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A single-institution series of perioperative outcomes following robotic redo pyeloplasties
Briony Varda, MD, Joseph Badway, BS, Archana Rajender, MD, Ashley Wietsma, MD, Tanya Logvinenko, PhD, Richard S. Lee, MD, Richard N. Yu, MD, PhD.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: Recurrence after pyeloplasty occurs in around 3% of cases. Revision after a failed pyeloplasty can be more complex due to increased inflammation and scarring. For this reason, it is unclear whether a robotic approach is preferable for these difficult reconstructive cases. Understanding the outcomes following redo RALP will help counsel families regarding the best approach for a revision procedure. As such, we aim to describe in detail perioperative outcomes following redo RALP.
METHODS: We performed a single-institution retrospective case series of our redo RALP cases between 2/2007 and 7/2014. We focused on perioperative outcomes, including operative time (OT), length of stay (LOS), complications, readmission, recurrence and improvement. Patient and procedure level characteristics were summarized using frequencies (percentage) and medians (range or IQR) for categorical and continuous variables, respectively.
RESULTS: Twenty-four redo RALPs were performed in 22 patients; 2 patients had 2 redo RALPs and were analyzed individually. A majority of patients were healthy (ASA scores 1-2), White (55%) boys (77%) with a left-sided obstruction (72%). Median age at initial pyeloplasty was 4.2 years (IQR 1.1-7.4), compared to 7.2 (IQR 2.5-10.9) at redo. The median time from initial pyeloplasty to redo was 1.55 years (IQR 1.1-3.5). Nine patients were decompressed via stent or PCN prior to redo RALP and the median function of the affected kidney was 47% (IQR 33-51). One patient had a concomitant nephrolithotomy.
Median LOS was 1 day (range 1-3) and OT was 178 minutes (IQR 165-207). During follow up (median 1.9 years [IQR 1.4-2.7]), 5 complications (21%) occurred in 4 patients: a pseudomonal febrile UTI after stent removal, stent migration requiring endoscopic repositioning, and 3 recurrent stenoses. The complications were associated with 2 ER presentations, 3 admissions, 1 nephrectomy and 2 redo RALPs. Both patients improved after the second redo RALP. Radiologic improvement was observed following 67% of cases and clinical improvement in 88%.
CONCLUSIONS: The robotic approach for managing complex repairs after a failed primary pyeloplasty can be performed efficiently, with a short LOS, and provide good clinical improvement. However, complication rates are notable. Providers can use this information to counsel families when redo pyeloplasty is necessary.
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