Open vs. Robot-Assisted Laparoscopic Pyeloplasty in Children: Our Preliminary Experience

Open vs. Robot-Assisted Laparoscopic Pyeloplasty in Children: Our Preliminary Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Open vs. Robot-Assisted Laparoscopic Pyeloplasty in Children: Our Preliminary Experience Grazia Spampinato, Carlotta Plessi, Diego Biondini, Viviana Durante, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7292163/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Dec, 2025 Read the published version in Journal of Pediatric Endoscopic Surgery → Version 1 posted You are reading this latest preprint version Abstract Introduction Robotic surgery has been performed in pediatric patients at our center since early 2022. The aim of this study is to analyze the feasibility and safety of robot-assisted laparoscopic pyeloplasty (RALP) by comparing it with the open surgical technique. Material and Methods We retrospectively analyzed data from patients who underwent pyeloplasty at our center between February 2022 and December 2024. Collected variables included patient sex, age and weight at the time of surgery, operative time, length of hospital stay and complication rate. Patients were divided into two groups: Group O (open pyeloplasty) and Group R (RALP). Results A total of 25 patients underwent pyeloplasty during the study period—13 via the open approach (Group O) and 12 via the robot-assisted approach (Group R). The mean age was 0.8 years in Group O and 12 years in Group R. The mean operative time was 191 minutes for Group O and 239 minutes for Group R. The average hospital stay was 4 days for open surgery and 3 days for RALP. Only one minor complication (Clavien-Dindo Grade I) was recorded, in Group O. Discussion and Conclusions Despite a longer operative time for RALP, the outcomes are comparable—and potentially superior—to those of open surgery. RALP was associated with a shorter hospital stay, potentially reducing overall costs. No complications were observed in the RALP group. These preliminary results suggest that RALP is a safe and feasible option for pediatric patients. Figures Figure 1 Figure 2 Introduction Robotic surgery has been performed in pediatric patients at our center since early 2022. The aim of this study is to analyze the feasibility and safety of robot-assisted laparoscopic pyeloplasty (RALP) by comparing it with the open surgical technique. Ureteropelvic junction obstruction (UPJO), caused by intrinsic fibrosis/stenosis or extrinsic compression (such as by aberrant vessels), is a common issue in pediatric urology [ 1 , 2 ]. UPJO is found in up to 41% of cases of prenatally diagnosed hydronephrosis and approximately 25% of them requires surgery [ 1 , 2 ]. Traditionally, the gold standard treatment for UPJO has been the Anderson–Hynes dismembered pyeloplasty, performed via an open flank approach, which offers high success rates ranging from 90–100% [ 1 – 5 ]. The advent of minimally invasive surgery (MIS) led to the development of laparoscopic pyeloplasty (LP). While safe and effective, LP was considered technically challenging, particularly regarding intracorporeal suturing, ergonomics, and the learning curve. The introduction of the da Vinci system in 2002 and the subsequent evaluation of the first RALP series marked a significant step forward. Over the past decade, RALP has gained wider adoption and become the most performed robotic procedure in pediatric urology. Robotic surgery is seen as a natural progression from open and laparoscopic procedures. RALP is now considered a new gold standard in pediatric MIS [ 1 , 4 , 5 ]. This study analyzes our preliminary experience with RALP compared to open pyeloplasty, contributing data from our center to the ongoing evaluation of this technology in pediatric UPJO treatment. Material and Methods We retrospectively analyzed data from patients who underwent pyeloplasty at our center between February 2022 and December 2024. Inclusion criteria comprised any patient undergoing an open or robot-assisted laparoscopic pyeloplasty. We excluded any patient treated for complex urologic anomalies or redo surgeries. Indications for pyeloplasty included symptomatic UPJO, progressive reduce in renal function associated or not with urinary tract infections and increasing antero-posterior pelvis diameter. All patients were preoperatively investigated with renal ultrasonography (US) and diuretic MAG3 scan. Surgical technique All open cases were performed with an Anderson-Hynes dismembered pyeloplasty through a flank incision. A double J stent was left in place in all cases. All robot-assisted cases were performed using the Da Vinci XI platform. The surgical procedure performed was a transperitoneal Anderson-Hynes dismembered pyeloplasty. The patient was placed in a flexed lateral decubitus (opposite to the side of UPJO) and 4 trocars were positioned: a 5 mm air seal trocar at the umbilicus and three 8 mm working ports on the pararectal line [figure 1 ]. After colon detachment the ureter was identified and dissected together with the pelvis and the UPJ. The pelvis was divided together with the ureter which was spatulated by incising its posterior margin. The pyeloplasty was performed with a running absorbable suture after the placement of a double j stent. The stent was removed cystoscopically 40–50 days after surgery. All the open surgeries were performed by a single surgeon in training as well as the RALP, performed by a different surgeon in training. The collected variables included patient sex, age and weight at the time of surgery, operative time, duration of hospital stay, and the rate and type of complications, classified according to the Clavien-Dindo system [ 6 ]. Patients were categorized into two groups based on the surgical approach: Group O for open pyeloplasty and Group R for RALP. Results During the study period (February 2022 - December 2024), a total of 25 patients underwent pyeloplasty. 13 patients were treated with the open approach (Group O) and 12 patients were treated with the robot-assisted approach (Group R). The mean age at the time of surgery was significantly different between the groups: 0.8 years (range 4 months- 2.9 years) in Group O and 12 years (range 2–17 years) in Group R. The mean weight was significantly different as well: 10.3 kg (range 7–15 kg) vs. 42.8 kg in Group O (range 14–60 kg). The mean operative time was 191 minutes (range 150–246 minutes) for Group O and 239 minutes for Group R1 (range 185–265 minutes). The average length of hospital stay was 4 days (range 3–6 days) for open surgery and 3 days (range 3–4) for RALP [Table 1]. Table 1: Comparison of Demographic and Clinical Characteristics Between Group O (Open Surgery) and Group R (Robot-Assisted Surgery) Characteristic Group O (Open, n = 13) Group R (Robot-Assisted, n = 12) Age at surgery 0.8 years (4 mo – 2.9 yrs) 12 years (2 – 17 yrs) Weight 10.3 kg (7 – 15 kg) 42.8 kg (14 – 60 kg) Operative time 191 min (150 – 246 min) 239 min (185 – 265 min) Hospital stay 4 days (3 – 6 days) 3 days (3 – 4 days) Only one minor complication (Clavien-Dindo Grade I) was recorded, occurring in Group O. This complication was described as urinary tract infection. No complications were observed in the RALP group in this preliminary series [Figure 2 ]. Discussion Our preliminary experience with pediatric pyeloplasty shows that RALP is feasible and safe, although associated with a longer operative time compared to the open approach in this initial series. A significant finding is the shorter average hospital stay for RALP (3 days) compared to open surgery (4 days). Furthermore, no complications were observed in the RALP group, while one minor complication occurred in the open group. These results align with some findings in the broader literature comparing RALP and open pyeloplasty. Systematic reviews and meta-analyses have consistently shown that RALP and LP are associated with shorter hospital stays compared to open surgery [ 1 ]. For instance, a meta-analysis focusing on infants (1–23 months) found MIP (minimally invasive pyeloplasty; including RALP and LP) resulted in a mean difference of 1.16 fewer hospital days compared to open surgery [ 2 ]. Another meta-analysis established a correlation between MIP and a shorter LOS (length of stay) [ 7 ]. MIP wounds were found to have a higher collagen deposition postoperatively in comparison to OP, which facilitated quicker postoperative recovery and consequently reduced LOS [ 7 , 8 , 9 ]. The diminished requirements for tissue manipulation and analgesia with MIP also contributed to the shorter LOS [ 7 , 10 ]. Regarding operative time, our finding that RALP is longer than open surgery is also a common observation, particularly in the initial learning curve phase of robotic surgery. Esposito et al. review notes that RALP operative times were initially longer than open, but in centers with high volume and surgeon experience, times have shortened, with many recent studies reporting overall operative times less than 120 minutes [ 1 ]. Our longer RALP times likely reflect that this study represents early experience at our center, consistent with the learning curve described in the literature, where operative times can become equivalent to open after a certain number of cases (e.g., 15–20 cases) [ 10 , 11 ]. Our observed complication profile, with only one minor complication in the open group and none in the RALP group, is very favorable in this small cohort. The literature reports varied complication rates and types for both approaches [ 1 , 2 , 3 , 7 , 10 ]. While a large comparative study found similar overall complication rates between RALP and Open, RALP was associated with fewer high-grade postoperative complications (Clavien ≥ 2) [ 2 ]. The meta-analysis in infants found no significant difference in overall complication rates [ 3 ]. Success rates for RALP reported in the literature are very high, ranging from 90–100%, comparable to open pyeloplasty [ 1 ]. A large comparative study reported similar success rates for RALP (96.7%) and Open (96.0%)[ 2 ]. The meta-analysis in infants found success rates of 96.16% for MIP and 93.97% for Open, with no statistically significant difference [ 3 ]. Our local follow-up data, showing resolution or improvement of hydronephrosis in all patients, aligns with these high reported success rates. The significant age difference between our groups (RALP patients much older than open patients) is a key characteristic of our preliminary cohort and is consistent with the literature indicating that RALP adoption, especially early on, was often in older children due to concerns about instrument size and working space in infants [ 1 ]. While our RALP group had a mean age of 12 years, the literature shows increasing experience and studies focused on RALP in infants as young as 1–23 months [ 1 , 3 ], demonstrating its safety and feasibility even in this challenging population, although operative times may still be longer than open surgery in infants [ 1 , 9 ]. Indeed, with increasing experience along the learning curve, we progressively broadened the selection criteria for RALP to include younger and lighter patients, with the youngest being 2 years old and the lightest weighing 14 kg. Regarding costs, concerns about the high cost associated with robot-assisted laparoscopic pyeloplasty (RALP) in children remain. While some literature suggests this cost differential compared to open pyeloplasty (OP) has decreased over time and with institutional experience, the high cost of training, maintenance, and materials generally suggests a greater overall cost for RALP compared to other modalities [ 1 ]. A more recent study in a low-volume center found similar costs for operative room, instruments, materials, and hospital stay between OP and RALP, but noted that double-J stent removal added cost [ 12 ]. A large single-institution study evaluating direct costs over the 0–60 day period post-surgery found no significant difference in overall 0–60 day direct costs between the RALP and OP groups (p = 0.47). However, this study noted that costs were higher in the RALP group in the 30–60 day period (p = 0.01), primarily attributing this difference to routine cystoscopy and stent removal procedures performed in the operating room [ 2 ]. In our study, the placement and cystoscopic removal of the double J stent were performed uniformly in both groups, suggesting no significant cost differences related to this aspect. However, the shorter hospital stay observed in the robot-assisted group may contribute to lower overall healthcare costs, underscoring the potential clinical and economic advantages of this minimally invasive approach. Limitations Our study is a preliminary, retrospective analysis from a single institution with a limited number of patients. There is a significant age disparity between the two surgical groups. The findings represent the experience during the early phase of adopting robotic surgery at our center. These limitations necessitate cautious interpretation and emphasize the need for larger, multicenter, prospective studies with longer follow-up to confirm these preliminary findings. Conclusions In conclusion, our initial experience supports the safety and feasibility of robot-assisted laparoscopic pyeloplasty in children. Consistent with the early learning phase and findings in the literature, RALP in our cohort had a longer operative time but demonstrated advantages in terms of shorter hospital stay and a low complication rate (with none observed in the RALP group). As robotic technology and surgeon experience evolve, RALP is increasingly becoming a preferred approach for pediatric UPJO, though ongoing research, particularly in specific subgroups like infants and focusing on cost-effectiveness and long-term outcomes, remains important. Declarations Disclosure Statement No competing financial interests exist. Funding Information No funding was received for this article Human Ethics and Consent to Participate declarations The study was reviewed and approved by the Comitato Etico Area Vasta Emilia Nord . Informed consent was obtained from all individual participants included in the study. Participants were informed about the purpose of the study, the procedures involved, and their right to withdraw from the study at any time. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. References Esposito C, Cerulo M, Lepore B, Coppola V, D’Auria D, Esposito G, et al. Robotic-assisted pyeloplasty in children: a systematic review of the literature. J Robot Surg 2023;17:1239–1246. https://doi.org/10.1007/s11701-023-01559-12.... Aghababian A, Abdulfattah S, Eftekharzadeh S, Xiang A, Weaver J, Van Batavia J, et al. Comparison of open and robot-assisted repair for ureteropelvic junction obstruction: Outcomes and direct costs from a single-institution. J Pediatr Urol xxxx;xxx:xxx–xxx. https://doi.org/10.1016/j.jpu.2025.05.0013... Ortiz-Seller D, Panach-Navarrete J, Valls-González L, Martı́nez-Jabaloyas JM. Comparison between open and minimally invasive pyeloplasty in infants: A systematic review and meta-analysis. J Pediatr Urol 2024;20:244–252. https://doi.org/10.1016/j.jpurol.2023.11.0174... Chan YY, Durbin-Johnson B, Sturm RM, et al (2017) Outcomes after pediatric open, laparoscopic, and robotic pyeloplasty at Academic Institutions. J Pediatr Urol 13(1):49.e1–49.e6 https://doi.org/10.1016/j.jpurol.2016.08.029 Tomaszewski JJ, Casella DP, Turner RM et al (2012) Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations. J Endourol 26(6):602–613. https://doi.org/10.1089/end.2011.0252 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004, 240:205-213. Wang M, Xi Y, Huang N, Wang P, Zhang L, Zhao M, Pu S. Minimally invasive pyeloplasty versus open pyeloplasty for ureteropelvic junction obstruction in infants: a systematic review and meta-analysis. PeerJ. 2023 Nov 20;11:e16468. doi: 10.7717/peerj.16468. Casale (2012).Casale P. Minimally invasive survey in infants: Pro. The Journal of Urology. 2012;188:1665–1666. doi: 10.1016/j.juro.2012.08.049. Dangle et al. (2013).Dangle PP, Kearns J, Anderson B, Gundeti MS. Outcomes of infants undergoing robot-assisted laparoscopic pyeloplasty compared to open repair. The Journal of Urology. 2013;190:2221–2226. doi: 10.1016/j.juro.2013.07.063. Andolfi et al. (2022).Andolfi C, Lombardo AM, Aizen J, Recabal X, Walker JP, Barashi NS, Reed F, Lopez PJ, Wilcox DT, Gundeti MS. Laparoscopic and robotic pyeloplasty as minimally invasive alternatives to the open approach for the treatment of uretero-pelvic junction obstruction in infants: a multi-institutional comparison of outcomes and learning curves. World Journal of Urology. 2022;40:1049–1056. doi: 10.1007/s00345-022-03929-0 Zhou L, Huang J, Xie H, Chen F. The learning curve of robot-assisted laparoscopic pyeloplasty in children. J Robot Surg. 2024 Feb 28;18(1):97. doi: 10.1007/s11701-024-01856-3. PMID: 38413450. Bennett WE, Whittam BM, Szymanski KM et al (2017) Validated cost comparison of open vs. robotic pyeloplasty in American Chil-dren’s Hospitals. J Robot Surg 11(2):201–206. https:// doi. org/ 10. 1007/ s11701- 016- 0645-1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Dec, 2025 Read the published version in Journal of Pediatric Endoscopic Surgery → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":1135797,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic Representation of Pediatric RALP Setup\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7292163/v1/6058adc00002b3b5f0c62a87.jpg"},{"id":91962456,"identity":"2d11ca00-f3d7-40b0-8bb2-19fb82f6b74a","added_by":"auto","created_at":"2025-09-23 07:55:16","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":428011,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Demographic, Surgical, and Perioperative Parameters Between Group O and Group R\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7292163/v1/c6e2078111b84f8bea51dbdd.jpg"},{"id":98244078,"identity":"1b9a40ef-f116-45a0-b5c1-f115dbcbfb2a","added_by":"auto","created_at":"2025-12-15 16:12:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2016254,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7292163/v1/ce818f75-14a9-4413-a39a-2887406b9da6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Open vs. Robot-Assisted Laparoscopic Pyeloplasty in Children: Our Preliminary Experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRobotic surgery has been performed in pediatric patients at our center since early 2022. The aim of this study is to analyze the feasibility and safety of robot-assisted laparoscopic pyeloplasty (RALP) by comparing it with the open surgical technique.\u003c/p\u003e\u003cp\u003eUreteropelvic junction obstruction (UPJO), caused by intrinsic fibrosis/stenosis or extrinsic compression (such as by aberrant vessels), is a common issue in pediatric urology [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. UPJO is found in up to 41% of cases of prenatally diagnosed hydronephrosis and approximately 25% of them requires surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Traditionally, the gold standard treatment for UPJO has been the Anderson\u0026ndash;Hynes dismembered pyeloplasty, performed via an open flank approach, which offers high success rates ranging from 90\u0026ndash;100% [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe advent of minimally invasive surgery (MIS) led to the development of laparoscopic pyeloplasty (LP). While safe and effective, LP was considered technically challenging, particularly regarding intracorporeal suturing, ergonomics, and the learning curve. The introduction of the da Vinci system in 2002 and the subsequent evaluation of the first RALP series marked a significant step forward. Over the past decade, RALP has gained wider adoption and become the most performed robotic procedure in pediatric urology. Robotic surgery is seen as a natural progression from open and laparoscopic procedures. RALP is now considered a new gold standard in pediatric MIS [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study analyzes our preliminary experience with RALP compared to open pyeloplasty, contributing data from our center to the ongoing evaluation of this technology in pediatric UPJO treatment.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eWe retrospectively analyzed data from patients who underwent pyeloplasty at our center between February 2022 and December 2024. Inclusion criteria comprised any patient undergoing an open or robot-assisted laparoscopic pyeloplasty. We excluded any patient treated for complex urologic anomalies or redo surgeries.\u003c/p\u003e\u003cp\u003eIndications for pyeloplasty included symptomatic UPJO, progressive reduce in renal function associated or not with urinary tract infections and increasing antero-posterior pelvis diameter.\u003c/p\u003e\u003cp\u003eAll patients were preoperatively investigated with renal ultrasonography (US) and diuretic MAG3 scan.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurgical technique\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll open cases were performed with an Anderson-Hynes dismembered pyeloplasty through a flank incision. A double J stent was left in place in all cases.\u003c/p\u003e\u003cp\u003eAll robot-assisted cases were performed using the Da Vinci XI platform. The surgical procedure performed was a transperitoneal Anderson-Hynes dismembered pyeloplasty.\u003c/p\u003e\u003cp\u003eThe patient was placed in a flexed lateral decubitus (opposite to the side of UPJO) and 4 trocars were positioned: a 5 mm air seal trocar at the umbilicus and three 8 mm working ports on the pararectal line [figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. After colon detachment the ureter was identified and dissected together with the pelvis and the UPJ. The pelvis was divided together with the ureter which was spatulated by incising its posterior margin. The pyeloplasty was performed with a running absorbable suture after the placement of a double j stent.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe stent was removed cystoscopically 40\u0026ndash;50 days after surgery.\u003c/p\u003e\u003cp\u003eAll the open surgeries were performed by a single surgeon in training as well as the RALP, performed by a different surgeon in training.\u003c/p\u003e\u003cp\u003eThe collected variables included patient sex, age and weight at the time of surgery, operative time, duration of hospital stay, and the rate and type of complications, classified according to the Clavien-Dindo system [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatients were categorized into two groups based on the surgical approach: Group O for open pyeloplasty and Group R for RALP.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period (February 2022 - December 2024), a total of 25 patients underwent pyeloplasty. 13 patients were treated with the open approach (Group O) and 12 patients were treated with the robot-assisted approach (Group R).\u003c/p\u003e\u003cp\u003eThe mean age at the time of surgery was significantly different between the groups: 0.8 years (range 4 months- 2.9 years) in Group O and 12 years (range 2\u0026ndash;17 years) in Group R. The mean weight was significantly different as well: 10.3 kg (range 7\u0026ndash;15 kg) vs. 42.8 kg in Group O (range 14\u0026ndash;60 kg).\u003c/p\u003e\u003cp\u003eThe mean operative time was 191 minutes (range 150\u0026ndash;246 minutes) for Group O and 239 minutes for Group R1 (range 185\u0026ndash;265 minutes).\u003c/p\u003e\u003cp\u003eThe average length of hospital stay was 4 days (range 3\u0026ndash;6 days) for open surgery and 3 days (range 3\u0026ndash;4) for RALP [Table\u0026nbsp;1].\u003c/p\u003e\u003cp\u003eTable 1: Comparison of Demographic and Clinical Characteristics Between Group O (Open Surgery) and Group R (Robot-Assisted Surgery)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup O (Open, n = 13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup R (Robot-Assisted, n = 12)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8 years (4 mo \u0026ndash; 2.9 yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 years (2 \u0026ndash; 17 yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.3 kg (7 \u0026ndash; 15 kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.8 kg (14 \u0026ndash; 60 kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperative time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e191 min (150 \u0026ndash; 246 min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e239 min (185 \u0026ndash; 265 min)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital stay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 days (3 \u0026ndash; 6 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 days (3 \u0026ndash; 4 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003eOnly one minor complication (Clavien-Dindo Grade I) was recorded, occurring in Group O. This complication was described as urinary tract infection. No complications were observed in the RALP group in this preliminary series [Figure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur preliminary experience with pediatric pyeloplasty shows that RALP is feasible and safe, although associated with a longer operative time compared to the open approach in this initial series. A significant finding is the shorter average hospital stay for RALP (3 days) compared to open surgery (4 days). Furthermore, no complications were observed in the RALP group, while one minor complication occurred in the open group.\u003c/p\u003e\u003cp\u003eThese results align with some findings in the broader literature comparing RALP and open pyeloplasty. Systematic reviews and meta-analyses have consistently shown that RALP and LP are associated with shorter hospital stays compared to open surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For instance, a meta-analysis focusing on infants (1\u0026ndash;23 months) found MIP (minimally invasive pyeloplasty; including RALP and LP) resulted in a mean difference of 1.16 fewer hospital days compared to open surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Another meta-analysis established a correlation between MIP and a shorter LOS (length of stay) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. MIP wounds were found to have a higher collagen deposition postoperatively in comparison to OP, which facilitated quicker postoperative recovery and consequently reduced LOS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The diminished requirements for tissue manipulation and analgesia with MIP also contributed to the shorter LOS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding operative time, our finding that RALP is longer than open surgery is also a common observation, particularly in the initial learning curve phase of robotic surgery. Esposito et al. review notes that RALP operative times were initially longer than open, but in centers with high volume and surgeon experience, times have shortened, with many recent studies reporting overall operative times less than 120 minutes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur longer RALP times likely reflect that this study represents early experience at our center, consistent with the learning curve described in the literature, where operative times can become equivalent to open after a certain number of cases (e.g., 15\u0026ndash;20 cases) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur observed complication profile, with only one minor complication in the open group and none in the RALP group, is very favorable in this small cohort. The literature reports varied complication rates and types for both approaches [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While a large comparative study found similar overall complication rates between RALP and Open, RALP was associated with fewer high-grade postoperative complications (Clavien\u0026thinsp;\u0026ge;\u0026thinsp;2) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The meta-analysis in infants found no significant difference in overall complication rates [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSuccess rates for RALP reported in the literature are very high, ranging from 90\u0026ndash;100%, comparable to open pyeloplasty [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A large comparative study reported similar success rates for RALP (96.7%) and Open (96.0%)[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The meta-analysis in infants found success rates of 96.16% for MIP and 93.97% for Open, with no statistically significant difference [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Our local follow-up data, showing resolution or improvement of hydronephrosis in all patients, aligns with these high reported success rates.\u003c/p\u003e\u003cp\u003eThe significant age difference between our groups (RALP patients much older than open patients) is a key characteristic of our preliminary cohort and is consistent with the literature indicating that RALP adoption, especially early on, was often in older children due to concerns about instrument size and working space in infants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While our RALP group had a mean age of 12 years, the literature shows increasing experience and studies focused on RALP in infants as young as 1\u0026ndash;23 months [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], demonstrating its safety and feasibility even in this challenging population, although operative times may still be longer than open surgery in infants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Indeed, with increasing experience along the learning curve, we progressively broadened the selection criteria for RALP to include younger and lighter patients, with the youngest being 2 years old and the lightest weighing 14 kg.\u003c/p\u003e\u003cp\u003eRegarding costs, concerns about the high cost associated with robot-assisted laparoscopic pyeloplasty (RALP) in children remain. While some literature suggests this cost differential compared to open pyeloplasty (OP) has decreased over time and with institutional experience, the high cost of training, maintenance, and materials generally suggests a greater overall cost for RALP compared to other modalities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A more recent study in a low-volume center found similar costs for operative room, instruments, materials, and hospital stay between OP and RALP, but noted that double-J stent removal added cost [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA large single-institution study evaluating direct costs over the 0\u0026ndash;60 day period post-surgery found no significant difference in overall 0\u0026ndash;60 day direct costs between the RALP and OP groups (p\u0026thinsp;=\u0026thinsp;0.47). However, this study noted that costs were higher in the RALP group in the 30\u0026ndash;60 day period (p\u0026thinsp;=\u0026thinsp;0.01), primarily attributing this difference to routine cystoscopy and stent removal procedures performed in the operating room [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our study, the placement and cystoscopic removal of the double J stent were performed uniformly in both groups, suggesting no significant cost differences related to this aspect. However, the shorter hospital stay observed in the robot-assisted group may contribute to lower overall healthcare costs, underscoring the potential clinical and economic advantages of this minimally invasive approach.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003cp\u003eOur study is a preliminary, retrospective analysis from a single institution with a limited number of patients. There is a significant age disparity between the two surgical groups. The findings represent the experience during the early phase of adopting robotic surgery at our center. These limitations necessitate cautious interpretation and emphasize the need for larger, multicenter, prospective studies with longer follow-up to confirm these preliminary findings.\u003c/p\u003e\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our initial experience supports the safety and feasibility of robot-assisted laparoscopic pyeloplasty in children. Consistent with the early learning phase and findings in the literature, RALP in our cohort had a longer operative time but demonstrated advantages in terms of shorter hospital stay and a low complication rate (with none observed in the RALP group). As robotic technology and surgeon experience evolve, RALP is increasingly becoming a preferred approach for pediatric UPJO, though ongoing research, particularly in specific subgroups like infants and focusing on cost-effectiveness and long-term outcomes, remains important.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo competing financial interests exist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was reviewed and approved by the \u003cem\u003eComitato Etico Area Vasta Emilia Nord\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003eParticipants were informed about the purpose of the study, the procedures involved, and their right to withdraw from the study at any time.\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEsposito C, Cerulo M, Lepore B, Coppola V, D’Auria D, Esposito G, et al. Robotic-assisted pyeloplasty in children: a systematic review of the literature. J Robot Surg 2023;17:1239–1246. https://doi.org/10.1007/s11701-023-01559-12....\u003c/li\u003e\n \u003cli\u003eAghababian A, Abdulfattah S, Eftekharzadeh S, Xiang A, Weaver J, Van Batavia J, et al. Comparison of open and robot-assisted repair for ureteropelvic junction obstruction: Outcomes and direct costs from a single-institution. J Pediatr Urol xxxx;xxx:xxx–xxx. https://doi.org/10.1016/j.jpu.2025.05.0013...\u003c/li\u003e\n \u003cli\u003eOrtiz-Seller D, Panach-Navarrete J, Valls-González L, Martı́nez-Jabaloyas JM. Comparison between open and minimally invasive pyeloplasty in infants: A systematic review and meta-analysis. J Pediatr Urol 2024;20:244–252. https://doi.org/10.1016/j.jpurol.2023.11.0174...\u003c/li\u003e\n \u003cli\u003eChan YY, Durbin-Johnson B, Sturm RM, et al (2017) Outcomes after pediatric open, laparoscopic, and robotic pyeloplasty at Academic Institutions. J Pediatr Urol 13(1):49.e1–49.e6 https://doi.org/10.1016/j.jpurol.2016.08.029\u003c/li\u003e\n \u003cli\u003eTomaszewski JJ, Casella DP, Turner RM et al (2012) Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations. J Endourol 26(6):602–613. https://doi.org/10.1089/end.2011.0252\u003c/li\u003e\n \u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004, 240:205-213.\u003c/li\u003e\n \u003cli\u003eWang M, Xi Y, Huang N, Wang P, Zhang L, Zhao M, Pu S. Minimally invasive pyeloplasty versus open pyeloplasty for ureteropelvic junction obstruction in infants: a systematic review and meta-analysis. PeerJ. 2023 Nov 20;11:e16468. doi: 10.7717/peerj.16468. \u003c/li\u003e\n \u003cli\u003eCasale (2012).Casale P. Minimally invasive survey in infants: Pro. The Journal of Urology. 2012;188:1665–1666. doi: 10.1016/j.juro.2012.08.049.\u003c/li\u003e\n \u003cli\u003eDangle et al. (2013).Dangle PP, Kearns J, Anderson B, Gundeti MS. Outcomes of infants undergoing robot-assisted laparoscopic pyeloplasty compared to open repair. The Journal of Urology. 2013;190:2221–2226. doi: 10.1016/j.juro.2013.07.063.\u003c/li\u003e\n \u003cli\u003eAndolfi et al. (2022).Andolfi C, Lombardo AM, Aizen J, Recabal X, Walker JP, Barashi NS, Reed F, Lopez PJ, Wilcox DT, Gundeti MS. Laparoscopic and robotic pyeloplasty as minimally invasive alternatives to the open approach for the treatment of uretero-pelvic junction obstruction in infants: a multi-institutional comparison of outcomes and learning curves. World Journal of Urology. 2022;40:1049–1056. doi: 10.1007/s00345-022-03929-0\u003c/li\u003e\n \u003cli\u003eZhou L, Huang J, Xie H, Chen F. The learning curve of robot-assisted laparoscopic pyeloplasty in children. J Robot Surg. 2024 Feb 28;18(1):97. doi: 10.1007/s11701-024-01856-3. PMID: 38413450.\u003c/li\u003e\n \u003cli\u003eBennett WE, Whittam BM, Szymanski KM et al (2017) Validated cost comparison of open vs. robotic pyeloplasty in American Chil-dren’s Hospitals. J Robot Surg 11(2):201–206. https:// doi. org/ 10. 1007/ s11701- 016- 0645-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7292163/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7292163/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e\u003cp\u003eRobotic surgery has been performed in pediatric patients at our center since early 2022. The aim of this study is to analyze the feasibility and safety of robot-assisted laparoscopic pyeloplasty (RALP) by comparing it with the open surgical technique.\u003c/p\u003e\u003ch2\u003eMaterial and Methods\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed data from patients who underwent pyeloplasty at our center between February 2022 and December 2024. Collected variables included patient sex, age and weight at the time of surgery, operative time, length of hospital stay and complication rate. Patients were divided into two groups: Group O (open pyeloplasty) and Group R (RALP).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 25 patients underwent pyeloplasty during the study period\u0026mdash;13 via the open approach (Group O) and 12 via the robot-assisted approach (Group R). The mean age was 0.8 years in Group O and 12 years in Group R. The mean operative time was 191 minutes for Group O and 239 minutes for Group R. The average hospital stay was 4 days for open surgery and 3 days for RALP. Only one minor complication (Clavien-Dindo Grade I) was recorded, in Group O.\u003c/p\u003e\u003ch2\u003eDiscussion and Conclusions\u003c/h2\u003e\u003cp\u003eDespite a longer operative time for RALP, the outcomes are comparable\u0026mdash;and potentially superior\u0026mdash;to those of open surgery. RALP was associated with a shorter hospital stay, potentially reducing overall costs. No complications were observed in the RALP group. These preliminary results suggest that RALP is a safe and feasible option for pediatric patients.\u003c/p\u003e","manuscriptTitle":"Open vs. Robot-Assisted Laparoscopic Pyeloplasty in Children: Our Preliminary Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:47:11","doi":"10.21203/rs.3.rs-7292163/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8cff5613-6937-4311-804f-8e95044b2594","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:05:46+00:00","versionOfRecord":{"articleIdentity":"rs-7292163","link":"https://doi.org/10.1007/s42804-025-00298-4","journal":{"identity":"journal-of-pediatric-endoscopic-surgery","isVorOnly":false,"title":"Journal of Pediatric Endoscopic Surgery"},"publishedOn":"2025-12-12 15:59:30","publishedOnDateReadable":"December 12th, 2025"},"versionCreatedAt":"2025-09-23 07:47:11","video":"","vorDoi":"10.1007/s42804-025-00298-4","vorDoiUrl":"https://doi.org/10.1007/s42804-025-00298-4","workflowStages":[]},"version":"v1","identity":"rs-7292163","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7292163","identity":"rs-7292163","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}