Is peri-operative urethral catheter drainage enough? The case for stentless pediatric robotic pyeloplasty.

Summary Background The necessity for urinary diversion with trans-anastomotic ureteral stenting during pyeloplasty is currently under debate. Performing a stentless repair could eliminate stent-related morbidity, including: stent migration, urinary tract infection, flank pain, and bladder spasms. In addition, there would be no need for a second procedure and associated anesthesia required for stent removal. This study describes the outcomes of robotic-assisted laparoscopic pyeloplasty without use of a ureteral stent. Materials and methods An IRB-approved prospective database of all pediatric patients undergoing robotic pyeloplasty from July 2012 to July 2014 at a single institution was reviewed. The ‘bypass pyeloplasty’ or Anderson-Hynes dismembered pyeloplasty (DP) technique was performed. In both groups, neither a ureteral stent nor an abdominal drainage catheter was utilized. Complications were recorded, including: postoperative pain, bladder spasms, fever, and urinary tract infections. Follow-up renal ultrasound was reviewed for hydronephrosis. Results Twenty-seven children (17 male, 10 female) with a mean age of 25 months (range 6–157 months) underwent robotic ureteral stentless pyeloplasty during the study time period. The bypass pyeloplasty technique was performed on 19 children (70%). Mean length of stay was 20.2 hours (range 11–46). No fever, urinary tract infections, or hematuria requiring intervention were experienced. Additionally, there were no reports of bladder spasms or pain requiring pharmacotherapy. The mean follow-up was 8 months (range 4–21). Pre-operative Society of Fetal Urology grading was 3.5 and 3.4 for the dismembered and bypass cohort, respectively, with improvements to 1.1 for both groups at 3 months. Postoperative renal ultrasound hydronephrosis resolved in eight children (29.6%), improved in 14 (51.9%), and was stable in five (18.5%). The overall success rate was 100%. Discussion This study was limited by its small cohort and short follow-up, which may not thoroughly describe the efficacy of the stentless repair as it has been shown that stricture and re-obstruction can occur several years after surgery. Conclusions Robotic stentless pyeloplasty is a feasible alternative to conventional methods, with excellent success rates and minimal complications. Importantly, this technique circumvents the need for a second procedure and the associated risks of anesthesia. Table . Summary of patient demographics and operative results. Dismembered Bypass Pre-operative variables Patients, n 8 19 Mean age, months (range) 32.6 (44–157) 21.8 (6–122) Male gender, n 6 11 Presumed cause of obstruction Crossing vessel, n 8 0 Intrinsic narrowing, n 0 5 High insertion, n 0 6 Combination (IN + HI) 0 8 Outcome variables Mean follow-up time, months (range) 6.2 (4–18) 8.8 (4–21) Mean length of stay, hours (range) 20.6 (11–46) 20.1 (14–23) 3-month USG results Resolution of hydronephrosis, n 5 3 Improvement of hydronephrosis, n 0 14 No change of hydronephrosis, n 3 2 Worsening of hydronpehrosis, n 0 0 HI, high insertion; IN, intrinsic narrowing; USG, Ultrasound