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Ureterocalicostomy was first introduced by Neuwirt (1947) and further described by Jameson et al. (1957) as an alternative procedure for repair of pelviureteric junction (PUJ) obstruction associated with an intrarenal pelvis. Performing ureterocalicostomy for PUJ repair has been suggested in cases with complex anatomical characteristics e.g. malrotated or horseshoe kidney, small renal pelvis or an intrarenal pelvis limiting access during the procedure. Similarly, in cases with a short ureter due to a long proximal urethral stenosis, ureterocalicostomy can facilitate formation of a tension-free anastomosis. It has also been used as a salvage procedure after failed pyeloplasty with extensive scarring at the PUJ level. Robotic-assisted laparoscopic ureterocalicostomy (RALUC) represents a potential surgical approach for patients after failed pyeloplasty or as an initial approach in those with complex anatomy. This is a three centre multi-institutional collaboration (Philadelphia, Atlanta and Chicago). Medical records of children undergoing RALUC between 2012 and 2020 were retrieved. The authors looked at both primary and redo RALUC procedures, as well as planned pyeloplasty intraoperatively converted to RALUC. Twenty-four patients were included (seven females and 17 males). Median age was 5.1 years. Previous pyeloplasty had been attempted in 21 (86%) of patients. Sixteen had had one failed attempt and five had two failed attempts. Prior to surgery, 23/24 patients had thinned renal parenchymal. Median time from initial failed pyeloplasty to RALUC was 15.7 months. The remaining three had no prior history of pyeloplasty. Two were planned to undergo pyeloplasty but converted intraoperatively due to complexity. One was scheduled for primary RALUC due to extensive scarring. Anatomical variations included intrarenal pelvis (50%) and malrotated kidney (13%). RALUC was preferred due to a short ureter in three (13%), intrarenal pelvis in five (21%) and extensive scarring at the PUJ level in 16 (67%). Median surgery time was 272 minutes and postoperative stay was two days. There were only three complications within 30 days of surgery (Clavien grade I-II). During the median follow-up of 16.1 months, 22 (92%) had improved symptoms and hydronephrosis and required no further intervention. Two patients underwent further endoscopic interventions (stenting and endopyelotomy); these failed and the patients required a nephrectomy. This manuscript shows that RALUC is feasible, safe and successful even for complex salvage procedures in a paediatric population (the caveat being that these are experienced robotic surgeons in high volume centres). It can also be used for primary treatment in patients with complex anatomy.

Robot-assisted laparoscopic ureterocalicostomy in the setting of ureteropelvic junction obstruction: a multi-institutional cohort.
Mittal S, Aghababian A, Eftekharzadeh S, et al.
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Neil Featherstone

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).

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