The Northeastern Society of Plastic Surgeons

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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.

Background:
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.
Results:
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.
Conclusion
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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