Robot-Assisted Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Infants Under 12 Months: A Multi-institutional Report from the Pediatric Urology Robotic Surgery (PURS) Consortium
Aznive Aghababian, BS1, Sahar Eftekharzadeh, MD, MPH1, Hannah Bachtel, MD2, Elizabeth Khusid, BS3, Christina Sze, MD3, Iqra Nadeem, BA1, Monica Xing, BS4, Asad Ahmed, BS1, Sonam Saxena, BS1, Kiersten Craig, MD3, Sameer Mittal, MD1, Karl Godlewski, MD1, John Weaver, MD1, Katherine Fischer, MD1, Christopher Long, MD1, Dana Weiss, MD1, Mohan Gundeti, MD4, Ardavan Akhavan, MD3, Chester Koh, MD2, Arun Srinivasan, MD1, Aseem Shukla, MD1.
1The Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2Texas Children's Hospital, Houston, TX, USA, 3New York Presbyterian Hospital, New York, NY, USA, 4The University of Chicago Medicine, Comer Children's Hospital, Chicago, IL, USA.
Introduction: The utilization of robot-assisted pyeloplasty (RALP) for the surgical correction of ureteropelvic junction obstruction (UPJO) continues to increase. There remains controversy regarding its application in infants compared to the conventional open pyeloplasty (OP). We hypothesized that RALP is a safe and equally efficacious procedure compared to OP in infants ≤12 months old.Methods: All patients ≤12 months old who underwent RALP or OP between January 2012-January 2021 at three participating centers were included. Patients who underwent pure laparoscopic approach/ureterocalicostomy, those with abnormal nephro-ureteral anomalies or lacked reviewable surgical records were excluded. Electronic health records were retrospectively reviewed to obtain baseline demographics, pre-operative clinical/radiological characteristics, intra and post-operative details, and long-term success. Success is defined as improved hydronephrosis without the need for redo reconstruction or nephrectomy. Regression analysis was performed to predict the risks associated with the incidence of post-operative complications.Results: Of the 343 patients identified during the study period, 297 patients met inclusion criteria: 149 RALP (50.2%) and 148 OP (49.8%), performed by 29 surgeons (RALP=11, OP=18) [Figure 1]. The median age at surgery was 6.8 months (IQR 4,11.9) for RALP and 4.9 months (IQR 3.1,7.9) for OP, with younger patients undergoing OP (p<0.001). RALP compared to OP was associated with a higher usage of ureteral stent placement (98.7% vs 77.77%; p<0.001), longer procedure time (195 vs 160.5 minutes; p<0.001), less administration of floor morphine-equivalents post-operatively (0.05 vs 0.1 mg/kg; p<0.001) and decreased length of stay (p=0.019) [Table 1 & 2]. There was no difference in the incidence of 30-day complications between the two groups, however higher-grade complications were seen in the OP group. When controlling for age, gender, intra-operative stent placement on logistic regression, OP was associated with increased risk of higher-grade complications (OR 3.88, 95% CI 1.22-12.34 p=0.02). During the median follow-up of 25.8 months (IQR 6.8, 26.2), patients undergoing OP had a higher incidence of post-operative surgical intervention (n=16, 11.2% vs n=2, 1.4%; p<0.001). The overall rate for redo reconstruction was 93.2% in RALP and 99.3% in OP (p=0.005)
Conclusion: In our series, the largest comparative series of infant pyeloplasty modalities to date, our results demonstrate that RALP is not only safe and feasible, but also confers the advantages of reduced opioid usage, length of stay, risk of high-grade complications and need for additional interventions.
Table 1: Pre-operative and intra-operative details for robot vs open pyeloplasty | |||
Robotic | Open | p-value | |
N | 149 | 148 | |
Gender | |||
Male | 105 (70.5%) | 115 (77.7%) | 0.19 |
Female | 44 (29.5%) | 33 (22.3%) | |
Pre-operative UTI | 20 (13.4%) | 10 (6.8%) | 0.082 |
Pre-operative Hydronephrosis | |||
UTD-P1 | 2 (1.3%) | 4 (2.7%) | 0.70 |
UTD-P2 | 29 (19.5%) | 26 (17.6%) | |
UTD-P3 | 117 (78.5%) | 115 (77.7%) | |
Pre-operative Pelvic Diameter (mm), median (IQR) | 32.4 (21.5, 66.4) | 34 (23.1, 60) | 0.81 |
Underwent Pre-operative Endoscopic Intervention | 7 (4.7%) | 1 (0.7%) | 0.067 |
Age at surgery (months), median (IQR) | 6.8 (4.0, 11.9) | 4.9 (3.1, 7.9) | <0.001 |
BMI, median (IQR) | 17.6 (16.3, 18.8) | 17.6 (15.9, 18.6) | 0.43 |
ASA Status | |||
1 | 30 (20.1%) | 12 (8.1%) | <0.001 |
2 | 113 (75.8%) | 108 (73.0%) | |
3 | 6 (4.0%) | 15 (10.1%) | |
Epidural Analgesia | 13 (8.7%) | 58 (39.2%) | <0.001 |
Laterality | |||
Unilateral | 144 (96.6%) | 145 (98.0%) | 0.72 |
Bilateral | 5 (3.4%) | 3 (2.0%) | |
Redo Procedure | 3 (2.0%) | 0 (0.0%) | 0.25 |
Etiology of Obstruction | |||
Crossing Vessel | 9 (6.0%) | 7 (4.7%) | 0.005 |
Narrowing | 126 (84.6%) | 139 (93.9%) | |
High Insertion | 14 (9.4%) | 2 (1.4%) | |
Intrarenal Pelvis | 4 (2.7%) | 4 (2.7%) | 1.00 |
Malrotated Kidney | 5 (3.4%) | 7 (4.7%) | 0.77 |
Intra-operative Stent Placement | 147 (98.7%) | 115 (77.7%) | <0.001 |
Stent Duration (days), median (IQR) | 36 (29, 53) | 35.5 (14, 53) | 0.018 |
Intra-operative Morphine Equivalent (mg/kg), median (IQR) | 0.27 (0.16, 0.41) | 0.24 (0.15, 0.43) | 0.66 |
Procedure Length median (IQR) | 195 (169, 220) | 160.5 (131, 191) | <0.001 |
Table 2: Post-operative outcomes for robot vs open pyeloplasty | |||
Robotic | Open | p-value | |
N | 149 | 148 | |
Length of Stay (days), median (IQR) | 1 (1, 1) | 1 (1, 2) | 0.019 |
Floor Morphine Administered | 54 (36.2%) | 73 (49.3%) | 0.026 |
Morphine Equivalent (mg/kg), median (IQR) | 0.05 (0, 0.1) | 0.1 (0.01, .2) | <0.001 |
Discharged with Opioid | 55 (36.9%) | 53 (35.8%) | 0.90 |
30 Day Complications | 29 (19.5%) | 27 (18.2%) | 0.88 |
Clavien Dindo Classification | |||
Grade 1 | 8 (5.4%) | 5 (3.4%) | 0.008 |
Grade 2 | 18 (12.1%) | 10 (6.8%) | |
Grade 3a | 0 (0.0%) | 1 (0.7%) | |
Grade 3b | 1 (0.7%) | 10 (6.8%) | |
Grade 4 | 2 (1.3%) | 1 (0.7%) | |
One-year Hydronephrosis Status | |||
Improved/Stable | 138 (92.6%) | 130 (87.8%) | 0.33 |
Worsened | 7 (4.7%) | 12 (8.1%) | |
NA | 4 (2.7%) | 6 (4.1%) | |
Required post-operative Intervention (>30 days after surgery) | 2 (1.4%) | 16 (11.2%) | <0.001 |
Endoscopic Intervention | 2 (1.3%) | 12 (8.1%) | 0.006 |
Stent | 1 (0.7%) | 11 (7.4%) | 0.003 |
Balloon Dilation | 0 (0.0%) | 1 (0.7%) | 0.50 |
Endopyelotomy | 0 (0.0%) | 1 (0.7%) | 0.50 |
Nephrostomy Tube | 1 (0.7%) | 5 (3.4%) | 0.12 |
Reconstruction | 1 (0.7%) | 10 (6.8%) | 0.005 |
Redo Pyeloplasty | 1 (0.7%) | 7 (4.7%) | 1.00 |
Nephrectomy | 0 (0.0%) | 3 (2.0%) | |
Approach to Reconstruction Surgery | |||
Robot | 0 (0.0%) | 6 (4.1%) | 0.015 |
Open | 1 (0.7%) | 4 (2.7%) | 0.21 |
Time to redo reconstruction (years), median (IQR) | 1.5 (1.5, 1.5) | 0.7 (0.6, 2.1) | 0.53 |
Follow-up Duration (months), median (IQR) | 22.1 (8.4 43. 6) | 30.1 (15.7 51.1) | <0.001 |
Success | 99.3% | 93.2% | 0.005 |
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