental hernia, and 1 for stent replacement). With a 42.5 % (37/87) response rate, our nationwide survey found 84.6 % primarily leave stents WITHOUT a string, 7.7 % left nephrostomy tubes, and 7.7 % stents with strings. During pediatric RAP, placement of a SWES takes little time, carries a risk of unplanned visit to the operating room, saves the patient a certain, second anesthetic for stent removal, and amounts to a cost savings of approximately 25 %.

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

This study aimed to clarify the advantage of retroperitoneoscopy-assisted dismembered pyeloplasty with single-site plus one port (RPSPO) for pediatric congenital hydronephrosis in patients aged ≥7 years. We retrospectively compared a group of patients aged ≥7 years (study group) with patients aged <7 years (comparison group), who underwent RPSPO between August 2015 and August 2018, in terms of preoperative patient characteristics, intra- and perioperative results, and postoperative results. The study group consisted of eight patients. The median body weight at surgery was 27 kg (20-38 kg). The median age at surgery was 102.5m (87-139 m). The severity of hydronephrosis on the affected side graded by the Society for Fetal Urology grade was grade 3 in one case and grade 2 or less in all other cases. All patients underwent a 99m Tc-MAG3 renogram. Comparison between the two groups showed significant differences in body weight at surgery (p=0.003), age (p < 0.001), and preoperative hydronephrosis grade (p=0.007), but the median length of the skin incision was 20 mm in both groups, with no significant difference (p=1.000). Redo pyeloplasty was not required in any patient in either group. RPSPO is an advantageous procedure for older children because it allows precise ureteropelvic neoanastomosis under direct vision and the same wound size as in younger children.

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.

Comparative Outcomes of Double-J and Cutaneous Pyeloureteral Stents in Pediatric Robot-Assisted Laparoscopic Pyeloplasty.

Background: Comparative outcome studies investigating internal Double-J (DJ) and externalized stents have primarily been performed for open and laparoscopic pyeloplasty, with a paucity of literature surrounding outcomes in robot-assisted laparoscopic pyeloplasty (RALP). Furthermore, outcomes of a modified external stent inserted into the renal pelvis, termed cutaneous pyeloureteral (CPU) stent, remain unexamined. This study investigates outcomes of DJ and CPU stents as methods of trans-anastomotic drainage. Materials and Methods: A retrospective analysis identified pediatric patients who underwent RALP between December 2007 and January 2020 at a single tertiary center, where CPU stents were introduced in June 2012. Operative success was defined as improved or stable hydronephrosis without subsequent redo pyeloplasty. Secondary outcomes included stent reinsertion, anesthesia requirements, opioid administration, urinary tract infection (UTI), and bladder spasms. Results: A total of 103 pediatric RALP procedures were analyzed (DJ = 70, CPU = 33). Operative success (DJ = 95.7%, CPU = 100%, p = 0.55), Society for Fetal Urology (SFU) grade improvement, and length of stay were comparable. Accidental stent expulsion was only seen with CPU stents (9%; p = 0.03). Intracorporeal stent migration also occurred more frequently in CPU stents (DJ = 3%, CPU = 15%, p = 0.03). Stent reinsertion, when needed, used a DJ stent with rates of 4% and 9% for DJ and CPU stents, respectively (p = 0.38). DJ stents were removed at a later postoperative day (DJ = 45.2 ± 25.0, CPU = 8.3 ± 4.2; p < 0.001) with increased general anesthesia (DJ = 99%, CPU = 3%; p < 0.001) and intravenous (IV) opioid (DJ = 27%, CPU = 9%; p = 0.04) requirements. Finally, DJ stents had nonsignificant increased rates of UTI (DJ = 17%, CPU = 3%, p = 0.06) and bladder spasms necessitating postoperative medication (DJ = 26%, CPU = 9%, p = 0.07). Conclusions: DJ and CPU stents display equivalent success rates in pediatric RALP and similar stent reinsertion rates. Appreciable differences can inform stent selection, including higher general anesthesia requirements and IV opioid administration among DJ stents and a higher incidence of accidental stent expulsion among CPU stents. In addition, DJ stents were associated with nonsignificant increased rates of UTI and bladder spasm necessitating medication.

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.

Management of proximal migration of double-J stents after Anderson-Hynes pyeloplasty in children

Proximal migration of double J stents after pediatric pyeloplasty is rare. Although retrograde removal of migrated stents is more common, the small calibre of the pediatric ureter may necessitate antegrade retrieval. Many techniques are described for the same in adults however, pediatric literature is sparse. We aim to describe the management of proximally displaced stents after pediatric pyeloplasty. This retrospective study included all children (<17 years age) who underwent retrieval of proximally displaced DJ stents after pyeloplasty between 2007 and 2019at a single institution. The retrograde technique employed ureteroscopic retrieval with a grasper while in the antegrade technique, an access sheath was placed percutaneously into a calyx and Nephroscopic retrieval was performed. There were 8 children (6 boys and 2 girls) of which 4 were infants. Median age was 3.5 (0.5-12) years and median follow-up was 7.5 (4-47) months. Two children had been referred with displaced stents after pyeloplasty from other centres. The incidence of proximal stent migration was 6/1644 (0.4%). Open pyeloplasty had been performed in seven while one child had undergone laparoscopic pyeloplasty. The lower coil of the migrated stent was in the renal pelvis in 6 (complete) and ureter in 2 (partial migration). Those with partial migration underwent successful ureteroscopic retrieval. Three infants required Antegrade stent removal while ureteroscopic retrieval was successful in an older child with complete stent migration. Nephrectomy for loss of function and redo pyeloplasty for pelvi-ureteric stricture was performed in one each. One child had self-limiting fever (Clavien 1) after stent removal. All had normal drainage on renogram after 6 months. The cause of proximal stent migration was likely to be an inadequate lower coil (<180°) in 5 children and a capacious pelvis with narrow ureter in one infant. The cause could not be ascertained in two children who were referred from other centres. The management algorithm for retrieval of proximally migrated DJ stents, is depicted in Fig.3. Proximal migration of DJ stent after pyeloplasty is a rare complication which may be safely managed with a stepwise approach using both Antegrade and retrograde techniques. Accurate stent length, adequate distal coil and appropriate placement are essential to avoid stent migration.

Surgical outcomes are equivalent after pure laparoscopic and robotic-assisted pyeloplasty for ureteropelvic junction obstruction

Minimally invasive (robotic and pure laparoscopic) pyeloplasty has been increasingly used for treatment of ureteropelvic junction obstruction (UPJO). However, few large-scale studies have compared these two modalities directly. We performed a retrospective single-center review of all patients who underwent pure laparoscopic (LP) or robotic pyeloplasty (RALP) between 2007 and 2018. Patients were excluded if the initial surgery at our institution was a redo pyeloplasty or if they lacked follow-up information. Outcomes of interest included operative time, length of stay, and complication rates, including rates of secondary procedures. We compared these outcomes between groups using Student's t test for continuous variables and a Chi-square for categorical variables. A total of 282 patients were identified. Forty-eight were excluded based on study criteria; therefore, our total study cohort was 234 patients: 119 RALP and 115 LP cases. Overall mean postoperative follow-up time was 20.8 months, with no significant differences between groups. Mean operative time was shorter in the LP group when compared the RALP group (3h 7min vs. 3h 41min, p<0.001). There were no significant differences between groups in length of stay (1.22 days vs 1.50 days, p=0.095). Complications occurred in 52 patients (22.2% of overall cohort) with no difference in incidence between groups. Twenty-five patients (14 in the RALP group and 11 in the LP group) underwent unplanned secondary procedures; 19 of these patients (9 in the RALP group and 10 in the LP group) needed a procedure to address secondary obstruction. We demonstrated no significant differences between RALP and LP in regards to complication rates. Surgeons performing RALP and LP have the potential to offer the same level of care for the surgical management of UPJO, especially in countries where robotic technology may not be readily available.

Advance in re-do pyeloplasty for the management of recurrent ureteropelvic junction obstruction after surgery

Ureteropelvic junction obstruction (UPJO) is characterized by decreased flow of urine down the ureter and increased fluid pressure inside the kidney. Open pyeloplasty had been regarded as the standard management of UPJO for a long time. Laparoscopic pyeloplasty reports high success rates, for both retroperitoneal and transperitoneal approaches, which are comparable to those of open pyeloplasty. However, open and laparoscopic pyeloplasty have yielded disappointing failure rates of 2.5%-10%. The main causes for recurrent UPJO are severe peripelvic and periureteric fibrosis due to urinary extravasation, ureteral ischemia, and inadequate hemostasis. In addition, failing to diagnose lower pole crossing vessels before or during the primary procedure is also responsible for recurrent UPJO. In addition, poor preoperative split renal function, hydronephrosis, presence of renal stones, patient age, diabetes, prior endopyelotomy history, and retrograde pyelography history were considered as predictors of pyeloplasty failure. The failure is usually defined by persistent pain, persistent radiographic obstruction (infection or stones), continued decline in split renal function, or a combination of the above. And the failure of pye-loplasty often occurs in the first 2 years after the surgery. The available options for managing recurrent UPJO with a salvageable renal unit include endopyelotomy, re-do pyeloplasty, stent implantation, percutaneous nephrostomy, ureterocalicostomy, and nephrectomy. Re-do pyeloplasty has such merits as high successful rates and rare complications, compared with endopyelotomy or ureterocalicostomy. And some investigators think that re-do pyeloplasty should be regarded as the gold standard for secondary therapy if feasible. Open pyeloplasty can enlarge the operating field, facilitate the exposure of the ureteropelvic junction, reduce the difficulty of operation, and thus reduce the occurrence of complications. There are no significant differences among the success rates of re-do pyeloplasty under open approach, traditional laparoscopy and robot-assisted laparoscopy, according to previous reports. However, traditional laparoscopic and robot-assisted pyeloplasty give advantages of cosmetology, small trauma, less postoperative pain, speedy recovery and shorter hospitalization, fewer complications and lower recurrent rates. If the primary pyeloplasty is an open operation in retroperitoneal approach, the traditional laparoscopic and robotic operation with retroperitoneal approach should be considered for secondary repair. The cause of recurrent UPJO should be evaluated before surgery and identified intraoperatively to minimize the possibility of recurrence.

Micropercutaneous endopyelotomy for the treatment of secondary ureteropelvic junction obstruction in children

The management of recurrent pyeloureteral junction obstruction (PUJO) is controversial, as there is no suitable technique for its correction. Percutaneous endopyelotomy shows better results in recurrent PUJO compared to primary PUJO. Micro-percutaneous approaches reduce damage to renal parenchyma and facilitate access to renal pelvis. To present our experience in the use of this minimally invasive technique for the treatment of recurrent PUJO. A retrospective study was performed collecting data of patients with recurrent PUJO treated in our hospital using the percutaneous approach between July 2014 and January 2018. Micropercutaneous access was performed in all patients. In Valdivia position, a 5 or 6mm high-pressure ballon is placed in the renal pelvis under cystoscopic and fluoroscopic guidance. The 4.8 or 8 Fr microperc puncture needle is placed into the pelvicalyceal system. Endopyelotomy is performed with a laser fiber or monopolar hook on a high-pressure balloon. To improve the exposure of the cutting area, the high-pressure balloon is placed at the pyeloureteral junction. Double J stent is left for weeks. The ages of the patients were 4, 8 and 18 months, and 2 and 4 years. All patients had previously undergone pyeloplasty due to pyeloureteral junction obstruction. Operative time was 50±21min. Hospital stay after surgery was 24h and hematuria disappeared within the 24 postoperative hours. The number of patients with recurrent PUJO is small, making it difficult to establish a standard surgical approach for failed pyeloplasty. Redo pyeloplasty is considered the gold standard by some authors but alternative methods, such as endourological techniques, may also have a role in the treatment of failed pyeloplasty. The percutaneous approach has shown very good results in this treatment and the miniaturization of percutaneous surgery has improved with the micropercutaneus access. We consider micropercutaneous approach helped with a high pressure balloon in the pyeloureteral junction is an alternative and minimally invasive technique that has shown good results in our small cases series. However, we must take into account the limitation of the study considering the low number of patients. We need prospective studies to support our results. Micropercutaneous endopyelotomy is a fairly effective technique to treat recurrent UPJO after failed pyeloplasty in children. In our experience, it reduces kidney damage without increasing complications.

Our experience on management of failed pediatric pyeloplasty.

The purpose of the study was to assess the outcomes of salvage procedures after failed pediatric pyeloplasty. Recurrent ureteropelvic junction obstruction treatment is a difficult course. The salvage surgery is more challenging in the pediatric population. We aimed to assess the outcomes of salvage procedures after failed pediatric pyeloplasty to determine the most efficient surgical intervention. 40 children with 41 renal units who have been treated for recurrent ureteropelvic junction obstruction after pyeloplasty were analyzed retrospectively. The outcomes of all initial and sequent interventions were assessed including redo pyeloplasty, endopyelotomy and balloon dilatation. Children's mean age at initial intervention for failed pyeloplasty was 45.9 (± 46.4) months. Our mean follow-up time after the initial intervention was 46.9 (± 46.6) months. The success rate of our initial treatment methods was 48.7% (20/41). Although redo pyeloplasty was the most successful intervention (83.3%) than DJS placement (45.5%), endopyelotomy (50%) and balloon dilatation (30.8%), the statistical difference was not significant in the initial operations. The overall success rates of redo pyeloplasty, double-J stent placement, endopyelotomy and balloon dilatation were 78.9%, 46.1%, 38.8% and 29.4%, respectively (p < 0.05). Redo pyeloplasty provides the best improvement in recurrent ureteropelvic junction obstruction in children. In selected patients, minimal invasive methods such as endopyelotomy and balloon dilatation offer alternative treatment.