Which Surgical Treatment is Best for UPJO in Infants: Open, Laparoscopic, Robotic Assisted

Shang-Jen ChangTaiwan Speaker Which Surgical Treatment is Best for UPJO in Infants: Open, Laparoscopic, Robotic AssistedAbstract Ureteropelvic junction obstruction (UPJO) in infants is a condition that can significantly impair renal function and requires timely surgical intervention when certain criteria are met, such as decreased split renal function, poor drainage on diuretic renography, or recurrent urinary tract infections. The three main surgical approaches for treating UPJO are open pyeloplasty (OP), laparoscopic pyeloplasty (LP), and robot-assisted laparoscopic pyeloplasty (RALP). Each technique has its own benefits and limitations, especially when applied to infants. Minimally invasive surgery (MIS), including LP and RALP, has gained popularity in pediatric urology due to advantages such as shorter hospital stays, reduced postoperative pain, faster recovery, and better cosmetic outcomes. However, the small working space in infants, the steep learning curve, and higher costs are significant limitations. In particular, the utility of MIS in infants remains controversial due to undefined benefits and technical challenges, including limited space for trocar placement and difficulty in intracorporeal suturing. Current guidelines from the European Association of Urology (EAU) indicate that while RALP is considered the gold standard for older pediatric patients, its role in infants remains less defined due to anatomical and logistical constraints. Open surgery continues to be the mainstay for infantile UPJO due to its well-established success rate and lower cost. Several studies have addressed the learning curve associated with these techniques. Laparoscopic pyeloplasty requires about 30 cases for a surgeon to achieve proficiency, while RALP demands approximately 18–31 cases depending on the metrics used. Simulation-based training, dry labs, and multicenter collaboration are proposed solutions to accelerate skill acquisition and ensure patient safety. Cost is another critical consideration. Although RALP generally incurs higher upfront costs, especially in low-volume centers, innovations such as magnetic stents have helped offset some of these expenses by eliminating the need for anesthesia during stent removal. Moreover, the availability of pediatric-specific robotic instruments remains limited and necessitates ongoing development to fully support MIS in smaller patients. In conclusion, while RALP is increasingly recognized as the standard for pediatric UPJO, its application in infants should be considered selectively, depending on surgeon experience, institutional resources, and patient anatomy. Open pyeloplasty remains a safe and effective option, particularly in very young children. Advances in surgical training, cost reduction strategies, and instrument development will be key to expanding the use of minimally invasive techniques in this population.