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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
RoboticOpenp-value
N149148
Gender
Male105 (70.5%)115 (77.7%)0.19
Female44 (29.5%)33 (22.3%)
Pre-operative UTI20 (13.4%)10 (6.8%)0.082
Pre-operative Hydronephrosis
UTD-P12 (1.3%)4 (2.7%)0.70
UTD-P229 (19.5%)26 (17.6%)
UTD-P3117 (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 Intervention7 (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
130 (20.1%)12 (8.1%)<0.001
2113 (75.8%)108 (73.0%)
36 (4.0%)15 (10.1%)
Epidural Analgesia13 (8.7%)58 (39.2%)<0.001
Laterality
Unilateral144 (96.6%)145 (98.0%)0.72
Bilateral5 (3.4%)3 (2.0%)
Redo Procedure3 (2.0%)0 (0.0%)0.25
Etiology of Obstruction
Crossing Vessel9 (6.0%)7 (4.7%)0.005
Narrowing126 (84.6%)139 (93.9%)
High Insertion14 (9.4%)2 (1.4%)
Intrarenal Pelvis4 (2.7%)4 (2.7%)1.00
Malrotated Kidney5 (3.4%)7 (4.7%)0.77
Intra-operative Stent Placement147 (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
RoboticOpenp-value
N149148
Length of Stay (days), median (IQR)1 (1, 1)1 (1, 2)0.019
Floor Morphine Administered54 (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 Opioid55 (36.9%)53 (35.8%)0.90
30 Day Complications29 (19.5%)27 (18.2%)0.88
Clavien Dindo Classification
Grade 18 (5.4%)5 (3.4%)0.008
Grade 218 (12.1%)10 (6.8%)
Grade 3a0 (0.0%)1 (0.7%)
Grade 3b1 (0.7%)10 (6.8%)
Grade 42 (1.3%)1 (0.7%)
One-year Hydronephrosis Status
Improved/Stable138 (92.6%)130 (87.8%)0.33
Worsened7 (4.7%)12 (8.1%)
NA4 (2.7%)6 (4.1%)
Required post-operative Intervention (>30 days after surgery)2 (1.4%)16 (11.2%)<0.001
Endoscopic Intervention2 (1.3%)12 (8.1%)0.006
Stent1 (0.7%)11 (7.4%)0.003
Balloon Dilation0 (0.0%)1 (0.7%)0.50
Endopyelotomy0 (0.0%)1 (0.7%)0.50
Nephrostomy Tube1 (0.7%)5 (3.4%)0.12
Reconstruction1 (0.7%)10 (6.8%)0.005
Redo Pyeloplasty1 (0.7%)7 (4.7%)1.00
Nephrectomy0 (0.0%)3 (2.0%)
Approach to Reconstruction Surgery
Robot0 (0.0%)6 (4.1%)0.015
Open1 (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
Success99.3%93.2%0.005


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