Open vs robotic infant ureteroureterostomy

A ureteroureterostomy (UU) is often used to manage some duplication anomalies. The operation is commonly performed through a Pfannenstiel incision, but other minimally invasive approaches have been described. The objective of this study is to compare open vs robotic infant UU with regards to operative time, complications, and operative success.

This is a retrospective institutional review board approved study of all infant UUs performed from July 2013 to January 2019. Before the DaVinci Xi became available (November 2017), UUs were primarily done open. All UUs after November 2017 were robotic. Surgery was recommended electively at 6 months in suspected cases of ectopic ureters or earlier for history of febrile UTI's or worsening hydronephrosis. Both open and robotic cases were started with cystoscopy and lower pole ureteral stent placement. A 5-0 polypropylene suture was tied in between in the stent and the Foley catheter. Foley and stent were removed 3-7 days after surgery in the clinic or at home by the parents. For both open and robotic approaches, patients were discharged on postoperative day (POD) 1 with the Foley draining into a double diaper on antibiotic prophylaxis.

From July 2013 to January 2019, 12 open and eight robotic infant UUs were performed. One patient in each group had a ureterocele, and the rest had ectopic ureters. Median age was 7 months for both the open and robotic groups. All patients except one had a 3.7 Fr by 10-12 cm stent placed attached to an 8-10 Fr silicone Foley catheter. The exception was the first robotic case who had a 3 Fr stent with no dangler placed after failed attempts with a 4.7 Fr stent (there were no 3.7 Fr stents that day). Median surgery time was 129 min (range 100-188, mean 133 min) for open and 130 min (range 79-226 min, mean 137 min) for robotic (P-value 0.8). In addition to the robotic case who had a 3 Fr stent placed with no dangler, an additional robotic case had to have her stent removed under anesthesia because the dangler broke or the knot got undone when the Foley was removed. One patient in the robotic arm who had the surgery done for a ureterocele had two postoperative febrile UTI's. Evaluation with VCUG and renal ultrasound (US) did not reveal hydronephrosis or reflux. She was managed conservatively. Other than the two cystoscopy and stent removals, no patient required a reoperation.

These data indicate that the laparoscopic robotic-assisted UU can be safely performed in infants with similar operative time compared with the traditional open Pfannenstiel approach. The two complications in the robotic arm were not related to the approach itself but to issues with the stents, which would have not been prevented by an open approach. There were no complications specific to the robotic approach.

Laparoscopic robotic-assisted infant UUs are safe, effective, and can be done in a similar time compared with the traditional open Pfannenstiel approach.