BACKGROUND: At our institution children under 1 year of age systematically undergo open pyeloplasty with a small ultrasound-guided incision, adjuvant regional anesthesia and an externalized ureteral stent. Herein evaluate our current outcomes compared to the reported literature of open and minimally-invasive (MIS) pyeloplasty.
METHODS: The study was registered on PROSPERO and systematic literature was performed in December 2022. Databases searched included Medline, Embase, Web of Science, and ClinicalTrials.gov. All studies reporting pyeloplasty outcomes in infants (age <1 year) were included. Our institutional pyeloplasty database was also used for comparison including outcomes between 1992-2019 and 2019-2023.
RESULTS: Twelve studies met inclusion criteria in addition to the institutional data (total 14). The meta-analysis showed a shorter operative time (11 datasets; open 643/MIS 399 patients; mean difference -28.98 [95%CI -38.64, -19.32], p<0.0001; Figure 1) but a longer length of stay (LOS) with open surgery (14 datasets; open 729/MIS 431 patients; mean difference -0.98 [95%CI -0.40, 1.57], p<0.0010; Figure 2). Reintervention rates were similar (13 datasets; open 690, MIS 431; petoOR 1.14 [95%CI 0.62, 2.08], p=0.68; Figure 3). LOS was similar when assessing studies in the last 5 years (8 datasets; open 565, MIS 325; mean difference IV 0.19 [95%CI -0.25, 0.63], p=0.40; Figure 1), yet significantly shorter when considering our protocol-driven series from 2019-2023 (0.72 ± 0.93 days [n=119] vs. 2.56 ± 1.89 days [n=542], p=0.0001)
CONCLUSIONS:
A standardized, protocol-driven, modern open surgical approach has better outcomes than historical series, including MIS. These outcomes challenge the notion that MIS is advantageous in infants. The onus for providers that champion MIS is on proving superiority to open interventions in a financially responsible way. Until then, open surgery should be the preferred approach and gold standard for the management of ureteropelvic junction obstruction in infants.
