Infant Robotic Pyeloplasty: Hidden Incisions (HIDES) versus Conventional Port placement

Background

Hidden Incision Endoscopic Surgery (HIDES) consists of port placement (PP) inside the umbilicus and at the bikini line, thus hiding incisions.

 

Although the cosmetic advantages are clear, the technique appears to be underutilized.  It is my belief HIDES PP facilitates pyeloplasty in Infants by creating more working space compared to conventional PP.

Objective

To compare outcomes of HIDES robotic pyeloplasty in infants with a contemporary multi-institutional experience using conventional port placement.

Methods

We retrospectively reviewed cases of consecutive patients 12 months or younger who underwent robotic pyeloplasty with HIDES technique between 2013 and 2017 from 2 academic medical centers.  Outcomes were compared to the ones published by Avery et al (J of Pediatric Urology 2015). All outcomes were calculated as described on Avery et al manuscript and using the same units and descriptors. Simultaneous bilateral pyeloplasty was excluded.

Results

 HIDESAvery et al
Total patients1560
Surgical age mean (SD)6.7 (±3.5)7.2 (±1.7)
Median weight  kg (IQR)7.5 (6.2-9.3)8.1  (7.1-9.2)
Operative time min (SD)143 (±29)232 (±43)
Length of stay days (IQR)1 (1-1)1 (1-2)
HydronephrosisResolved: 6.5%(1/15)

Improved: 73%(11/15)

Stable: 13%(2/15)

Worse: 6.5% (1/15)

Resolved: 1.7%

Improved: 89.8%

Stable: 6.8%

Worse: 1.7%

Complications20%11%
Port site hernia02
Urine leak01
UTI31
Retained stent01
Calculus01
Prolonged ileus01

The table above summarizes the outcomes and compares them to the outcomes of Avery et al. One patient had worse postoperative hydronephrosis and continued to be obstructed on the nuclear medicine renal scan. He underwent successful reoperative HIDES pyeloplasty while still under 12 months of age with improved hydronephrosis postoperatively. Both techniques had one failed pyeloplasty but the difference was not significant (p=0.3).

On average, HIDES pyeloplasty took 89 minutes less than pyeloplasty done using conventional PP (p=0.0001). We had 3 postoperative febrile UTI’s, 2 of them in infants that were left with a dangler coming out the urethra attached to the stent (which we no longer do).

Conclusions

HIDES PP for robotic pyeloplasty does not appear to be inferior to conventional port placement with regards to hospital stay and resolution of hydronephrosis. Although our cohort had an increased incidence of postoperative UTI, this is likely not associated with the PP.  Operative times appear to be shorter with HIDES PP which could be due to the greater operating space provided by the technique, although further studies will be needed to validate this statement.

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