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Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and
Valentina Cascini1, Giuseppe Lauriti2,1, Dacia Di Renzo1
1Pediatric Surgery Unit, "Spirito Santo" Hospital of Pescara, Pescara, Italy.
Insights
Minimally invasive surgery (MIS) pyeloplasty is feasible and safe for infants with ureteropelvic junction obstruction (UPJO), offering shorter hospital stays than open pyeloplasty (OP) with similar success rates. Further research is needed to confirm these findings.
Area of Science:
- Pediatric Urology
- Minimally Invasive Surgery
- Surgical Outcomes
Background:
- Open Anderson-Hynes dismembered pyeloplasty (OP) is the traditional treatment for ureteropelvic junction obstruction (UPJO).
- Minimally invasive surgery (MIS) approaches, including laparoscopic and robot-assisted pyeloplasty, offer potential benefits like reduced morbidity and shorter hospital stays.
- Historically, MIS has been limited to children over one year due to patient age and weight.
Purpose of the Study:
- To evaluate the feasibility and benefits of MIS pyeloplasty compared to OP for UPJO in children under one year of age.
- To assess surgical outcomes, including operative time, length of hospital stay, complications, and success rates, in infants undergoing MIS versus OP.
Main Methods:
- A systematic review and meta-analysis of studies comparing MIS pyeloplasty with OP in infants.
- Data from nine included studies (3,145 pyeloplasties) were analyzed using Rev.Man 5.4.
- Statistical significance was set at p < 0.05.
Main Results:
- MIS pyeloplasty involved a slightly longer operative time (144.0 ± 32.3 min) compared to OP (129.4 ± 24.1 min).
- MIS procedures resulted in a significantly shorter length of hospital stay (LOS) (2.2 ± 0.9 days) compared to OP (3.2 ± 1.9 days).
- No significant differences were observed in postoperative complications or surgical failure rates between MIS and OP.
Conclusions:
- MIS pyeloplasty is feasible and safe for treating UPJO in infants, demonstrating comparable success rates to OP with the advantage of a shorter LOS.
- Despite longer operative times, MIS offers benefits for infants, but its application should be considered in high-volume centers with experienced surgeons due to low-quality evidence.
- Further high-quality research is warranted to solidify the evidence base for MIS pyeloplasty in infants.
Introduction:
The historical gold standard treatment for ureteropelvic junction obstruction (UPJO) was the open Anderson-Hynes dismembered pyeloplasty (OP). Minimally invasive surgery (MIS) procedures, including laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP), have been reported to achieve better outcomes (i.e., decreased morbidity, reduced postoperative pain, superior esthetic results, and shortened length of hospital stay, LOS), with a success rate similar to OP. The main limitation of the MIS approach is the age and weight of patients, limiting these procedures to children >1 year. This study aims to evaluate the feasibility and benefits of MIS pyeloplasty compared to OP to surgically treat UPJO in children <1 year of age.
Materials And Methods:
A systematic review was independently performed by two authors. Papers comparing both techniques (MIS pyeloplasty vs. OP) in infants were included in the meta-analysis. Data (mean ± DS or percentage) were analyzed using Rev.Man 5.4 A p < 0.05 was considered significant.
Results:
Nine studies (eight retrospective and one prospective) meet the inclusion criteria. A total of 3,145 pyeloplasties have been included, with 2,859 (90.9%) OP and 286 (9.1%) MIS. Age at operation was 4.9 ± 1.4 months in OP vs. 5.8 ± 2.2 months in MIS, p = ns. Weight at surgery was 6.4 ± 1.4 kg in OP vs. 6.9 ± 1.4 kg in MIS, p = ns. Operative time was 129.4 ± 24.1 min for OP vs. 144.0 ± 32.3 min for MIS, p < 0.001. LOS was 3.2 ± 1.9 days for OP vs. 2.2 ± 0.9 days for MIS, p < 0.01. Postoperative complications were present in 10.0 ± 12.9% of OP vs. 10.9 ± 11.6% in MIS, p = ns. Failure of surgery was 5.2 ± 3.5% for OP vs. 4.2 ± 3.3% for MIS, p = ns.
Conclusion:
The development of miniaturized instruments and technical modifications has made MIS feasible and safe in infants and small children. MIS presented a longer operative time than OP. However, MIS seemed effective for treating UPJO in infants, showing shortened LOS compared to OP. No differences have been reported with regard to the incidence of postoperative complications and failure of pyeloplasty. Given the low quality of evidence of the meta-analysis according to the GRADE methodology, we would suggest limiting MIS procedures in infants to only those high-volume centers with experienced surgeons.
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