Single-Port Robot-Assisted Laparoscopic Pyeloplasty in a Pediatric Cohort Using a Mini-Pfannenstiel Incision
Brendan Thomas Frainey, MD, Mahmoud Abou Zeinab, MD, Audrey Rhee, MD, Jihad Kaouk, MD.
Cleveland Clinic, Cleveland, OH, USA.
Background:Single-port (SP) robot-assisted laparoscopic pyeloplasty (RALP) has shown promising initial results in adult patients when compared to multi-port (MP) pyeloplasty in terms of length of stay and opioid usage. However, data on the use of the SP system for RALP in pediatric patients are lacking. The aims of this study were to assess the feasibility of SP RALP in a pediatric cohort, describe our current technique using a mini-pfannenstiel incision, and provide initial perioperative outcomes.
Methods:Data from a prospectively maintained single-institution database of pediatric patients undergoing SP RALP between June 2019 and June 2022 were reviewed. All patients had ureteropelvic junction obstruction (UPJO) diagnosed with a combination of cross-sectional imaging or retrograde pyelogram plus a MAG3 renal scan prior to surgery. All patients elected for pyeloplasty due to either declining renal function or symptomatic UPJO. Dismembered pyeloplasty was performed with the da Vinci SP system through a pure single site approach (no assistant port) using a 3.0-3.5 cm mini-pfannenstiel incision and "air-docking" technique (Figure 1). Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected.
Results: Overall, 6 consecutive subjects were included in the study. Five subjects were male (83%). Median age was 12.5 years old (interquartile range [IQR] 5-16 years). Median BMI was 18.6 (IQR 16.3-21.2). Left sided SP RALP was performed in 4/6 subjects (67%). Median preoperative renal function in the affected kidney was 46% (IQR 34-48%). Median operative time was 208 minutes (IQR 190-236 mins) and estimated blood loss was 5 cc (IQR 5-10cc) (Table 1). There were no intraoperative complications or conversions to open or MP surgery. The only complication was a displaced ureteral stent requiring cystoscopy and ureteral stent replacement on postoperative day 1. The median post-operative length of stay was 24 hours (IQR 23-27 hrs). All patients had their foley catheter removed within 25 hours of surgery and median time to ureteral stent removal was 29 days (IQR 25-38 d). The majority of subjects did not receive narcotic analgesia during their inpatient stay or at discharge. Median follow up was 9.5 months (IQR 1-24 mos.). At last follow up, no subjects had recurrence of pain or evidence of obstruction on postoperative ultrasound.
Conclusion: Single-port robotic-assisted laparoscopic pyeloplasty is feasible and safe in pediatric patients using a pure single-port technique through a mini-pfannenstiel incision with acceptable perioperative outcomes. 
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