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Robotic-Assisted Laparoscopic Dismembered Pyeloplasty and Vascular Hitch Technique In Children: Comparison of Outcomes

Sunday, October 21, 2012: 1:22 PM
Grand Ballroom B (Hilton Riverside)
Candace F. Granberg, M.D.1, Daniel Dajusta, M.D.1, Linda A. Baker, MD, FAAP2 and Patricio C. Gargollo, M.D.1, (1)Pediatric Urology, Children's Medical Center, Dallas, TX, (2)Ambulatory Care Pavilion, Children's Medical Center, Dallas, TX

Purpose:   While dismembered pyeloplasty is standard for intrinsic ureteropelvic junction obstruction (UPJO), surgical management of extrinsic crossing vessel UPJO without intrinsic disease has been debated between dismemberment or the Hellstrom vascular hitch technique.  Given the utility of the robotic platform, we contrasted the surgical demographics and outcomes of robotic-assisted laparoscopic dismembered pyeloplasty (RAL-DP) and vascular hitch (RAL-VH) in pediatric patients with UPJO.

Methods:   We retrospectively reviewed records of 73 patients who underwent RAL-DP or RAL-VH for UPJO from November 2008 to March 2012, excluding reoperations and horseshoe kidneys.   Data collected included pre- and post-operative patient and surgical characteristics.   In patients with crossing vessels at the UPJ, the vascular hitch technique was performed if renal pelvis decompression with ureteric peristalsis was observed after mobilization of vessels, suggesting no intrinsic UPJO.  Otherwise, dismembered pyeloplasty was performed.   Successful outcome at follow-up was defined as an asymptomatic patient with stable or improved ultrasound findings and/or no obstruction on nuclear medicine lasix renogram.  Two tailed chi-square analysis was used for comparison.

Results:   Of 76 cases in 73 patients (3 bilateral), 27 had crossing vessels of which 24 met intraoperative criteria for RAL-VH; 3 (11%) did not exhibit decompression of renal pelvis after mobilization of crossing vessels and RAL-DP was done.  The remaining 49 cases without crossing vessels also underwent RAL-DP.  Median age at surgery was 6 (0.4-17) years in RAL-DP and 9.5 (0.6-20.1) years in RAL-VH.  Median operative time was 162 (64-359) and 114 (50-226) minutes, respectively (p=0.01). Estimated blood loss was similar in both groups (mean 5mL).  There were no intraoperative complications.  Average hospital stay was 1.2 days after RAL-DP and 0.9 days after RAL-VH (p=0.04); 3 RAL-VH patients were dismissed the day of surgery.  After RAL-DP, 4/37 (11%) patients had complications (calcified stent, pyelonephritis, urine leak, malpositioned stent); no RAL-VH patients had complications.  Of 35 RAL-DP with follow-up data thus far, 33 (94%) had successful outcomes at median follow-up of 6.5 (2.9-25) months.  Of 15 RAL-VH patients with follow-up data thus far, all 15 (100%) had successful outcomes at median follow-up of 6.1 (3-18) months.

Conclusion:   In patients with crossing vessel UPJO without intrinsic UPJO based on strict intraoperative criteria, the vascular hitch technique has similar success as RAL-DP with  significantly shorter operative times and length of hospital stay.  Only 11% of cases with crossing vessels did not have visible decompression of the renal pelvis after mobilization of the crossing vessels, thus warranting dismembered pyeloplasty.  While RAL pyeloplasty overall is highly successful, our modest series at early follow-up supports an individualized surgical treatment approach to extrinsic UPJO.