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      Defining the Pros and Cons of Open, Conventional Laparoscopy, and Robot-Assisted Pyeloplasty in a Developing Nation

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          Abstract

          Introduction. Congenital pelviureteric junction obstruction (PUJO) is one of the most common causes of hydronephrosis. Historically, open dismembered pyeloplasty has been considered the gold standard intervention for correcting PUJO. The aim of this study was to compare the surgical and functional outcomes of three different approaches, namely, open, conventional laparoscopy, and robotic pyeloplasty. Material and Methods. 60 patients underwent minimally invasive pyeloplasty (30 conventional laparoscopies and 30 robotics) for congenital PUJO at a tertiary health center in India. Demographic, perioperative, and postoperative data were prospectively collected and analyzed. The data of these patients were retrospectively compared with another cohort of 30 patients who had undergone open pyeloplasty. Results. There was significant difference in operative time, time to drain removal, hospital stay, pain score, and complications rate between open and minimally invasive pyeloplasty ( P < 0.05). SFI was considerably lesser in robotic as compared to conventional laparoscopy. The success rate in OP, CLP, and RP was 93.33, 96.67, and 96.67%. Conclusion. Robotic pyeloplasty is safe, effective, and feasible. It is associated with significantly lesser operative time, lesser blood loss, less pain, shorter hospital stay, and fewer complications. It is also associated with considerably lesser surgeon fatigue as compared to conventional laparoscopy pyeloplasty.

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          Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate.

          Luis Braga, Kenneth Pace, Jorge DeMaria … (2009)
          Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO). To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate. We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement). Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity. We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity. We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: -10.4 min; 95% CI: -24.6-3; p=0.15) and significantly shorter hospital stay compared with CLP (WMD: -0.5 d; 95% CI: -0.6-0.4; p<0.01). There were no differences between the approaches with regard to rates of complication (OR: 0.7; 95% CI: 0.3-1.6; p=0.40) and success (OR: 1.3; 95% CI: 0.5-3.5; p=0.62). RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time.
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            Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience.

            Patrick Mufarrij, Michael Woods, Ojas D Shah … (2008)
            The introduction of the da Vinci Surgical System to perform complex reconstructive procedures, such as repair of ureteropelvic junction obstruction, has helped to overcome some of the technical challenges associated with laparoscopy. We review our large multi-institutional experience with long-term followup of robotic dismembered pyeloplasty. A total of 140 patients from 3 university medical centers underwent robotic dismembered pyeloplasty. An institutional review board approved retrospective chart review was performed to collect demographic, preoperative, operative and postoperative data. Patients were analyzed as an entire cohort and then divided into various subgroups. Of the cases 117 (84.6%) were primary repairs and 23 (16.4%) were secondary repairs. There were 13 (9.3%) patients who underwent concomitant stone extraction and 5 (3.6%) procedures were performed on patients with solitary kidneys. A crossing vessel was found in 77 (55%) patients. Mean operative time was 217 minutes (range 80 to 510), estimated blood loss was 59.4 ml (range 10 to 600), mean length of hospital stay 2.1 days (range 0.75 to 7) and mean followup was 29 months (range 3 to 63). Radiographic resolution of obstruction on first postoperative diuretic renal scan or excretory urogram was noted in 134 patients (95.7%). There was a 7.1% major complication rate and a 2.9% minor complication rate. No statistically significant differences were found in any parameters among patients from the various cohorts. To our knowledge this review represents the largest multi-institutional experience of robotic dismembered pyeloplasty with long-term followup. Robotic pyeloplasty appears to be safe, durable and efficacious for primary and secondary ureteropelvic junction obstruction with or without concomitant stone extraction, and for patients with a solitary kidney.
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              Laparoscopic versus open pyeloplasty for ureteropelvic junction obstruction in children: a systematic review and meta-analysis.

              Hong Mei, Liduan Zheng, Qiangsong Tong … (2011)
              To comprehensively review the available evidences in the literature on the use of laparoscopic pyeloplasty (LP) vs open pyeloplasty (OP) for the repair of ureteropelvic junction (UPJ) obstruction in children. Published studies until the end of October 2010 were searched from Medline, Embase, Web of Science, Ovid, and Cochrane databases. The literature search, quality assessment, and data extraction were independently performed by two reviewers. A systematic review and meta-analysis were performed by using Review Manager 4.2.8 software. Of 1403 studies, one randomized controlled trial (RCT), two prospective comparative studies, and six retrospective observational studies were eligible for inclusion criteria, comprising 694 cases of LP and 7334 cases of OP. The OP has significantly reduced operative time (weighted mean difference [WMD] = 59.00; 95% confidence interval [CI] = 41.15 to 76.85; P < 0.00001) and higher stent placement rate (odds ratio [OR] = 5.97; 95% CI=3.17 to 11.26; P<0.00001) compared with LP, whereas the duration of hospital stay was shorter in the LP group (WMD = -0.40; 95% CI = -0.77 to -0.03; P=0.03). No difference was observed between LP and OP regarding complications (OR = 0.78; 95% CI = 0.46 to 1.34; P = 0.37) or success rate (OR = 1.76; 95% CI = 0.71 to 4.36; P = 0.22). LP is a minimally invasive, safe, and effective therapy method for UPJ obstruction in children, with shorter hospital stay and excellent outcomes, and without additional risk of postoperative complications. Because of the publishing bias, a series of RCTs are necessary to explore the efficiencies of LP in the management of UPJ obstruction in children.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Adv Urol
                Journal ID (iso-abbrev): Adv Urol
                Journal ID (publisher-id): AU
                Title: Advances in Urology
                Publisher: Hindawi Publishing Corporation
                ISSN (Print): 1687-6369
                ISSN (Electronic): 1687-6377
                Publication date (Print): 2014
                Publication date (Electronic): 2 February 2014
                Volume: 2014
                Electronic Location Identifier: 850156
                Affiliations
                1Sir Ganga Ram Hospital, 78-c, Mianwali Colony, Gurgaon 122001, India
                2Lady Hardinge Medical College, New Delhi 110001, India
                3University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
                Author notes

                Academic Editor: M. Hammad Ather

                Author information
                http://orcid.org/0000-0003-2534-3782
                Article
                DOI: 10.1155/2014/850156
                PMC ID: 3929287
                SO-VID: 913cb9ee-9a78-42d7-8681-f1d18d0037db
                Copyright © Copyright © 2014 Mrinal Pahwa et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 31 July 2013
                Date revision received : 8 December 2013
                Date accepted : 15 December 2013
                Categories
                Subject: Clinical Study

                ScienceOpen disciplines: Urology
                Data availability:
                ScienceOpen disciplines: Urology

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