Robot-assisted laparoscopic pyeloplasty (RALP) in children with complex pelvi-ureteric junction obstruction (PUJO): results of a multicenter European report

Abstract

Purpose This study aimed to report a multi-institutional retrospective case series of outcomes after robot-assisted laparoscopic pyeloplasty (RALP) in pediatric patients with complex pelvi-ureteric junction obstruction (PUJO). Methods All patients undergoing complex RALP over the last 5 years were included. RALP was defined complex in the following cases of PUJO: anatomic variations including ectopic, malrotated, horseshoe, or duplex kidney and recurrent PUJO after failed open pyeloplasty. Results Forty-eight patients underwent complex RALP in four European centers in the study period and included 18 girls and 30 boys with a median age of 8 years (range 5-12). The PUJO was associated with anatomic variations in 35/48 (72.9%), whereas a recurrent PUJO was present in 13/48 (27.1%). A dismembered Anderson-Hynes pyeloplasty was performed in all patients. The median operative time including docking was 178.5 min (range 117-255) and the median anastomotic time was 64.8 min (range 50-76). All patients were discharged on 2nd postoperative day (POD). The median follow-up was 18.2 months (range 14-43). The overall success rate was 95.8% (46/48). Early postoperative complications (< 30th POD) included urinary tract infections (UTIs) and stent-related irritative symptoms in 4/48 (8.3%) [II Clavien], whereas late complications (> 30th POD) included recurrence of PUJO in 2/48 (4.2%), who needed re-operation [IIIb Clavien]. Conclusions RALP was safe, feasible, and with good mid-term outcome in complex PUJO. An accurate pre-operative planning, a standardized technique, and an experienced surgical robotic team represented key points to manage successfully such complex cases.

Robotic-assisted laparoscopic pyeloplasty (RALP), for ureteropelvic junction obstruction (UPJO), is an alternative to open pyeloplasty in the pediatric population

“…Esposito. et al demonstrated, in large multi-institutional case series, overall success rate of 95.8% (46/48) in pediatric RALP with complex UPJO in general, and the success rate of 100% (13/13) in children who had Redo RALP in particular [6]. Also in the present study, the operating time, length of hospital stay or success rate did not differ significantly among redo group and an established control group-primary RALP.…”

“…Our study showed that neither primary or redo repairs nor low-weight children had an impact on the outcome of RALP once sufficient experience has been gained. A surgeon with extensive experience in MIS surgery and a strong urological background should perform these complex procedures to achieve high success rates [6]. As we reported in our previous series, experience in OP and LAP surgery may contribute to a shorter learning curve of robotic surgery required for the surgeon to achieve a similar outcome to that of OP [21].…”

“…With the advancement of minimally invasive surgical techniques, RALP has become more popular than open pyeloplasty as an initial intervention. As the role of robotic assisted pyeloplasty has evolved and has become more familiar, several descriptive series have advocated its use during management of challenging cases such as redo surgeries, low-weight children, and anatomic anomalies such as Duplex kidney with lower pole UPJO [6]. Esposito.…”

“…In addition to three-dimensional visualization and improved dexterity instrumentation, this technology simplifies minimally invasive pyeloplasty with a short learning curve [2][3][4]. Though RALP is associated with shorter hospital stays, lower analgesic requirements, and better cosmetic outcomes than open pyeloplasty, there is limited evidence regarding the robotic procedure for challenging cases as patients with difficult UPJOs in pediatric patients [5][6][7][8][9][10][11][12][13]. This study aimed to evaluate the safety and efficacy of RALP for UPJO in a heterogeneous pediatric population.…”

Treatment of ureteropelvic junction obstruction and urolithiasis in children with minimally invasive surgery

“…8,9 While several series describe MIS approach for UPJO and associated anomalies, universal agreement in case of concomitant UPJO and renal stones disease is still missing in the pediatric population. 5,10 Although nowadays open approach still represented the gold standard in this setting of patient, according to stone size and children's features, a combination of LP or RAP with rigid nephroscope or ureteroscope may successfully reach stones with the same benefit of MIS before mentioned.…”