Commentary: Early Robotic-Assisted Laparoscopic Pyeloplasty for Infants Under 3 Months With Severe Ureteropelvic Junction Obstruction

Dear Prof. Arjan Te Pas,

Dear Dr. Miguel Alfedo Castellan,

We read the recently published article “Early Robotic-Assisted Laparoscopic Pyeloplasty for Infants Under 3 Months With Severe Ureteropelvic Junction Obstruction” with great interest (1). In this study, the authors performed a retrospective study of nine infants under 3 months submitted to robotic-assisted laparoscopic pyeloplasty (RALP) at their institution showing acceptable peri- and postoperative outcomes, including no major complication, a significant decrease in renal pelvis diameter, and improved renal function at 6- and 12-month follow-up.

The use of minimally invasive approach, and in particular the robotic one, to treat benign conditions in the pediatric urology field has tremendously expanded over the last few years with increasing consistent evidence showing comparable successful rate to the open treatment (2, 3) while offering decreased surgical morbidity and better cosmetic result (4). Moreover, as witnessed by several investigations, the indications for robotic correction of ureteropelvic junction obstruction (UPJO) has widened and comprised smaller (<15 kg) and younger (<1 year) infants (5, 6).

In this light, the present study seems to pose a little further cornerstone in the process of expansion of the robotic-assistance in this field. However, some key points need to be clarified. In particular, the authors reported a median operative time (OT) of 109.5 (±10.4) min, a length of hospitalization of 5.57 (±0.73) days, and an overall complication rate of 22% in their series. These outcomes seem to be high as compared with other minimally invasive surgical alternatives, in particular mini-laparoscopic.

Mini-laparoscopic pyeloplasty, indeed, has shown an optimal success rate among several studies, demonstrating a shorter OT and a lower complication rate (7, 8) as compared to the outcomes reported in the present study. Moreover, the mini-laparoscopic approach employs less invasive working ports than the robotic one (3 and 5 vs. 8 mm), translating into better scar acceptance and cosmetic results, which are key outcomes in this specific set of patients and pathologies.

Surprisingly, the authors did not qualitatively assess the cosmetic results in their series, which would have increased the value of the paper.

In addition, other surgical techniques needed to be mentioned since they have been investigated in a similar setting with favorable outcomes and in particular one-trocar-assisted pyeloplasty (OTAP) and open pyeloplasty via mini-flank incision (9, 10). Which are the patient-related benefits provided by RALP over these approaches?

On the contrary, as brilliantly discussed by the authors in their paper, RALP has the undoubted advantage of being an easier and reproducible procedure compared to the laparoscopic one, thus leading to a faster learning process; meanwhile, mini-laparoscopic pyeloplasty is burdened by a steep learning curve and thus demanding for highly skilled operators.

To conclude, the management of UPJO in the pediatric urology field is progressively changing, and the latest minimally invasive procedures are replacing the open strategy as the gold standard treatment. However, although RALP has shown enthusiastic results even in the setting of very small and young children, its adoption among infants <3 months has still to be carefully selected since faster surgeries with objectively assessed cosmetic results have been outlined in several papers without compromising the peri- and postoperative outcomes. Further studies with an adequate sample size and, hopefully, in a randomized setting are warranted to draw definitive conclusions.

Statements

Summary

Keywords

UPJO, pediatric, pyeloplasty, minimally invasive surgery, robot

Citation

Sforza S, Grosso AA and Masieri L (2021) Commentary: Early Robotic-Assisted Laparoscopic Pyeloplasty for Infants Under 3 Months With Severe Ureteropelvic Junction Obstruction. Front. Pediatr. 9:724219. doi: 10.3389/fped.2021.724219

Received

12 June 2021

Accepted

02 July 2021

Published

10 August 2021

Volume

9 - 2021

Edited by

Lisandro Ariel Piaggio, Universidad Nacional del Sur, Argentina

Reviewed by

Matthieu Peycelon, Indiana University, United States; Juan Manuel Moldes, Italian Hospital of Buenos Aires, Argentina; Santiago Vallasciani, Sidra Medicine, Qatar; Mohan S. Gundeti, University of Chicago, United States

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Copyright

© 2021 Sforza, Grosso and Masieri.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Simone Sforza simone.sforza1988@gmail.com

This article was submitted to Pediatric Urology, a section of the journal Frontiers in Pediatrics

†These authors have contributed equally to this work

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