Reoperative robotic pyeloplasty in children

SummaryIntroductionReoperative pyeloplasty for recurrent ureteropelvic junction obstruction (UPJO) can be technically challenging and is associated with greater morbidity and lower success rates than an initial repair. Robotic-assisted laparoscopic pyeloplasty (RALP) previously has been demonstrated to be a safe and effective approach for management of recurrent UPJO; however, the length of follow-up has been limited. The objective of this study was to confirm the safety and efficacy of RALP for UPJO in children following failed previous pyeloplasty and provide clinical benchmarks for intermediate length follow-up in this patient population.MethodsAn IRB approved retrospective chart review was performed for all patients undergoing reoperative RALP from June 2006 to December 2014. All cases were performed by surgeons from two institutions for persistent UPJO following failed initial pyeloplasty. Information including demographic information, radiographic studies, and operative interventions performed between the initial repair and reoperative surgery, reoperative RALP intraoperative data, postoperative clinical course and imaging studies, and subsequent interventions following reoperative RALP were extracted.ResultsTwenty-three children underwent reoperative RALP. Eleven patients had right- and 12 left-sided repairs. Median age at reoperative RALP was 4.0 years and median interval between surgeries was 1.3 years. Indications for repeat repair included pain, infection, and/or radiographic evidence of worsening obstruction and/or deteriorating renal function. Mean operative time was 198 min from incision to port closure. Mean length of stay was 2.3 days. Six complications occurred in five patients within 30 days postoperatively, including ileus, pneumonia, and urinary tract infection. Median length of follow-up was 26 months (range 4-45 months) for all patients and 31 months (range 16-45 months) in 18 patients with >12 months of follow-up. More than 80% of patients presenting with flank pain prior to reoperative RALP had resolution of this symptom. To date, 78% of patients with >12 months of follow-up have not required further operative intervention. Excellent results have been achieved in 14 of 18 patients (78%) with sufficient postoperative follow-up in terms of length of follow-up (>12 months), symptom resolution, and/or improved imaging results.ConclusionsRALP following previous pyeloplasty is technically feasible with acceptable operative times, lengths of stay, and complication rates. Reoperative RALP is our preferred modality for repair of recurrent UPJO with the vast majority of patients having successful outcomes based on imaging, resolution of symptoms, and the rare need for further intervention across an intermediate length follow-up period.Table. Summary of reoperative pyeloplasty experience in 23 patients.Median age (years) at Redo Surgery (Range)4.0 (14 months-19 years)Median time (years) between Primary and Redo Surgery (Range)1.3 (4 months-17 years)Reconstructive technique utilized Anderson-Hynes Dismembered20 Y-V plasty1 Lower-to-upper pole moiety pyeloureterostomy2Retrograde ureteral stent placement/exchangea13Antegrade ureteral stent placement10 (1 nephroureteral stent utilized)Conversion to open technique0Mean length of stay2.3 days (1.1-4.4 days)OutcomebMedian length of follow up: 26 months (range 4-45 months) Improved (%)19 (83%) Stable (%)3 (13%) Worse (%)1 (4%)Outcomeb in patients with > 12 months follow-up (N = 18)Median length of follow up: 31 months (range 16-45 months) Improved (%)14 (78%) Stable (%)3 (17%) Worse (%)1 (5%)See text for further details.a1 patient had nephrostomy tube placed at presentation (pyelonephritis) and a retrograde stent placed at the time of surgery.bCriteria: Resolution of symptoms and/or improvement on imaging.