Robotic pyeloplasty in children: A barbed shortcut
Ramnath Subramaniam, MBBS, FRCS, FEAPU, PhD, Anna Radford, FRCS, PhD, Alex Turner, FRCS, PhD, Junaid Ashraf, FRCS, FEAPU.
Leeds Teaching hospitals NHS trust, Leeds, United Kingdom.
Dismembered pyeloplasty remains the gold-standard for the treatment of pelvi-ureteric junction obstruction (PUJO) in the paediatric population. Robotic approach to this procedure has proven its efficacy and is gaining popularity. The introduction of barbed sutures such as "V-loc™" (Covidien) has provided an alternative and a small series of three patients has been described in the literature. This work provides our experience with the V-loc™ suture for closure of pelvis in robotic pyeloplasty (RP), in the paediatric age group.
Materials & Methods:
A review of 10 paediatric RP (Da Vinci Robotic System) during which the V-Loc™ suture was used was performed. Comparison was made with 15 cases in which 5-0 Vicryl ® suture was used as an alternative. Overall median age was 4 (range 9 months-16 years), M: F=14: 9. All had confirmed PUJO on renal ultrasound and MAG-3. RP was done in the standard fashion with the placement of a multi-length JJ ureteral stent intraoperatively. Postoperatively all patients had a urethral catheter, this was removed on the day of discharge (post-op day 1). Patients were followed with a renal ultrasound 3-4 months later.
Twenty-five robotic pyeloplasties have been performed between May 2013 and November 2015, of which 10 have had closure of the pelvis performed using the V-loc™ suture and 15 with Vicryl ®. One patient (6.67%) in the Vicryl ® group underwent redo-pyeloplasty secondary to a stent-related complication. The entire V-loc™ group made an eventful initial recovery; however four (40%) developed worsening hydronephrosis on ultrasound and MAG3 after stent removal, despite remaining completely asymptomatic. These four required either re-stenting & observation (n=1) or redo-pyeloplasty (n=3). Histology demonstrated a "plaque like" inflammatory reaction at the pelvic suture line.
Closure of the pelvis using V-loc™ suture material during RP can lead to a significant hydronephrosis requiring further procedures and even redo-pyeloplasty.
Despite being clinically asymptomatic the evolving problem was identified during routine ultrasound scanning 3-4 months post-operatively.
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