Robotic Pyeloplasty in Children: A Barbed Shortcut

Introduction: Dismembered pyeloplasty remains the gold standard for the treatment of pelviureteric junction obstruction (PUJO). Robotic approach to this procedure has proven its efficacy and is gaining popularity. The introduction of barbed sutures such as V-Loc (Covidien) has provided an addition to the sutures available for pyeloplasty. This work provides our experience with the V-Loc suture for closure of pelvis in children for robotic pyeloplasty (RP). Materials and Methods: A review of 10 pediatric RP (da Vinci Robotic System) during which the V-Loc suture was used was performed. Comparison was made with 15 cases in which 5-0 Vicryl((R)) suture was used as an alternative. Overall median age was 4 (range 9 months to 16 years), M:F=14:9. All had confirmed PUJO on renal ultrasound and mercaptoacetyltriglycine (mertiatide) (MAG-3). RP was done in the standard Anderson-Hynes manner with the placement of a multilength JJ ureteral stent intraoperatively. Patients had removal of the JJ stent 6 weeks postoperatively followed by renal ultrasound 3-4 months later. Results: Twenty-five RPs have been performed between May 2013 and November 2015, of which 10 have had closure of the pelvis performed using the V-Loc suture and 15 with Vicryl. One patient (6.67%) in the Vicryl group underwent redo-pyeloplasty secondary to a stent-related complication. The entire V-Loc group made an eventful initial recovery; however, four (40%) developed worsening hydronephrosis and drainage on ultrasound and MAG-3 after stent removal, despite remaining completely asymptomatic. These four required either restenting and observation (n=1) or redo-pyeloplasty (n=3). Histology demonstrated a plaque-like inflammatory reaction at the pelvic suture line. Conclusion: Closure of the pelvis using V-Loc suture material during RP can lead to a significant hydronephrosis requiring further procedures, including redo-pyeloplasty. These children can be asymptomatic and so extra vigilance on postoperative follow-up is essential.