Pyeloplasty in Children with Ureteropelvic Junction Obstruction and Associated Kidney Anomalies: Can a Robotic Approach Make Surgery Easier?

Round 1

Reviewer 1 Report

The authors describe their experience with their first 7 cases of robotic pyeloplasty in paediatric patients with ureteropelvic junction obstruction (UPJO) in association with other renal malformations or diseases.

They should explain why they believe macrohaematuria with anaemia requiring blood transfusion occurred postoperatively in one patient.

IRB approval is necessary even in retrospective studies. Even if no experimental data are collected, you must have IRB approval from the institution. 

What is the accessory laparoscopic trocar necessary for? In principle, three robotic trocars are sufficient for pyeloplasty. The need for this fourth trocar should be explained, as it adds incisions to the patient that can be avoided with percutaneous traction stitches.

Moderate editing of English language required

Author Response

Thank you for your comments and for taking the time to review our article. I hope to be able to answer you fully point by point. 1. The presentation of macrohematuria occurred approximately 12 hours after surgery, and in view of the presence of anastomosis and stent placement, we explained the event as secondary to the surgery. As described in the article, blood loss from the urinary tract resolved spontaneously. Transfusion was performed only because of the rapid decrease in hemoglobin values. 2. There is also a paragraph in our consent document for surgery in which we explain that patient data could be collected retrospectively for scientific studies. Parents may consent or not. The parents of the patients included in the study have all given consent, so automatically our institute authorizes us to collect the data. 3. To perform pyeloplasty surgery using a robot-assisted approach, we have long since standardized the technique as it is described in the article. The 5-mm laparoscopic trocar serves as surgical access for the surgeon to assist at the operating table and, through it, it is possible to assist the operator at the console in certain maneuvers as well as make possible the insertion, the extraction, and the cut of sutures.

Reviewer 2 Report

In this study, the authors described their own experience with robot-assisted pyeloplasty in cases with ureteropelvic junction obstruction (UPJO) associated with renal anomalies.

The main drawback of this research is that only 7 patients (4 with UPJO  + horseshoe, 1 UPJO + 180 rotation of the kidney and 2 UPJO + nephrolithiasis) were included in the study. It is very small number of patients and is not enough to make a valid conclusion.

Also, control group was omitted.

Maybe, it is more appropriate for the authors to describe their experience through case report, or to include in the control group, patients with the same diseases, treated with different surgical method and compare them to the group treated with robot-assisted pyeloplasty.

 

 Minor editing of English language required.

Author Response

Thank you for your comments and for taking the time to review our article. I hope to be able to answer you fully point by point. Ours is a pediatric center that now has long experience in minimally invasive surgery. Since 2016, we have the ability to perform robotic surgery. The aim of this paper is to present our experience in the treatment of ureteropelvic junction obstruction in cases complicated by the presence of other abnormalities and/or pathological conditions affecting the kidney. Over a 5-year study period, we report the experience of 7 patients. One of the most recent papers on this topic (Faddegon S, Granberg C, Tan YK, et al. Minimally invasive pyeloplasty in horseshoe kidneys with ureteropelvic junction obstruction: a case series. Int Braz J Urol. 2013 Mar-Apr;39(2):195-202.) describes, over a 12-year period, the cases of 9 patients of which, however, only 4 were pediatric with robotic technique. Another work of 2020 (Adamic BL, Lombardo A, Andolfi C, Hatcher D, Gundeti MS. Pediatric robotic-assisted laparoscopic ureterocalycostomy: Salient tips and technical modifications for optimal repair. BJUI Compass. 2020 Nov 14;2(1):53-57) reported 4 pediatric patients treated with robot-assisted technique. We know full well that this is not a large enough number of cases to make a statistical analysis meaningful and consequently allow absolute conclusions to be drawn. In fact, in our work, there is no statistical analysis both because it would not be applicable and because it is not our goal.
In addition, it is not possible to have a control group of patients with the same clinical features, treated with different surgical approaches. In our center, UPJO is treated almost exclusively with robotic technique, all the more so if they have associated abnormalities that could make surgery more complicated if performed with other techniques. The conclusions we report in our paper are simply descriptive of our experience and have no expectation of presenting themselves as scientific evidence.

Reviewer 3 Report

The study evaluated patients undergoing robotic pyeloplasty from January 2016 to November 2021, including those who presented with a ureteropelvic junction obstruction associated with other anomalies of the kidney. The parameters  examined were: age, weight, associated renal malformations, conversion rate, operative time, and intra- and post-operative complications. 

However, the sample size is not enough to draw an conclusion to that extent, please add specific statistical methods to the methods part and calculate the power.

or it can be as an correspondence article not an original article.

 

 

Author Response

Thank you for your comments and for taking the time to review our article. I hope to be able to answer you fully point by point. Ours is a pediatric center that now has long experience in minimally invasive surgery. Since 2016, we have the ability to perform robotic surgery. The aim of this paper is to present our experience in the treatment of ureteropelvic junction obstruction in cases complicated by the presence of other abnormalities and/or pathological conditions affecting the kidney. Over a 5-year study period, we report the experience of 7 patients. One of the most recent papers on this topic (Faddegon S, Granberg C, Tan YK, et al. Minimally invasive pyeloplasty in horseshoe kidneys with ureteropelvic junction obstruction: a case series. Int Braz J Urol. 2013 Mar-Apr;39(2):195-202.) describes, over a 12-year period, the cases of 9 patients of which, however, only 4 were pediatric with robotic technique. Another work of 2020 (Adamic BL, Lombardo A, Andolfi C, Hatcher D, Gundeti MS. Pediatric robotic-assisted laparoscopic ureterocalycostomy: Salient tips and technical modifications for optimal repair. BJUI Compass. 2020 Nov 14;2(1):53-57) reported 4 pediatric patients treated with robot-assisted technique. We know full well that this is not a large enough number of cases to make a statistical analysis meaningful and consequently allow absolute conclusions to be drawn. In fact, in our work, there is no statistical analysis both because it would not be applicable and because it is not our goal.
In addition, it is not possible to have a control group of patients with the same clinical features, treated with different surgical approaches. In our center, UPJO is treated almost exclusively with robotic technique, all the more so if they have associated abnormalities that could make surgery more complicated if performed with other techniques. The conclusions we report in our paper are simply descriptive of our experience and have no expectation of presenting themselves as scientific evidence.

Round 2

Reviewer 2 Report

The authors responded to comments.

Minor editing of English language required.

Reviewer 3 Report

accept