OUTCOMES OF DRAINLESS ROBOTIC ASSISTED LAPAROSCOPIC PYELOPLASTY IN A PEDIATRIC POPULATION BY A SINGLE SURGEON
Leah Beland, MD1, Pablo Gomez, MD2, Lina Posada, MD3.
1Northwell, New Hyde Park, NY, USA, 2AdventHealth, Orlando, FL, USA, 3Weill Cornell Medicine, New York, NY, USA.
BACKGROUND: Ureteropelvic junction obstruction (UPJO) is the leading cause of hydronephrosis in children with approximately 50% of these cases requiring surgical correction. Since its advent in 1949, the standard of care is the Anderson and Hynes open dismembered pyeloplasty.
Robotic assisted laparoscopic pyeloplasty (RALP) was first described in 2002 by Gettman and colleagues. RALP has consistently demonstrated successful outcomes and low complication rates akin to the open approach. While the open Anderson and Hynes pyeloplasty remains the most common, RALP is rapidly gaining popularity and is currently the most popular robotic surgery performed in pediatrics.
Drains (stents or nephrostomy tubes) are commonly utilized postoperatively after laparoscopic and robotic pyeloplasties to assist with the healing process, prevent urine leaks, decrease risk of stricture and align the anastomosis suture lines. However, stents are associated with significant morbidity and lower quality of life. Furthermore, children often require a secondary procedure under general anesthesia to remove the stent whereas adults have removal under local anesthetic.
Several studies have shown open drainless pyeloplasties to be both safe and efficacious with comparable outcomes to stented procedures. However, few studies have evaluated robotic drainless pyeloplasties. These few preliminary studies have promising results with low rates of complications and high rates of success. The purpose of this study is to describe the outcomes of drainless robotic pyeloplasty in a pediatric population.
METHODS: Retrospective analysis was performed of all children with UPJO who underwent robotic assisted laparoscopic dismembered pyeloplasty by a single surgeon between August 2012 and January 2019. Criteria for placing intraoperative stent included massive reduction of renal pelvis, renal malrotation, and tension in the anastomosis. All patients demonstrated radiographic evidence of obstruction pre-operatively. Operative success was defined as improved or resolved hydronephrosis on imaging, stabilization of renal function , and/or resolution of clinical symptoms. Additional outcomes included post-operative complications and perioperative details including EBL, length of stay, operative time, and analgesia requirement.
RESULTS: Preliminary results of 70 children who underwent RALP include 52 drainless procedures. Mean operative time was 157 and 184 minutes without and with drains, respectively. There were no intraoperative complications. Post-operative complications included a urinoma in a 4-month-old boy secondary to stricture requiring redo open pyeloplasty. Two patients required endoscopic management with dilation and stent placement post-operatively. Mean follow-up time was 11 months. Drainless RALP was successful in 49 of 52 children (94%).
CONCLUSIONS: Drainless robotic pyeloplasty in the pediatric population is safe and effective. Advantages include reduction of stent-associated morbidity and potentially avoidance of a second anesthetic. It also reduces operative time and the costs associated with the drain and secondary procedure.As minimally invasive techniques gain popularity in pediatrics, a drainless approach needs to be explored to afford the benefits of robotics while avoiding pediatric specific stent risks. The current literature on pediatric drainless RALP is sparse, consisting of only a few studies. While the results are promising, more data is needed. Our study will contribute valuable data to increase our understanding of the utility, efficacy, and safety of drainless RALP in pediatrics.
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