Ureteropelvic Junction Obstruction Research Articles

V01-03 SINGLE-PORT MINI PFANNENSTIEL ROBOTIC EXTRAPERITONEAL PEDIATRIC PYELOPLASTY: INITIAL EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023V01-03 SINGLE-PORT MINI PFANNENSTIEL ROBOTIC EXTRAPERITONEAL PEDIATRIC PYELOPLASTY: INITIAL EXPERIENCE Jaya Sai Chavali, Brendan Frainey, Albert Geskin, Ethan Ferguson, Roxana Ramos, Audrey Rhee, and Jihad Kaouk Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Brendan FraineyBrendan Frainey More articles by this author , Albert GeskinAlbert Geskin More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Roxana RamosRoxana Ramos More articles by this author , Audrey RheeAudrey Rhee More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aim to report our technique and functional and radiological outcomes of extra peritoneal robotic pediatric pyeloplasty through a mini-pfannenstiel (3 cm) incision using da-Vinci single-port (SP) robotic surgical system in pediatric population. METHODS: We present our initial series of 8 pediatric patients that underwent robotic SP pyeloplasty between 2020 - 2022. The case presented in current video is 1 year old male with known history antenatal hydronephrosis that presented with worsening postnatal hydronephrosis and renal function on split function and renal ultrasound imaging studies. The patient underwent cystoscopy, stent placement that confirmed severe ureteropelvic junction (UPJ) obstruction prior to proceeding with robotic surgery. He was placed in relaxed lateral position, extra peritoneal space was developed through mini pfannenstiel incision before docking the SP surgical system. The following robotic surgical steps were described: (1) development of extra peritoneal space, (2) identification of ureter and ureteropelvic junction, (3) dismemberment and reduction of redundant renal pelvis, (4) ureteropelvic junction anastomosis using running 5-0 Vicryl sutures. RESULTS: Overall operative time was 120 minutes and associated with minimal blood loss. No complications and patient discharged on POD1 and stent removed in 4 weeks as outpatient. The attached tables describe our study patient demographics, indications (Table 1) and outcomes among our study population (Table 2). All patients tolerated the surgery with minimal postsurgical pain and no narcotic requirement. CONCLUSIONS: Single port extra peritoneal pyeloplasty is a safe and feasible option for upper tract reconstruction in pediatric patients. All patients had complete resolution of symptoms both clinically and based on imaging upon follow up. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e79 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jaya Sai Chavali More articles by this author Brendan Frainey More articles by this author Albert Geskin More articles by this author Ethan Ferguson More articles by this author Roxana Ramos More articles by this author Audrey Rhee More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-06 ASSESSING THE ACCURACY OF PREOPERATIVE RADIOGRAPHIC IMAGING IN DETERMINING URETERAL STRICTURE LENGTH AT TIME OF ROBOTIC URETERAL RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP42-06 ASSESSING THE ACCURACY OF PREOPERATIVE RADIOGRAPHIC IMAGING IN DETERMINING URETERAL STRICTURE LENGTH AT TIME OF ROBOTIC URETERAL RECONSTRUCTION Labeeqa Khizir, Alain Kaldany, Hiren V. Patel, and Sammy E. Elsamra Labeeqa KhizirLabeeqa Khizir More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Hiren V. PatelHiren V. Patel More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: During robotic ureteral reconstruction, accurate measurement of ureteral stricture length is important for surgical planning. We aimed to determine the accuracy of using conventional fluoroscopic imaging compared to ureteroscopy and direct measurement with measuring tape during intra-operative robotic repair. METHODS: A retrospective review was conducted for 15 patients with ureteral stricture disease at a single institution treated with robotic repair. Data was collected regarding etiology of ureteral stricture disease, measured preoperative radiographic stricture length on fluoroscopy, and measured intraoperative robotic stricture length. A Wilcoxon matched-pairs rank test was performed to compare ureteral length measurements. RESULTS: The most common etiologies of ureteral stricture were prior medical history of stone disease (n=10), prior ureteropelvic junction obstruction repair (n=3), and other iatrogenic causes (n=2) (Table 1). A majority of patients had ureteral stricture repair using buccal mucosa (n=7) or appendiceal onlay (n=6) grafts (Table 1). A total of 11 patients (73%) had >1 cm difference in stricture length between radiographic and robotic measurement (Figure 1). Of these patients, 73% (n=8) had prior medical history of stone disease (Table 1). The intraoperative robotic length was significantly longer compared to preoperative radiographic length (Median difference 1.2 cm, 98% CI 0.15-2.3, p<0.05) (Figure 1). CONCLUSIONS: Conventional preoperative radiographic measurement significantly underestimates the ureteral stricture length compared to intraoperative measurement. This may have clinical significance in influencing operative planning, technique, and the length of graft that is harvested. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e568 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Labeeqa Khizir More articles by this author Alain Kaldany More articles by this author Hiren V. Patel More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

MP70-05 ASSOCIATION BETWEEN THE HYDRONEPHROSIS OUTCOME PREDICTION SCORE AND OBSTRUCTION ON MAG-3

You have accessJournal of UrologyCME1 Apr 2023MP70-05 ASSOCIATION BETWEEN THE HYDRONEPHROSIS OUTCOME PREDICTION SCORE AND OBSTRUCTION ON MAG-3 Carol Davis-Dao, Sarah Williamson, Rebecca Zee, Shannon Cannon, Luis Braga, Timothy Boswell, Kai-Wen Chuang, Melissa Mcgrath, Nora Kern, Gina Lockwood, Anne Dudley, Heidi Stephany, Elias Wehbi, Valre Welch, Antoine Khoury, and C.D. Anthony Herndon Carol Davis-DaoCarol Davis-Dao More articles by this author , Sarah WilliamsonSarah Williamson More articles by this author , Rebecca ZeeRebecca Zee More articles by this author , Shannon CannonShannon Cannon More articles by this author , Luis BragaLuis Braga More articles by this author , Timothy BoswellTimothy Boswell More articles by this author , Kai-Wen ChuangKai-Wen Chuang More articles by this author , Melissa McgrathMelissa Mcgrath More articles by this author , Nora KernNora Kern More articles by this author , Gina LockwoodGina Lockwood More articles by this author , Anne DudleyAnne Dudley More articles by this author , Heidi StephanyHeidi Stephany More articles by this author , Elias WehbiElias Wehbi More articles by this author , Valre WelchValre Welch More articles by this author , Antoine KhouryAntoine Khoury More articles by this author , and C.D. Anthony HerndonC.D. Anthony Herndon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: For patients with isolated hydronephrosis and suspected ureteropelvic junction obstruction, diuretic renal scan (MAG-3) is one tool used for determining which patients may be obstructed. We sought to evaluate the Hydronephrosis Outcome Prediction (HOP) Score, which utilizes ultrasound measurements, for its association with obstruction based on MAG-3. METHODS: Patients with prenatally detected and postnatally confirmed isolated hydronephrosis were prospectively enrolled from 7 centers from 2007-2022. Baseline ultrasounds were included if performed between 3 days to 6 months of life and with SFU grade, anterior posterior renal pelvis diameter (APD) and renal lengths available for analysis. Exclusion criteria were vesicoureteral reflux, primary megaureter, other urologic anomalies, and follow-up <3 months. The HOP score, adapted from Li et al,1 utilizes 3 ultrasound parameters: SFU grade, APD, and absolute percentage difference of renal lengths. HOP score was calculated on a 12-point scale with each parameter assigned a score from 0-4, 0 being least severe and 4 being most severe. Obstruction on MAG-3 was defined as T half-time ≥20 minutes and function<40%. Area under the curve and logistic regression were determined for association between HOP scores and MAG-3 results. RESULTS: Of 1983 patients enrolled, 180 met inclusion criteria. Median HOP score was 8.0 (IQR 6-10) and median follow-up time was 34 months (IQR 22-48). Among the 19 (11%) patients with obstruction on MAG-3, the median HOP score was 9.0, while the remaining 161 patients had median HOP score of 8.0. HOP score≥9 was the optimum threshold for predicting obstruction with AUC 0.67 (95% CI: 0.55-0.77). On logistic regression, patients with HOP score≥9 at initial ultrasound were significantly more likely to have obstruction on MAG-3 (OR=3.8, 95% CI: 1.3-11, p=0.01). Overall, 92 (51%) of patients underwent pyeloplasty, while 25 (11%) resolved and 63 (35%) were under continued follow-up. CONCLUSIONS: We found that patients with HOP scores≥9 on initial ultrasound were more likely to show obstruction on subsequent MAG-3. In combination with our previous study that showed HOP scores≤4 are correlated with resolution, the HOP score is an accessible tool that predicts the outcomes of hydronephrosis from the initial postnatal ultrasound. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1004 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Carol Davis-Dao More articles by this author Sarah Williamson More articles by this author Rebecca Zee More articles by this author Shannon Cannon More articles by this author Luis Braga More articles by this author Timothy Boswell More articles by this author Kai-Wen Chuang More articles by this author Melissa Mcgrath More articles by this author Nora Kern More articles by this author Gina Lockwood More articles by this author Anne Dudley More articles by this author Heidi Stephany More articles by this author Elias Wehbi More articles by this author Valre Welch More articles by this author Antoine Khoury More articles by this author C.D. Anthony Herndon More articles by this author Expand All Advertisement PDF downloadLoading ...

Redo Robotic Ureteroplasty After Prior Failed Ureterocalicostomy

Clinical History: Surgical management of patients with recurrent strictures after prior ureterocalicostomy for complex ureteropelvic junction obstruction is challenging because of extensive periureteral fibrosis and scarring that is present in this setting. Physical Examination: The patient presented with left flank pain. Diagnosis: We report the case of a 37-year-old male patient with a recurrent symptomatic stricture after undergoing a laparoscopic converted to open left ureterocalicostomy 12 years prior. Retrograde pyelogram showed a small filling defect and 1 cm narrowed segment at the ureter's insertion point into the lower pole calix. Intervention: We describe our approach for robotic ureteral reconstruction for patients with recurrent strictures after prior ureterocalicostomy. We highlight the utilization of intravenous indocyanine green (ICG) to facilitate identification of the strictured aspect of the ureter. A longitudinal incision was made along the strictured segment and a buccal mucosa graft was anastomosed to the defect in onlay manner. Follow-Up/Outcomes: Intraoperatively, operative time was 213 minutes and estimated blood loss was 100 mL. There were no intraoperative complications and the patient was discharged on the same day. At follow-up of 20 months, the patient had no flank pain and his postoperative renal scan showed normal split function and half washout time of 12 minutes bilaterally. Robotic ureteral reconstruction may be utilized for management of patients with recurrent ureteral strictures after prior ureterocalicostomy. Near infrared fluorescence with ICG may assist with identification of the strictured ureter in these complex settings. This surgical approach may reduce damage to the fragile periureteral blood supply and minimize the risk of stricture recurrence. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The study was approved by the institutional review board at Temple University (protocol number 20793). M.L. and J.J. have no conflicts of interest to disclose. D.E. is founder of Melzi corp and a consultant for Intuitive Surgical and Johnson and Johnson. Runtime of video: 4 mins 45 secs

V01-09 ROBOTIC URETEROURETEROSTOMY OF RETROCAVAL URETER

You have accessJournal of UrologyCME1 Apr 2023V01-09 ROBOTIC URETEROURETEROSTOMY OF RETROCAVAL URETER Rainjade Chung, Justin Lee, George W Moran, Miyad Movassaghi, Belinda Li, and Christina P. Carpenter Rainjade ChungRainjade Chung More articles by this author , Justin LeeJustin Lee More articles by this author , George W MoranGeorge W Moran More articles by this author , Miyad MovassaghiMiyad Movassaghi More articles by this author , Belinda LiBelinda Li More articles by this author , and Christina P. CarpenterChristina P. Carpenter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retrocaval ureter, also known as “circumcaval ureter” or “preureteral vena cava,” is a relatively rare anatomical variant with an incidence of 0.13% that occurs when the right ureter courses posterior to the vena cava rather than anterior. More commonly seen in males, the etiology is a developmental abnormality of the vena cava, not the ureter. Many cases are clinically silent, but surgical reconstruction is indicated if the patient has severe hydronephrosis, significant functional obstruction, or pain. This patient presented with right flank pain, severe hydronephrosis, and a characteristic "S sign" on retrograde pyelogram (Figure 1). Our objective was to describe our approach to an uncommon case, robotic ureteroureterostomy of a retrocaval ureter. METHODS: The patient was placed in the left lateral decubitus position. The Da Vinci Xi system was utilized and 4 ports were placed in a linear fashion at the lateral border of the rectus 6 cm apart. A 5 mm AirSeal was placed between the 2nd and 3rd arm. ProGrasp Forceps are used in the 1st arm, Maryland bipolar forceps are used in the 2nd arm, and a monopolar curved scissor is used in the 4th arm. Vessel loops were placed on the proximal and distal ureter on either side of the vena cava and were pulled back and forth to allow for visualization and dissection (Figure 2). RESULTS: Successful robotic ureteroureterostomy of a retrocaval ureter. CONCLUSIONS: Robotic ureteroureterostomy is a minimally invasive procedure to manage ureteropelvic junction obstruction caused by a retrocaval ureter. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e82 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rainjade Chung More articles by this author Justin Lee More articles by this author George W Moran More articles by this author Miyad Movassaghi More articles by this author Belinda Li More articles by this author Christina P. Carpenter More articles by this author Expand All Advertisement PDF downloadLoading ...

Long-term maintenance treatment of recurrent ureteropelvic junction obstruction with covered metallic ureteral stent.

Whether or not the covered metallic ureteral stent can be used as maintenance treatment for recurrent ureteropelvic junction obstruction (UPJO) after pyeloplasty is unknown. Therefore, this study aims to analyze its feasibility. We retrospectively analyzed the records of 20 patients with recurrent UPJO who were treated with the covered metallic ureteral stents from March 2019 to June 2021 at our institution. Then, we assessed their renal function, stent patency and stent-related quality of life by the blood creatinine, renal ultrasound (or computed tomography), and the Chinese version of the ureteral symptom score questionnaire (USSQ). The last follow-up mean blood creatinine dropped from 0.98 ± 0.22 to 0.91 ± 0.21 mg/dL (P = .04), and the median renal pelvic width was reduced from 3.25 (3.10) to 2.00 (1.67) cm (P = .03) compared with the preoperative conditions. Meanwhile, the last follow-up mean USSQ total score of the covered metallic ureteral stent among the 16 patients with preoperative indwelling double-J ureteral stent was 78.56 ± 14.75, significantly lower than the preoperative USSQ total score, which was 102.25 ± 5.57 (P < .001). During the median duration of follow-up of 27.00 (18.00) months, 85% (17/20) of patients maintained unobstructed drainage from the renal pelvis to the ureter. Stent-related complications occurred in 7 patients, 3 of which failed because of complications, including stent migration (1 patient), stent encrustation (1 patient), and stent-related infection (1 patient). The covered metallic ureteral stent is feasible for the long-term maintenance treatment of recurrent UPJO after pyeloplasty.

Robot-assisted pyeloplasty for ureteropelvic junction obstruction in renal anomalies

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

Robot-assisted Laparoscopic Pyeloplasty: Experience of a Single Pediatric Institution, Including Long-term and Safety Outcomes

To evaluate the efficacy and safety of robot-assisted laparoscopic pyeloplasty (RALP) and describe the short and long-term outcomes of pediatric RALP. We retrospectively reviewed all patients ..±21 years old who underwent primary RALP from 7/2007 through 12/2019. Patients were excluded from postoperative analysis if follow-up data after stent removal was not available. The primary outcome was surgical success, defined as radiographic improvement of hydronephrosis without need for reoperation. Secondary outcomes were time to reoperation and 90-day complication rate. A total of 356 patients underwent primary repair of ureteropelvic junction obstruction during the study period; 29.ßpatients were limited to intraoperative data due to lack of follow-up imaging. Radiographic improvement at latest follow-up was seen in 308/327 (94.2%). Ten of 327 patients (3.1%) underwent reoperation: 7 were identified within 1 year of RALP and 3 were identified over 1 year after RALP. The median time to reoperation was 13.0 months (IQR 9.3-21.7). We defined long-term as>3 years after pyeloplasty. Over one-third (122/327, 37.3%) of the cohort had>3 years of follow-up, none of whom developed evidence of recurrent obstruction requiring reoperation beyond 3 years. Complications occurred within 90 days of surgery in 20/327 (6.1%). This largest single-institution series confirms short- and long-term surgical effectiveness and safety of RALP. Our data also indicate that most patients who needed reoperation were identified within 1 year, and reoperation more than 3 years after RALP is rare.

Rare Single Nucleotide and Copy Number Variants and the Etiology of Congenital Obstructive Uropathy: Implications for Genetic Diagnosis.

Congenital obstructive uropathy (COU) is a prevalent human developmental defect with highly heterogeneous clinical presentations and outcomes. Genetics may refine diagnosis, prognosis, and treatment, but the genomic architecture of COU is largely unknown. Comprehensive genomic screening study of 733 cases with three distinct COU subphenotypes revealed disease etiology in 10.0% of them. We detected no significant differences in the overall diagnostic yield among COU subphenotypes, with characteristic variable expressivity of several mutant genes. Our findings therefore may legitimize a genetic first diagnostic approach for COU, especially when burdening clinical and imaging characterization is not complete or available. Congenital obstructive uropathy (COU) is a common cause of developmental defects of the urinary tract, with heterogeneous clinical presentation and outcome. Genetic analysis has the potential to elucidate the underlying diagnosis and help risk stratification. We performed a comprehensive genomic screen of 733 independent COU cases, which consisted of individuals with ureteropelvic junction obstruction ( n =321), ureterovesical junction obstruction/congenital megaureter ( n =178), and COU not otherwise specified (COU-NOS; n =234). We identified pathogenic single nucleotide variants (SNVs) in 53 (7.2%) cases and genomic disorders (GDs) in 23 (3.1%) cases. We detected no significant differences in the overall diagnostic yield between COU sub-phenotypes, and pathogenic SNVs in several genes were associated to any of the three categories. Hence, although COU may appear phenotypically heterogeneous, COU phenotypes are likely to share common molecular bases. On the other hand, mutations in TNXB were more often identified in COU-NOS cases, demonstrating the diagnostic challenge in discriminating COU from hydronephrosis secondary to vesicoureteral reflux, particularly when diagnostic imaging is incomplete. Pathogenic SNVs in only six genes were found in more than one individual, supporting high genetic heterogeneity. Finally, convergence between data on SNVs and GDs suggest MYH11 as a dosage-sensitive gene possibly correlating with severity of COU. We established a genomic diagnosis in 10.0% of COU individuals. The findings underscore the urgent need to identify novel genetic susceptibility factors to COU to better define the natural history of the remaining 90% of cases without a molecular diagnosis.

Percutaneous management of ureteropelvic junction obstruction.

The development of endoscopic and minimally invasive techniques has revolutionized the treatment of ureteropelvic junction obstruction (UPJO). Patients can now undergo successful UPJO repair without the morbidity and complications associated with open surgery. Laparoscopic and robotic repair has supplanted open surgery as the gold standard, but percutaneous endoscopic treatment remains a relevant alternative to more invasive surgery. This review will focus on the percutaneous approach for the treatment of UPJO. Percutaneous endopyelotomy was popularized during the 1980 s due to advances in the field of endourology, allowing for well tolerated and reliable percutaneous access to the kidney. After percutaneous access to the kidney is achieved, the narrowed ureter at the UPJ is incised in a full thickness fashion in the posterolateral position from the ureteral lumen to the periureteral fat. Success rates for this procedure are nearly 90% at high-volume centres. The ideal patient who has success with percutaneous endopyelotomy has a short segment of narrowing less than 2 cm, no crossing vessel, good ipsilateral renal function and mild hydronephrosis. Although the development of laparoscopic and robotic approaches to pyeloplasty has produced outcomes that surpass those of percutaneous endopyelotomy, it remains a viable option in the appropriately selected patient, but success rates tend to decrease with longer follow up.

Robotic versus Open Pyeloplasty: Perioperative and Functional Outcomes

We designed a retrospective study to assess the surgical and economic outcomes of robot-assisted laparoscopic pyeloplasty (RALP) compared with open pyeloplasty (OP), including consecutive patients suffering from ureteropelvic junction obstruction and operated on from January 2012 to January 2022 at a single center. Preoperative, intraoperative, and postoperative outcomes, including costs, were comparatively analyzed. The primary outcome was 3-month success, defined as symptom resolution and no obstruction upon diuretic renal scintigraphy. Overall, 91 patients were included (48 OP and 43 RALP). The success rate at 3 months was 93.0% and 83.3% in the RALP and OP group, respectively (p = 0.178), and the results remained stable at the last follow-up (35.4 ± 22.8 months and 56.0 ± 28.1 months, respectively). Intraoperative blood loss (p < 0.001), need for postoperative analgesics (p = 0.019) and antibiotics (p = 0.004), and early postoperative complication rate (p = 0.009) were significantly lower in the RALP group. None of the assessed variables were a predictor for failure. The mean total direct cost per surgical procedure and related hospital stay was 2373 € higher in the RALP group. RALP is an effective and safe treatment for ureteropelvic junction obstruction; however, further studies are needed to evaluate the cost-effectiveness of RALP, accounting for indirect costs and cost-saving with new surgical platforms.

Influencing factors of parental selections of minimally invasive procedure in children's abdominal surgery: a cross-sectional study in China.

The purpose of our study was to explore the influencing factors of parental selections of minimally invasive procedure including laparoscopic or robotic methods in children's abdominal surgery. The questionnaire survey was conducted among the parents of patients who received abdominal laparoscopic or robotic surgery in our hospital from December 2020 to June 2022. The contents included basic information of the patients and parents, parental educational background, monthly income, insurance details and the parental considerations. Univariate and multivariate logistic regression were applied for the influencing factors analysis. Six categories of diseases involving choledochal cyst (198 cases), spleen related diseases (31 cases), hirschsprung disease (40 cases), inguinal hernia (330 cases), adrenal tumor (15 cases) and ureteropelvic junction obstruction (73 cases) were included in this study. After univariable and multivariable logistic regression analysis accomplished, we discovered that college degree or above (OR = 0.545, P < 0.001), monthly income > 5000 RMB (OR = 0.761, P < 0.001) and involving reconstruction during operation (OR = 0.842, P < 0.001) were the influencing factors for parental selections of robotic surgery. In children's abdominal surgery, parents with college degree or above, monthly income > 5000 RMB and considering the need for reconstruction during operation are more inclined to choose the robotic surgery.

Outcome of Renal Function after Laparoscopic Pyeloplasty in Children with High-Grade Hydronephrosis

Introduction: This study aimed to analyze the changes in differential renal function (DRF) after laparoscopic pyeloplasty in children with high-grade hydronephrosis and factors influencing DRF improvement. Methods: We reviewed the clinical data of unilateral ureteropelvic junction obstruction (UPJO) patients with SFU grade IV who underwent laparoscopic pyeloplasty between February 2018 and October 2020. The patients were divided into two groups: DRF improvement ≥5% (group 1) and DRF improvement <5% (group 2). Preoperative, operative, and postoperative parameters were included in the statistical analysis in both groups. Results: A total of 29 patients with a median age of 6 months were included. The preoperative DRF in group 1 was significantly lower than that in group 2 (36.97 ± 8.47% vs. 45.19 ± 5.22%, p = 0.004). Logistic regression and receiver operating characteristic analysis showed the preoperative DRF was the predictor for renal function improvement after pyeloplasty (p = 0.021) and had a significant predictive value (p = 0.004). Conclusion: Nearly half of the patients with high-grade UPJO had improved renal function at 1 year follow-up after laparoscopic pyeloplasty. Preoperative DRF was a predictor of renal function improvement, and postoperative functional recovery was superior in children with lower preoperative DRF.

Comparative study between ureter first approach and conventional open Anderson-Hynes pyeloplasty in paediatric patients: A prospective randomised study

Uretero-pelvic junction obstruction is the most common form of congenital anomaly of the kidney and urinary tract with an incidence of about 1/1.000-1.500 of births and the aetiology and pathogenesis of this anomaly are still unclear until now. This is a prospective randomized comparative study conducted from March 2022 to December 2022. Thirty children with uretero-pelvic junction obstruction were included and randomly divided into two groups according to a 1:1 ratio (computer-generated randomization, single blind). Fifteen cases (12 males and 3 female) were subjected to ureter first approach pyeloplasty, and another fifteen (9 males and 6 female) were subjected to conventional Anderson Hynes pyeloplasty. The mean age of all patients was 6.7 ± 5.4 years in ureter first approach group and 5.1 ± 4.3 years in conventional Anderson-Hynes pyeloplasty group. There were no significant differences between the two groups regarding age, gender, presentation, side, preoperative renogram and post-operative renogram. Also, there were no significant differences between the two groups regarding operative time (in first group 110.3 ± 12.4 and in the second group 111.2 ± 12.0 with p < 0.836), pre and post-operative complication rate. Two cases of urinary tract infections in the first group, one of them having fever, and four cases in the second group, two of them having fever (p < 0.651); four cases of loin pain in the first group and one case in the second group (p < 0.330); one case in the first group having pro- longed leakage of urine for 7 days in post-operative period (p < 0.309). However GFR and t 1⁄2 improved significantly after operation in both groups (p < 0.001). Ureter first approach is a simple and effective procedure in children with good short term outcomes and could be done safely especially for beginners and less expert surgeons. Finally, it can overcome the problem of long ureteric stricture that may be found intraoperatively because you can shift easily to a flap procedure and complete a tension free anastomosis.

What is the Critical age for the Improvement of Parenchymal Thickness after Pyeloplasty?

The most important point in cases of ureteropelvic junction obstruction (UPJO) is to decide on the need and timing of surgical treatment. Renal damage may become irreversible as the duration of the obstruction is prolonged. Worsening of hydronephrosis and decrease in renal parenchymal thickness after pyeloplasty may herald an irreversible renal damage. It is important to know at what age this damage begins. In this study, we aimed to determine the relationship between the age of the patients at the time of pyeloplasty performed for UPJO and parenchymal recovery. In our study, 156 patients (mean age: 43.5 months) who underwent pyeloplasty with the diagnosis of UPJO between 2007 and 2019 were evaluated retrospectively. Demographic characteristics, ultrasonographic (USG) and nuclear renal scintigraphy findings, previous surgeries ​of the patients were recorded. Numerical variables were evaluated statistically, and the best cut-off point was determined. Parenchymal thickening was determined as the most important criterion in postoperative renal recovery which was more evident at early ages. Based on statistical assessments , the cut-off age for renal parenchymal recovery was determined as 38 months. While parenchymal recovery was inadequate after pyeloplasty performed in patients older than 38 months, the most significant improvement in renal functions was seen in children younger than 13 months of age. Pyeloplasty should be performed in patients with UPJO before development of severe renal damage. Statistically, the best parameter to evaluate the recovery after pyeloplasty is the change in parenchymal thickness. With advancing age, it is impossible to reverse the obstructive nephropathy.

Comparison of early surgical and conservative therapy in children with ureteropelvic junction obstruction

Ureteropelvic junction obstruction is a relatively common urologic problem in children. Most cases present with pelvicaliceal dilatation in antenatal period. Historically most UPJO cases were treated with surgical procedures, but recently many of these children have been treated by nonsurgical observational plans. We compared the outcome of children with UPJO treated in surgical and observational ways. In a retrospective study, we assessed the medical history of patients diagnosed as UPJO, march 2011 to march 2021. The case definition was based on grade 3-4 hydronephrosis and obstructive pattern in dynamic renal isotopescan. Patients were put into two groups; Group 1 children were treated with a surgical procedure, and group 2 patients without any surgical procedure for at least a six months' period after diagnosis. We assessed long-term events and improvement of obstruction. Seventy-eight children (mean age 7.32mo., 80% male) enrolled in the study, 55 patients in group one and 23 as group 2. Severe hydronephrosis was the problem of 96% of all patients significantly led to 20% in group 1 and 9% in group 2 (P < 0.001). Severe kidney involvement was observed at 91% in group 1 and 83% in group 2, decreased to 15% and 6%, respectively (P < 0.001). There were no significant differences in sonographic and functional improvement between the two intervention groups. Long-term prognostic issues; growth, functional impairment, and hypertension were not different between the two groups, but group 1 children experienced more recurrence of UTI than group 2 patients. Conservative management is as effective as early surgical treatment in the management of infants with severe UPJO.

Can we improve the usefulness of the diuretic renogram in the diagnosis of ureteropelvic junction obstruction (UPJO) in children? Introduction of mercaptoacetyltriglycine-suspected obstruction scoring system (MAG-SOS)

Mercaptoacetyltriglycine (MAG-3) renogram is one of the gold standard diagnostic tools of ureteropelvic junction obstruction (UPJO); however, there is no widely agreed indications of pyeloplasty based on MAG-3 findings. In this study, we introduce a renogram scoring system that can help improve the prognostic value of MAG-3 renogram and in the decision making of pyeloplasty. We retrospectively reviewed consecutive pyeloplasties for antenatal hydronephrosis from 2010 to 2020. A control group was included of non-operatively managed SFU grade 3 and 4. The initial renal ultrasound and preoperative MAG-3 Lasix renogram were reviewed for differential renal function (DRF), type of renogram curve and tracer washout half-time (T1/2). A ROC curve was used to evaluate the cut-off points that can be associated with obstruction. A multivariate linear regression model was used to assess the best renogram parameter that can predict surgical intervention. We included 188 patients with 209 renal units. The median age for pyeloplasty was 5.4 months. The mercaptoacetyltriglycine-Suspected Obstruction Scoring System (MAG-SOS) was associated with pyeloplasty (AUC=0.97, P<0.001) (FigureA). A score of 5 is 100% specific for obstruction. 78% of units required surgical intervention had a MAG-SOS score of≥5 while all units of the control group had a range of score 0-4. Using the multivariate analysis, the MAG-SOS system showed to the only independent predictor for pyeloplasty (HR=0.03, p<0.001). This study has some limitations. Firstly, the retrospective nature of the cohort; however, all patients were reviewed by one investigator who was blinded to the line of management. This is a single institutional study; therefor, this MAG-SOS should be evaluated by other centers to ensure its efficiency. Lastly, the pyeloplasty decision was taken by 3 different urologists; nevertheless, all of them adopt the same indications which are similar to those of the Society for Pediatric Urology and the Canadian Urological Association guidelines. The MAG-SOS system showed to be a useful tool that can predict pyeloplasty. A score of 5 has 100% specificity for patients having a pyeloplasty performed. Prospective studies are required to confirm the usefulness of this novel tool.

Application of Indocyanine Green in Combination with Da Vinci Xi Robot in Surgeries on the Upper Urinary Tract: A Case Series Study

To explore the application value of intraoperative imaging by indocyanine green (ICG) injection through the collection system of the urinary tract for Da Vinci Xi robot navigation in complex surgeries on the upper urinary tract. Data of 14 patients who underwent complex surgeries of the upper urinary tract post-ICG injection through the collection system of the urinary tract in combination with Da Vinci Xi robot navigation in the Tianjin First Central Hospital between December 2019 and October 2021 were analyzed in this retrospective study. The operation duration, estimated blood loss, and exposure time of ureteral stricture to ICG were evaluated. The renal functions and tumor relapse were evaluated after surgery. Of the fourteen patients, three had distal ureteral stricture, five had ureteropelvic junction obstruction, four presented duplicate kidney and ureter, one had a giant ureter, and one presented an ipsilateral native ureteral tumor after renal transplantation. The surgeries in all patients were successful, with no conversion to open surgery. In addition, no injury to the surrounding organs, anastomotic stenosis or leakage, or ICG injection-related side effects were detected. Imaging at 3 months post-operatively revealed improved renal functions compared to those before the operation. No tumor recurrence or metastasis was observed in patient 14. Fluorescence imaging compensating for the inadequacy of tactile feedback in the surgical operating system has advantages in identifying the ureter, determining the site of ureteral stricture, and protecting the blood flow for the ureter.

Primary laparoscopic ureterocalicostomy as an option in selected cases of ureteropelvic junction obstruction

Primary laparoscopic ureterocalicostomy as an option in selected cases of ureteropelvic junction obstruction

Robot-Assisted Retroperitoneoscopic Diamond Bypass Pyeloplasty

AimRobot (da Vinci Si; Intuitive Surgical, Sunnyvale, CA) assisted retroperitoneoscopic diamond bypass pyeloplasty (R-RDBP) performed for ureteropelvic junction (UPJ) obstruction (n = 5) is presented. MethodsPatients were placed affected side up and the retroperitoneal space accessed conventionally using 3–4 trocars. The diamond-shaped anastomosis involved incising the lowest part of the renal pelvis 12–15 mm transversely and the ureter distal to the obstruction 10–12 mm longitudinally. The first two sutures were placed retroperitoneoscopically; one from the mid-caudal line of the renal pelvis to the apex of the ureteric incision (the apex of the diamond) and the other from the corner of the incision in the renal pelvis to halfway along the ureteric incision. Trocars were replaced and the robot system docked. The first robot suture was placed between these two sutures, and the anastomosis completed by suturing from posterior to ventral applying minimal tension to keep the anastomosis close to the renal pelvis. All sutures were interrupted absorbable 5-0 monofilament. ResultsMean age at R-RDBP was 4.3 (range: 1–14) years old. Height/weight were average. Preoperative Society for Fetal Urology (SFU) grading was 4.0 in all cases. All repairs were primary and progressed smoothly without perioperative complications; 3/5 had improved appetite postoperatively. Mean SFU grades 1–3 months postoperatively were 2.8, 2.2, and 1.6, respectively. Diuretic renography that was obstructive in all cases preoperatively was normal in four and delayed in one case, postoperatively. ConclusionR-RDBP prevented rotation/kinking of the ureter, enhanced precision of suturing, and maximized the diameter at the anastomosis, facilitating smooth urine flow. Level of EvidenceLEVEL IV.