Robot-Assisted Laparoscopic Pyeloplasty (RALP) in Infants: Technical Modifications,Surgical Experience,and Outcomes

Abstract

Aims:

Robot-assisted laparoscopic pyeloplasty (RALP) pyeloplasty in infants with pelvi-ureteric junction obstruction (PUJO) poses distinct challenges due to limited working space, small anatomical structures, and the need to adapt adult robotic systems for pediatric use. This study presents surgical experience and highlights technical refinements that optimize the procedure and reduce complications.

Methods:

A retrospective review was conducted of infants who underwent RALP between January 2023 and May 2025 using the da Vinci Xi system. Operative challenges were analyzed, and standardized strategies were implemented to improve exposure, minimize complications, and achieve precise anastomosis. Postoperative outcomes were assessed using renal ultrasonography and EC scans.

Results:

Eleven male infants (mean age: 5.9 months; mean weight: 6.7 kg) underwent unilateral robotic dismembered pyeloplasty. All had antenatally detected hydronephrosis, with postnatal confirmation of PUJO (left: 6; right: 5). Presenting features included urinary tract infection (18.1%), palpable lump (45.4%), and asymptomatic cases (36.3%). Associated anomalies were noted in 45%—crossing vessels (n = 2), crossing vessel with malrotated kidney (n = 1), undescended testis (n = 1), and left renal agenesis (n = 1). All surgeries were completed robotically without conversion. Three robotic arms were used, omitting the assistant port. Mean operative time was 168 minutes, with a console time of 133.3 minutes. The average hospital stay was 4.4 days. Several technical refinements—preoperative bowel decompression, aspiration of the dilated renal pelvis, supraumbilical camera port placement, optimal port spacing, burping of trocars, and precise alignment of the remote center—were crucial in facilitating effective surgery within the restricted working space. No intraoperative complications were encountered. On follow-up (mean duration: 17.8 months), 90% of patients demonstrated improved drainage, while one required a redo pyeloplasty.

Conclusion:

RALP in infants is a technically feasible, safe, and effective procedure when performed with appropriately tailored technical modifications and refinements.