title: Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery.
abstract: BACKGROUND
  Surgical management of duplex renal anomaly (DRA) is complex because of individual anatomic variation, competing priorities of vesicoureteral reflux (VUR) and ureteral obstruction present in the same child, the varied differential function of the different renal moieties, and the presence of voiding dysfunction and recurrent urinary tract infection (UTI). Robot-assisted laparoscopic (RAL) surgical management has been under-reported in this group of children but is becoming a viable alternative to traditional open surgery.
  
  
  OBJECTIVE
  The aim was to report the surgical outcomes of a series of children with DRA who had RAL surgery and compare these outcomes to historical cohorts of open and laparoscopic surgery.
  
  
  METHODS
  This was a retrospective analysis of a prospective series of children who had RAL surgery for DRA over an 8-year period. Forty-five RAL surgeries were performed in 47 children. RAL heminephrectomy (RAL HN) was performed in 19 children for poorly or non-functional renal moiety. One had staged bilateral RAL HN. RAL ureteroureterostomy (RAL UU) was performed in 14 children for upper pole ureteral obstruction. Thirteen RAL common sheath ureteral reimplants (RAL csUN) with or without ureteral tapering were performed in 12 children with VUR and UTI. Diagnosis and demographics, results of preoperative imaging, intraoperative time stamps, perioperative complications, success rate, and renal outcomes were recorded.
  
  
  RESULTS
  Low-grade VUR present preoperatively in the RAL UU group all resolved within the follow-up period. Four (25%) children in the RAL HN group developed de novo VUR after surgery, which resolved in two (50%) and required surgery in two (50%). Grade I VUR after RAL csUR that occurred in two (14.3%) children was asymptomatic and observed when off preventative antibiotics.
  
  
  CONCLUSIONS
  Most children with DRA who need surgical treatment can be offered RAL surgery. We report good outcomes and improved operative times for RAL HN and UU that approach historical open and pure laparoscopic cohorts. However, RAL csUR, especially with ureteral tapering, is more complex and inherently susceptible to complications, and has not met the outcomes of the open gold standard. The limits of this study are that selection bias is present, and there is no study control cohort.
  
  
  CONCLUSIONS
  This report achieves its aim to report surgical outcomes of children who had RAL surgery for DRA.
authors.affiliation: Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA. Electronic address: daniel.herz@nationwidechildrens.org.
authors.forename: Daniel
authors.initials: D
authors.lastname: Herz
authors.affiliation: Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Smith
authors.affiliation: Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Daryl
authors.initials: D
authors.lastname: McLeod
authors.affiliation: Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Megan
authors.initials: M
authors.lastname: Schober
authors.affiliation: Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Janae
authors.initials: J
authors.lastname: Preece
authors.affiliation: Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Merguerian
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007668:Kidney / Q000002:abnormalities* / Q000000981:diagnostic imaging / Q000601:surgery; D007674:Kidney Diseases / Q000151:congenital / Q000175:diagnosis / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D012189:Retrospective Studies; D012371:Robotics; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods*; D013520:Urologic Surgical Procedures / Q000379:methods*
keywords: Duplex renal anomaly; Heminephrectomy; Robot-assisted laparoscopic; Ureteral reimplantation; Ureteroureterostomy