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Pelviureteric junction obstruction (PUJO) is a common cause of paediatric hydronephrosis. Indications for intervention include reduced renal function (<40%), symptoms (urinary tract infection or pain) and increasing dilatation. Although the Anderson-Hynes open pyeloplasty (OP) has long been the gold standard treatment (first described 1949), laparoscopic and robot-assisted laparoscopic pyeloplasty (RALP) has gained popularity following its first report in 1993. RALP has been reported to reduce recovery times, decrease postoperative pain and increase cosmesis. However, the benefits of minimally invasive surgical approaches and specifically RALP are less clear in infants. Here, Rague et al. have aimed to evaluate their own single institution experience (Ann and Robert H. Lurie Children’s Hospital of Chicago) in a retrospective manner and provide comparative outcome data for RALP and OP. All patients less than one year of age undergoing primary OP or RALP between January 2009 and June 2020 were included. Either da Vinci Xi or S platform were used for RALP. Overall, 204 patients underwent pyeloplasty (121 underwent OP and 83 underwent RALP). There was an increasing number of RALPs performed over time and in 2020, all infant pyeloplasties were undertaken robotically. Surgical modality was not randomised and chosen by surgeon preference. OP patients were younger (median 2.9 vs. 7.2 months) and smaller (median 5.9 vs. 8.2Kg). RALP was more commonly performed with two attending co-surgeons compared to OP (31.3% vs. 3.3%). Complications within 30 days (seven OP and three RALP) and the need for re-operative pyeloplasty (10 OP and four RALP) were not significantly different. RALP did require longer total operating room times (median 255 minutes vs. 214). This is the largest series of infant RALP published to date. It does show safety and efficacy for RALP. They have shown that while workspace is limited, these obstacles can be overcome. However, due to its non-randomised nature (OP patients being younger and smaller), it unfortunately does not really answer the question that they hoped to examine. Perhaps, in time, sufficient data will be collected to allow direct comparison and to determine whether RALP is possible in the smallest and youngest of our patients, if there are limits of application and finally if it is as good as the tried and tested OP.

Safety and efficacy of robot-assisted laparoscopic pyeloplasty compared to open repair in infants under 1 year of age.
Rague JT, Arora HC, Chu DI, et al.
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Neil Featherstone

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).

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