Robot-assisted buccal graft uretero-pyeloplasty for pediatric recurrent UPJO: a multi-center case-series

Redo pyeloplasty is technically more complex due to more significant scar tissue and risk for poor ureteral blood supply affecting outcomes. Use of buccal graft uretero-pyeloplasty was originally reported in the pediatric population back in 2017 as an alternative for complex reoperations. We hypothesize that in highly selected group of pediatric patients undergoing redo pyeloplasty, a buccal graft uretero-pyeloplasty would demonstrate efficacy. A total of 6 institutions identified patients undergoing a robot-assisted buccal uretero-pyeloplasty from 2014 to 2025. Demographic, pre-operative, intraoperative and postoperative variables were aggregated. Success was defined as improvement of hydronephrosis and or resolution of initial presenting symptoms. A total of 12 cases were identified. Median age at the time of initial pyeloplasty was 12 years (IQR 9.75-15.25 years), and buccal graft redo pyeloplasty was at a median of 16 years (IQR11-18 years). Median length of the buccal graft was 4 cm (include SD). Nine cases (75%) had omental wrap and all except one were onlay grafts. The most common reason for failure was persistent pain (6 patients) followed by worsening dilation (3 patients). With a median follow-up of 2 years (IQR11-18 years), nine patients (75%) reported improvement of their symptoms and 6 (50%) improved the hydronephrosis. Two continued with chronic flank pain despite no reports of obstruction or worsening dilation. This is the largest pediatric cohort reporting outcomes after buccal graft uretero-pyeloplasty for recurrent UPJO. In a small sample size of highly selected pediatric patients, buccal graft onlay may be utilized with reasonable efficacy while acknowledging lower success than reported in other recurrent UPJO case series.