The missed crossing vessel during open pyeloplasty: a potential advantage of the robot-assisted approach in children.

OBJECTIVE: To investigate whether the panoramic view offered by robot-assisted laparoscopic pyeloplasty (RALP) reduces the likelihood of missing a crossing vessel compared to open pyeloplasty in cases where initial pyeloplasty fails. METHODS: A single institution redo-pyeloplasty database was reviewed for children treated between January 2012 to July 2023. Clinical history, imaging and operative details were reviewed to identify the etiology for the redo procedure. RESULTS: Cohort consisted of 45 patients undergoing a redo RALP during the study period. 29 of 45 patients had an initial open surgical approach, whereas 16 had an initial RALP. 10 patients were noted to have a missed crossing vessel on redo pyeloplasty - 9 had an initial open approach whereas 1 had an initial RALP (p<0.0001). CONCLUSIONS: RALP may reduce the risk of missing a crossing vessel due to the panoramic view of the surgical field intrinsic to an intraperitoneal RALP approach.

A simple technique for percutaneous antegrade retrieval of proximally migrated double J stents after pyeloplasty in infants.

Proximal migration of double J (DJ) stent after pyeloplasty poses a difficult problem in infants whose small ureter renders retrograde ureteroscopic retrieval difficult. Previously described antegrade techniques used large access sheaths or blind removal under fluoroscopic guidance. We describe a technique for antegrade retrieval of the stent under direct vision. A 8F vascular access sheath is placed into the renal pelvis under ultrasound guidance. A 6F nephroscope with 3F forceps placed through the sheath grasps and retrieves the stent under direct visualization. This technique is simple, quick, avoids radiation exposure and was used by us successfully in 2 small infants.

Case Report; Concomitant Left Nutcracker Syndrome and Right Ureteropelvic Junction Obstruction.

We report rare case of concomitant left nutcracker syndrome and right ureteropelvic junction obstruction (UPJO) on adult female patient diagnosed by CT urogram after she presented with intermittent bilateral flank pain. For this we did Anderson-Hynes pyeloplasty for right ureteropelvic obstruction, it was laparoscopic initially but due to difficulty of stenting it is changed to open. She had smooth post-op course then discharged on 3rd post-op day. Symptoms of nutcracker syndrome are not that much bothersome for the patient so we planned to follow her conservatively.

Does Age Influence the Functional Recovery after Infant Pyeloplasty?

Purpose: The purpose was to study the correlation between age at surgery and functional recovery after infant pyeloplasty. Materials and Methods: All infants who underwent pyeloplasty were analyzed retrospectively in this multicenter study. Anteroposterior diameter (APD) >2 cm, split renal function (SRF) <40%, and Society of Fetal Urology (SFU) grade 3-4 were surgical indications. Based on the age at pyeloplasty, they were divided into Group 1 (1-3 months) and Group 2 (4-12 months). APD and SRF were compared before and after surgery in both groups. The fractional recoverable function (post-SRF-pre-SRF)/(50-pre-SRF) ×100 was correlated with age. Results: Fifty-one infants underwent pyeloplasty (mean age: 1.6 months - Group 1 and 7.2 months - Group 2). The mean APD decreased from 3 cm to 1.2 cm in Group 1 while 2.8 cm to 2 cm in Group 2 (P = 0.001). The mean SRF increased from 32.28% to 42.81% in Group 1 while 31%-34.18% in Group 2. SRF recovery was significantly higher in Group 1 compared to Group 2 (P = 0.001). Regression analysis showed a weak negative correlation (r = -0.2792) between age at surgery and renal function improvement. Conclusion: Functional recovery after pyeloplasty is better when done earlier (1-3 months), as this gives the growing kidney the best opportunity to recover.

Is cortical transit time a parameter to prove relief of obstruction after pyeloplasty in antenatally diagnosed ureteropelvic junction obstruction.

PURPOSE: The study aims to determine the possible improvement in cortical transit time (CTT) after surgery in infants with antenatally diagnosed ureteropelvic junction obstruction (UPJO), and investigate the correlation of CTT with preoperative renal function and parenchymal thickness. PATIENTS AND METHODS: Medical charts of 32 antenatally diagnosed children with UPJO operated on between 2014 and 2021 were reviewed. Patients' demographics, preoperative and postoperative anteroposterior diameter (APD), parenchymal thickness (PT) ratio, differential renal function (DF), drainage patterns and CTT were compared to determine operative benefit. Preoperative CTT of each patient was also grouped as severely delayed (> 6 min) and moderately delayed (3-5 min) and compared. The correlation between the preoperative CTT and preoperative DF and PT ratio was investigated. RESULTS: The median age of the patients was 8.8 months (1-24 months). The CTT (mean: 6.8 ± 3.0 min) was prolonged before surgery and was significantly improved (mean 4.6 ± 1.0 min) after the operation (p < 0.001). A significant negative correlation was detected between the CTT and preoperative DF and between the CTT and preoperative PT ratio. Preoperative DF was found significantly impaired in patients within the severely prolonged CTT group compared to those within the moderately prolonged CTT group. Significant improvement in DF was detected in patients in the severely prolonged CTT group after surgery. CONCLUSION: CTT is a parameter to prove relief of obstruction in patients with antenatally diagnosed UPJO after surgery. CTT is negatively correlated with preoperative DF and PT ratio. Severely prolonged CTT may be considered to be an indication of early surgical intervention.

Differential renal length index: useful measure in management of isolated unilateral hydronephrosis?

OBJECTIVE: To explore the usefulness of the 'differential renal length index' (iDRL) before and after pyeloplasty, as the anteroposterior diameter is commonly used to quantify hydronephrosis but inaccuracies arise due to interobserver variability, hydration status and pure intra-renal dilatation. PATIENTS AND METHODS: Prospectively collected data, from two centres, of all children undergoing pyeloplasty for isolated unilateral pelvi-ureteric junction obstruction (PUJO) (2015-2021) were analysed. Subgroup analysis was undertaken: Group A - differential renal function (DRF) ≥40%, Group B - subnormal DRF (20-39%), and Group C - symptomatic. Children with structural anomalies of upper and lower urinary tract, bilateral involvement, and subnormal DRF (<20%) were excluded. All the children had a pre- and postoperative ultrasound scan and Tc99m mercapto-acetyltriglycine (MAG3) renograms. The iDRL was calculated as follows: iDRL = ([a - b]/b) × 100, where 'a' is the length of hydronephrotic kidney (cm) and 'b' is the length of contralateral normal kidney (cm). The mean difference and standard error of mean (SEM) between the pre- and postoperative iDRL was evaluated using the paired Student's t-test, with P < 0.05 considered statistically significant. RESULTS: A total of 119 children with 1-year follow-up were included. For the entire cohort, the mean (SEM) preoperative iDRL was 27.7 (1.4) and postoperatively was 12.5 (1.1), with a mean (range) DRF improvement of 54% (44-66%) (P < 0.001). In Group A (n = 97), the mean (SEM) preoperative iDRL was 26.6 (1.5) and postoperatively was 13.1 (1.2), with a mean (range) DRF improvement of 50% (38-63%) (P < 0.001). In Group B (n = 22), the mean (SEM) preoperative iDRL was 32.6 (3.5) and postoperatively was 10.0 (2.8), with a mean (range) DRF improvement of 69% (49-89%) (P < 0.001). In Group C (n = 28), the mean (SEM) preoperative iDRL was 19.9 (2.3) and postoperatively was 7.7 (1.9), with a mean (range) DRF improvement of 61% (38-85%) (P < 0.001). CONCLUSION: Our study identifies the iDRL as a useful measure of improvement following successful pyeloplasty. In the subgroup with DRF of >39% minimum improvement was >37%. Similar minimum DRF improvement was also noted (>37%) in hypo-functioning kidneys and symptomatic PUJO.

Long-term outcome of retroperitoneoscopic one-trocar-assisted pyeloplasty: a single-center and single-surgeon experience.

PURPOSE: The aim of this study was to assess the long-term outcomes of retroperitoneoscopic one-trocar-assisted pyeloplasty (OTAP) for ureteropelvic junction obstruction (UPJO) in children. METHODS: This retrospective analysis included 70 pediatric cases, all under the age of 5, diagnosed with UPJO and treated with the OTAP technique between May 2011 and June 2013 by a single surgeon. A single 10 mm operative scope with a 5 mm working channel was utilized to mobilize the ureteropelvic junction (UPJ) and exteriorize it through the trocar insertion site. Subsequently, conventional Anderson-Hynes dismembered pyeloplasty was conducted extracorporeally. Patient's demographics, operative time, hospital stay, complications, and success rate were evaluated. RESULTS: Seventy pediatric patients (65 males and 5 females) underwent OTAP, with ages at the time of operation ranging from 1 month to 5 years (mean = 22.6 ± 18.6 months). The mean operative time was 74.8 ± 15.2 min. There was a significant reduction in the mean renal pelvis size from 34.3 ± 8.1 mm preoperatively to 13.8 ± 4.7 mm postoperatively (p < 0.05). Moreover, the mean differential renal function (DRF) increased from 47.9 ± 9.8% preoperatively to 51.2 ± 5.9% postoperatively (p < 0.05). All patients experienced an uneventful postoperative recovery, with a median hospital stay of 3.4 days. The success rate was 95.7%, with a median follow-up time of 75 months (range: 6-125 months). CONCLUSION: OTAP is a safe and feasible minimally invasive technique to correct ureteropelvic junction obstruction in children. It could be considered as a treatment of choice for children under the age of 5 as it combines the advantages of open and retroperitoneoscopic pyeloplasty and presents excellent long-term outcomes. TRIAL REGISTRATION NUMBER: NCT06349161 April 4th, 2024, retrospectively registered.

Effect of ultrasound-guided quadratus lumborum block on neuroendocrine stress response and postoperative analgesia in paediatric patients undergoing elective open pyeloplasty - A randomised clinical trial.

Background and Aims: Quadratus lumborum block (QLB) is a compartmental block of the anterior abdominal wall. Surgical trauma produces neuroendocrine surgical stress responses, which are modified by anaesthetic blocks. The aim of this study was to evaluate the effect of ultrasound (US)-guided QLB on analgesia and surgical neuroendocrine stress response in paediatric patients undergoing pyeloplasty. Methods: A randomised trial was conducted in 60 children aged 1-7 years undergoing elective open pyeloplasty. Patients were randomised into Group QLB [US-guided QLB with 0.5 ml/kg of 0.25% ropivacaine after induction of general anaesthesia (GA)], and Group GA, which received only GA. Perioperative haemodynamic parameters, serum cortisol, blood glucose, analgesic consumption and postoperative FLACC scores were recorded. Unpaired t-test, Wilcoxon rank-sum test or Mann-Whitney U test was used to compare variables between the two groups. Two-way analysis of variance or the Friedmann test was used to compare quantitative variables at various points within a group. Results: A decrease in serum cortisol and blood glucose values was observed in Group QLB at 30 min after surgical incision and 24 h after surgery compared to the preoperative value and compared to Group GA (P < 0.05). The quality of analgesia assessed by the FLACC scale was significantly better in group QLB. Dose of fentanyl consumption (µg/kg) was higher in Group GA compared to Group QLB in the intraoperative and postoperative period (P < 0.05). Conclusion: QLB is effective as part of multimodal analgesia and attenuates the neuroendocrine stress in paediatric patients undergoing open pyeloplasty.

Utility of ultrasound-based scoring system in post-pyeloplasty recovery.

BACKGROUND/OBJECTIVE: Differentiation of uretero-pelvic junction obstruction (UPJO) from non-obstructive dilatation (NOD) is a major challenge. The aim of this retrospective study is to determine whether pyeloplasty prediction score (PPS) could predict the need for surgery and resolution after surgery. METHODS: Among patients with antenatally diagnosed hydronephrosis, those who were stable during post-natal follow-up were considered NOD. The UPJO group were the ones who worsened and underwent pyeloplasty based on conventional indications. All patients with UPJO underwent laparoscopic dismembered pyeloplasty. PPS was determined based on three ultrasound parameters obtained retrospectively: Society of Fetal Urology (SFU) grade of hydronephrosis, transverse anteroposterior (APD), and the absolute percentage difference of ipsilateral and contralateral renal lengths. RESULTS: Among 137 patients included (R:L = 59:73; M:F 102:35), 96 were conservatively managed (NOD), while 41 patients (29%) needed pyeloplasty (UPJO). Mean PPS was 4.2 (1.2) in the NOD group and it was significantly higher at 10.8 (1.63) in the UPJO group (p = 0.001). All patients with PPS > 8 needed a pyeloplasty, while two patients with PPS of 7 needed pyeloplasty due to drop in renal function. PPS cutoff value of >8 had a sensitivity 95%, specificity 100% and a likelihood ratio of 20. Post-pyeloplasty PPS resolution was proportional to the duration of follow-up. CONCLUSIONS: A PPS cutoff value of 8 or above is associated with the presence of significant UPJO. PPS is also useful in the assessment of hydronephrosis recovery post-pyeloplasty. The limitation of PPS: it can only be applied in the presence of contralateral normal kidney.

Propensity score matched analysis of treatment outcomes in pediatric ureteropelvic junction obstruction: a comparison between horseshoe and non-horseshoe kidneys.

BACKGROUND: Pediatric hydronephrosis poses distinct challenges, particularly in cases involving horseshoe kidneys (HSK). This retrospective study compares treatment outcomes between HSK and non-horseshoe kidneys (NHSK) in pediatric ureteropelvic junction obstruction (UPJO) patients. METHODS: A retrospective cohort study included 35 patients with HSK and 790 patients with NHSK undergoing pyeloplasty. Preoperative, intraoperative, and postoperative parameters were evaluated. Propensity score matching (PSM) balanced patient characteristics in the NHSK group. RESULTS: In comparison with NHSK, HSK exhibited a higher crossing vessel incidence (51.6% vs. 5.12%, P < 0.001) and smaller preoperative anteroposterior pelvic diameter (APD). Post 6 and 12 months, NHSK maintained a larger APD, with a higher P/C ratio at 12 months. PSM retained significantly higher crossing vessel incidence in HSK (51.6 vs. 3.61%, P < 0.001). Laparoscopic pyeloplasty (LP) in HSK showed lower postoperative length of stay (LOS). Postoperative ultrasound parameters favored NHSK. In HSK and NHSK with crossing vessels, HSK demonstrated higher complications even post-PSM (38.5% vs. 0%, P = 0.039). CONCLUSIONS: The study emphasizes the importance of recognizing crossing vessels in HSK-related hydronephrosis. Surgical success, although comparable between HSK and NHSK, requires tailored approaches. This investigation contributes valuable insights to pediatric urology, emphasizing personalized management for optimal outcomes.

Prospective comparison of two methods for correct ureteral stent placement in pediatric laparoscopic pyeloplasty.

INTRODUCTION: Ureteral stent placement during laparoscopic pyeloplasty is a common procedure in pediatric patients. Although an apparently safe maneuver, ascending placement of the stent can lead to complex removal or repositioning reinterventions. OBJECTIVE: In this study we compare two methods for intraoperative verification of correct positioning. STUDY DESIGN: Prospective observational study collecting data on laparoscopic pyeloplasties in pediatric patients in our center over three years. We carried out descriptive and univariate comparative analyses. Data were compared between ultrasound and reflux visualized by the catheter after intraoperative salineinjection into the bladder through the urethral catheter. We recorded time to catheter visualization in both ultrasonography and in reflux from the start of bladder instillation, as well as bladder volume at the time of placement verification with each method. RESULTS: Data were collected from 20 patients (15 male and 5 female) with a median age of 48 months. Pyeloplasty was successful in 100% of the sample (as observed by ultrasound and MAG-3), while one patient had postoperative leak requiring nephrostomy placement. Correct distal positioning of the ureteral stent could be verified by intraoperative ultrasound and reflux in all cases. Using reflux, the bladder volume needed to verify correct positioning exceeded the age-related maximum in half the cohort, while on ultrasound, the stent was visualized in the bladder without reaching the maximum bladder capacity for age in any case (p = 0.02 comparing percentages). Likewise, mean time to verification was lower with ultrasound than with reflux (61.8 s versus 115 s), but without these differences reaching statistical significance (p = 0.14). DISCUSSION: The present study is the first to compare two methods to verify the correct positioning of the ureteral stent in laparoscopic pyeloplasties in pediatric patients. Our results show that both intraoperative ultrasound and visualization of reflux are useful methods, although ultrasound requires a lower volume of saline instilled through the bladder catheter for verification. This work can be very useful for the daily clinical practice of urologists and pediatric surgeons. CONCLUSIONS: Both intraoperative ultrasound and visualization of reflux are useful methods to verify the correct positioning of the ureteral stent in laparoscopic pyeloplasty of pediatric patients. With ultrasound, a smaller volume is required to check for reflux. Although ultrasound is faster for verification, there are no differences in procedural times.

Surgical intervention and long-term renal outcomes of congenital ureteropelvic junction obstruction in a young adult cohort.

PURPOSE: To evaluate the impact of surgical intervention on long-term renal outcomes for adult patients with congenital ureteropelvic junction obstruction (UPJO). METHODS: We queried service members diagnosed with UPJO from the United States Military Health System electronic health records from 2005 to 2020. We assessed demographic, laboratory, radiology, surgical intervention, and outcome data. We evaluated the impact of surgical intervention on renal function based on the estimated glomerular filtration rate (eGFR), hypertension (HTN, defined as any prescription for blood pressure [BP] medication and/or average of two BP readings ≥ 130/80 mmHg more than 2 weeks apart), and changes in renal excretory function on radionuclide scans. RESULTS: We identified 108 individuals diagnosed with congenital UPJO; mean follow-up of 7 years. Mean age at diagnosis was 25 years; 95% male; 69% White, 15% Black. At diagnosis, median BP was 130/78 mmHg and mean eGFR 93 ml/min/1.73m2. Subsequently, 85% had pyeloplasty and 23% had stent placement. There were no significant differences in mean eGFR pre- and post-intervention (94 vs. 93 ml/min/1.73m2, respectively; p = 0.15) and prevalence of defined HTN (59% vs. 61%, respectively; p = 0.20). Surgical intervention for right-sided UPJO significantly reduced the proportion of patients with delayed cortical excretion (54% pre vs. 35% post, p = 0.01) and T½ emptying time (35 min vs. 19 min, p = 0.009). Similar trends occurred with left-sided UPJO but were not significant. CONCLUSION: Surgical intervention was not associated with significant differences in the long-term outcomes of kidney function and HTN prevalence in our young adult cohort. However, renal excretory function improved on radionuclide scans.

Transumbilical single-incision hybrid pyeloplasty for infant ureteropelvic junction obstruction.

Ureteropelvic junction obstruction (UPJO) can be treated by various pyeloplasty techniques. We present a hybrid technique incorporating elements of laparoendoscopic single-site surgery and open pyeloplasty through a single umbilical incision. As a result, seven infants with UPJO underwent the hybrid pyeloplasty smoothly. The mean operative time was 131.9 min. At a follow-up of 11.8-50.0 months, all infants showed significant improvement and no symptoms except for one febrile urinary tract infection. The cosmetic results were very satisfactory without obvious visible scars. Therefore, the hybrid pyeloplasty appears to be a simple and effective minimally invasive surgery for treating infant UPJO.

Ureteropelvic Junction Obstruction Caused by Crossing Vessels in Infants and Young Children.

BACKGROUND: To analyze the clinical characteristics of ureteropelvic junction obstruction (UPJO) caused by crossing vessels (CV) in infants and young children. METHODS: A retrospective analysis was performed on children with UPJO who underwent primary surgery. Patients were classified into laparoscopic pyeloplasty (LP) and open pyeloplasty (OP) groups and classified as ≤3 or >3 (years old) groups. Children with CV-caused UPJO were identified. RESULTS: A total of 747 patients were included. Ninety cases of CV were identified. The CV discovery rate was higher in the LP group (78/457, 17.1%) than in the OP group (12/290, 4.1%) (P < 0.001). In the ≤3 group, the CV discovery rate in the LP group (27/144, 18.8%) was higher than that in the OP group (11/274, 4.0%) (P < 0.001). In the LP group, there was no significant difference between ≤3 (27/144, 18.8%) and >3 (51/313, 16.3%) groups in the CV discovery rate. The rate in children with UPJO was not significantly different at any age (P > 0.05). Progressive aggravation of hydronephrosis (21/27, 77.8%) and symptomatic hydronephrosis (44/51, 86.3%) were the main surgical indications in the ≤3 and > 3 groups, respectively. There were no preoperatively confirmed cases of CV in the ≤3 group. In the OP group, five patients underwent reoperation, three of whom were due to failure to detect CV during the initial operation. CONCLUSIONS: The CV distribution is similar in children with UPJO across all ages; CV in infants and young children are not rare. LP should be considered as CV are prone to being missed during OP. LEVELS OF EVIDENCE: III.

Is Percentage Improvement in Anteroposterior Pelvic Diameter a Valuable Marker for Successful Drainage Postpyeloplasty in Isolated Pediatric Pelvi-ureteric Junction Obstruction.

Context: Pelvic-ureteric junction obstruction (PUJO) causes urine stasis in the renal pelvis and progressive kidney damage. Postpyeloplasty improvement of renal function and urinary drainage is assessed by diuretic isotope renogram and ultrasonography. Renograms are expensive and have radiation exposure. This study explores whether ultrasound parameters such as percentage improvement in anteroposterior pelvic diameter (PI-APD) is a valuable markers for successful pediatric pyeloplasties. Aims: The aim of this study was to identify patients who would benefit from ultrasound monitoring of PI-APD alone instead of diuretic isotope renal scan for postoperative follow-up of pyeloplasty. Settings and Design: This was a retrospective descriptive study. Subjects and Methods: We analyzed 127 pediatric pyeloplasties performed and under follow-up between June 2016 and May 2021. We recorded the postoperative ultrasound and isotope renogram parameters. PI-APD (preoperative AP diameter - postoperative AP diameter)/preoperative AP diameter × 100) was compared with improvement in renogram parameters (differential renal function, Tmax, curve pattern, and retention) to look for a correlation between them. Statistical Analysis Used: SPSS version 20.5, Chi-square and paired t-test were used for statistical analysis. Results: About 73.2% of patients were males, with most cases detected antenatally (76.4%). The majority was left-sided PUJO (67.7%). The mean age at surgery was 30.8 months. We identified a statistically significant correlation between the ultrasound parameter PI-APD and the renogram parameter Tmax. There is no significant correlation between PI-APD and other renogram parameters. Conclusions: In patients whose ultrasound parameter PI-APD is >40% and renal parenchymal thickness has increased, isotope renograms can be avoided for follow-up of postpyeloplasty patients.

Single-port robot-assisted pyeloplasty using the da vinci SP system versus multiport pyeloplasty: Comparison of outcomes and costs.

OBJECTIVE: To investigate the feasibility of single-port (SP) robotic pyeloplasty by comparing perioperative outcomes with those of multiport (MP) robotic pyeloplasty. MATERIALS AND METHODS: We reviewed the data from patients who underwent robot-assisted pyeloplasty for ureteropelvic junction obstruction (UPJO) at a single tertiary institution between March 2016 and May 2022. Radiographic and symptomatic improvements were assessed 3 months postoperatively. Propensity score matching was performed for age, sex, body mass index, and hydronephrosis grade. RESULTS: Of the 15 S P-pyeloplasty and 28 MP-pyeloplasty cases, 14 from each group were matched using 1:1 matching. The SP group had shorter console and operative times without significant differences. Blood loss was lower in the SP group than in the MP group (p = 0.019). The length of hospital stay, opioid use on the operative day, and pain score at discharge did not differ between the two groups. The mean cost for surgery was higher in the SP group than in the MP group (p < 0.001). The mean cost of hospitalization was comparable between the two groups (p = 0.083). The cosmetic numerical rating scale scores were significantly higher in the SP group (p = 0.014). Symptoms improved in all patients, and the radiographic improvement rates were 92.9% in the SP group and 100% in the MP group. CONCLUSION: SP-pyeloplasty showed cosmetic benefits, lower blood loss, operative time, and console time compared with MP-pyeloplasty. In patients who underwent surgery for UPJO for the first time, SP surgery can show comparable outcomes when compared to MP surgery.

Utility of F-15 diuretic MAG3 renography in assessment of paediatric hydronephrosis.

INTRODUCTION: Diuretic renography is crucial in evaluation of paediatric hydronephrosis. Furosemide is conventionally given 15-20 min after radiolabelled tracer (F+15/F+20 protocol), however this is equivocal in around 15% of patients. Giving furosemide 15 min prior to tracer (F-15 MAG3 protocol) has been suggested as an additional tool in the investigation of patients with suspected upper urinary tract obstruction. However, the role of this method in assessment and management of paediatric hydronephrosis is not widely reported. OBJECTIVE: To investigate utility of F-15 renograms in children with hydronephrosis being assessed for Pelvi-Ureteric Junction Obstruction (PUJO). STUDY DESIGN: Retrospective review of patients <16 years old undergoing F-15 MAG3 renogram between 2018 and 2021 in our tertiary paediatric surgical centre. Data collected included patient demographics, mode of presentation, investigations, management and outcomes. RESULTS: Eighteen patients were included. Median age at F-15 renogram was 7.3 years. Eleven patients presented with antenatal hydronephrosis, 5 with symptoms in childhood and 2 with incidental hydronephrosis on trauma imaging. Fourteen patients were symptomatic. Ten had a prior non-obstructed F+20 renogram but persisting symptoms suggestive of PUJO. Seven had previous equivocal F+20 renograms. One symptomatic patient directly underwent an F-15 renogram. A conclusive result was obtained in 16/18 (89%); 11 patients had obstructed curves and 5 non-obstructed. Two asymptomatic patients' scans were inconclusive. All symptomatic patients had conclusive scans. Of 11 patients with an obstructed F-15, 9 have undergone pyeloplasty to date. All have had post-operative resolution in symptoms and static or improved post-operative ultrasound. One patient with an inconclusive scan underwent pyeloplasty due to persisting hydronephrosis and parent preference. Three patients with non-obstructed F-15 renograms have been discharged. One symptomatic patient with a non-obstructive F-15 had a ureteric stent inserted due to persistent flank pain; 1 continues under surveillance. DISCUSSION: It is known that conventional F+20 MAG3 renograms can give equivocal results. Published experience suggests that F-15 renograms are conclusive in the majority of patients. Routine primary use is, however, discouraged as they can 'over diagnose' obstruction and limit the study of tracer transit under physiological flow rates. This study indicates that the F-15 renogram is a useful adjunct in the assessment of patients with symptoms suggestive of PUJO who have previously had an equivocal or a non-obstructed F+20 renogram. CONCLUSION: F-15 renogram was conclusive in 89% of patients. We recommend using F-15 renograms to aid surgical decision-making in children with equivocal F+20 renograms, especially in the presence of symptoms.

Interstitial Cells of Cajal and P2X3 Receptors at Ureteropelvic Junction Obstruction and Their Relationship with Pain Response.

Introduction: Etiopathogenesis and the symptomatology of ureteropelvic junction obstruction (UPJO) in the pediatric population has not yet been definitely clarified, suggesting a multifactorial nature of the condition. The aim was to analyze the association between the number of Interstitial Cells of Cajal (ICCs), as well as P2X3 receptors in ureteropelvic junction (UPJ) and the pain response in pediatric patients with hydronephrosis. Methods: 50 patients with congenital hydronephrosis underwent open or laparoscopic pyeloplasty at one of two departments of pediatric surgery and urology in Poland. Patients were divided into two groups according to the pain symptoms before surgery. A total of 50 samples of UPJ were obtained intraoperatively and underwent histopathological and immunohistochemical (IHC) analysis. Quantitative assessment of ICCs was based on the number of CD117(+) cells of adequate morphology in the subepithelial layer and the muscularis propria. Expression of P2X3 receptors was evaluated as the intensity of IHC staining. Results: Patients with hydronephrosis and accompanying pain were on average 60 months older (77 vs. 17 months) than children with asymptomatic hydronephrosis (p = 0.017). Symptomatic children revealed higher numbers of ICCs in both the subepithelial layer and in the lamina muscularis propria. In particular, symptomatic patients aged 2 years or more exhibited significantly higher numbers of ICCs in the subepithelial layer. Significant differences in the distribution of ICCs between the subepithelial layer and the lamina muscularis propria were observed in both groups. Expression of P2X3 receptors was limited to the urothelium and the muscle layer and correlated between these structures. There was no relationship between pain response and the expression of P2X3 receptors. Conclusions: ICCs and P2X3 receptors may participate in the pathogenesis of UPJO and in the modulation of pain response to a dilatation of the pyelocaliceal system. Explanation of the role of ICCs and P2X3 receptors in propagation of ureteral peristaltic wave and the modulation of pain stimuli requires further studies.

Comparison of analgesic efficacy of ultrasound-guided quadratus lumborum block versus erector spinae plane block in children undergoing elective open pyeloplasty - A randomized, double-blinded, controlled study.

Background and Aims: Comparison of analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block (QL-3) and erector spinae block (ESP) in children undergoing open pyeloplasty was done in this study. Material and Methods: This was a randomized, double-blinded, controlled study conducted in a tertiary care center, operating rooms, post-anesthesia care unit (PACU), and paediatric surgical ward. Sixty children of age 1-6 years, with American Society of Anesthesiologists (ASA) status I or II, undergoing elective open pyeloplasty were included in the study. Patients were randomized into two groups: group I (QL block-3) and group II (ESP). Both blocks were performed under USG guidance using 0.5 ml/kg of 0.25% ropivacaine after induction of general anesthesia. Postoperative Modified Objective Pain Score (MOPS), perioperative hemodynamic parameters, perioperative time for first rescue analgesia, total rescue analgesia, and incidence of complications were recorded. Statistical tests were applied as follows: (i) quantitative variables were compared using independent t-test/Mann-Whitney test (when the data sets were not normally distributed) between the two groups, and repeated measure analysis of variance (ANOVA)/Friedman test was used for comparison between different time intervals within the same group and (ii) qualitative variables were correlated using the Chi-square test/Fisher's exact test. A P value of <0.05 was considered statistically significant. Results: Pain was assessed using MOPS in the postoperative period at 0, 30 min, 1, 2, 4, 6, 12, and 24 h. Overall, the pain scores were low and showed a decreasing trend toward baseline as time progressed. Group I showed lower score, but was statistically significant only at the sixth hour. Highest mean score was 2.4 ± 2.01 in group I and 2.67 ± 2.32 in group II. Perioperative hemodynamic parameters were comparable. Total rescue analgesia during the perioperative period was not statistically significant (intraoperative P = 0.075 and postoperative P = 0.928). Also, 63.33% patients in group I and 63% patients in group II required rescue analgesia in the postoperative period and were comparable. Mean ± standard deviation (SD) for first rescue analgesia time was 6.32 ± 12.57 in group I and 16.67 ± 31.25 in group II, but not significant. The distribution in group II was skewed, hence the larger value for group II, but when compared to group I, this was statistically not significant. Conclusion: Both ultrasound-guided ESP block and QL block using 0.25% ropivacaine 0.5 ml/kg provided adequate analgesia during the first 24 h post-surgery in children undergoing open pyeloplasty. The fentanyl requirement during the first 24-h postoperative period was also decreased.

Expanding safety boundaries in pediatric robotic-assisted laparoscopic surgery: are we protecting our children?

Little is known about the effects of CO2 insufflation (CDI) on cerebral oxygen saturation (CrSO2) during laparoscopy in the pediatric population. In children undergoing robotic-assisted laparoscopic pyeloplasty (RALP), we prospectively assessed the effects of CDI using standard monitoring and cerebral near-infrared spectroscopy (NIRS). We also explored whether a correlation existed between CrSO2 and parameters known to affect cerebral blood flow. Between January 2021 and September 2023, a cohort of consecutive children older than 2 years underwent RALP at Necker-Enfants Malades Hospital in Paris. A ventilation protocol aimed to prevent hypercarbia was implemented. Data collected included standard monitoring parameters and CrSO2 by NIRS. Thirty patients (16 females), mean age 5.5 ± 3.9 (2.0-9.5) years, were included. Twenty-three patients underwent a retroperitoneal approach. The mean baseline CrSO2 value was 83.0 ± 9.8. Mean CrSO2 decreased during progressive CDI, never below baseline values, while standard-monitoring parameters did not significantly change. No significant correlation was detected between CrSO2 and end tidal CO2, or between CrSO2 and mean arterial pressure, at any operative time. During RALP, a gradual CDI doesn't cause pathological derangements of CrSO2. The lack of correlation between CrSO2 and standard parameters affecting cerebral blood flow suggests the likely presence of cerebral autoregulation in our population.