Comparison of outcomes of open, laparoscopic, and robot-assisted laparoscopic pyeloplasty in children with pelviureteric junction obstruction: a systematic review and meta-analysis

Introduction

Pelviureteric junction obstruction (PUJO) is a very common cause of hydronephrosis in the paediatric population (1). The aetiology of PUJO can be intrinsic or extrinsic (2). Intrinsic causes include fibrosis or stricturing of the proximal ureter (3). Extrinsic PUJO results from a crossing lower-pole blood vessel which compresses the proximal ureter (3).

A dismembered pyeloplasty is the gold standard of care for patients diagnosed with PUJO (4). This was pioneered in 1949, in the United Kingdom, by Anderson and Hynes (5).

The introduction of minimally invasive technologies has resulted in a natural progression from Anderson-Hynes’ open technique (4). Minimally invasive approaches include laparoscopic and robot-assisted techniques (4). These minimally invasive procedures promote reduced inpatient length of stay (LOS), and operative and postoperative complications (6).

Robot-assisted laparoscopic pyeloplasty (RALP) has been increasingly adopted in the management of PUJO in paediatric patients and is the most commonly reported robotic operation in the paediatric population (2,7). The robotic approach has generally demonstrated promising results in paediatric patients, excluding very small infants (8,9).

However, robotic surgery is not globally available (2). Accordingly, open and laparoscopic techniques remain the techniques of choice in many centres (4). Consequently, while robotic outcomes represent the area of greatest current clinical uncertainty, comparisons with open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) remain clinically relevant for the many centres worldwide where robotic platforms are inaccessible (2). This clinical uncertainty is compounded by variability in surgeon experience, institutional resource availability, and the robotic learning curve across centres, underscoring the need for a pooled quantitative synthesis to clarify comparative outcomes.

Several systematic reviews have previously examined comparative outcomes of OP, LP, and robotic pyeloplasty in children. Early meta-analyses, such as that by Autorino et al., which also included adult patients, demonstrated equal success rates across techniques with a tendency for shorter hospital stay in minimally invasive approaches (10). More recently, Ortiz-Seller et al. evaluated infants and also reported comparable operative success between laparoscopic and robotic pyeloplasty, with associated reduced LOS (11). Additional studies have supported these findings, consistently suggesting that minimally invasive techniques offer perioperative advantages without compromising efficacy (12). However, many earlier reviews included small robotic series representing early learning-curve experience (12). Few studies incorporate the substantial volume of data published in the last decade demonstrating the rapid global expansion of paediatric robotic surgery (13). Furthermore, some reviews included patients who underwent a repeat procedure rather than primary pyeloplasties, which impacts the generalisability of the outcomes (14).

This systematic review and meta-analysis aims to deliver an up-to-date, comprehensive synthesis of the evidence surrounding paediatric PUJO operative management, with particular focus on the comparative role of RALP against traditional benchmarks. We present this article in accordance with the PRISMA reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0252/rc) (15).

Methods

Search strategy

The two investigators, P.N. and N.C., systematically searched PubMed, Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases using the following search strategy.

Medical Subject Headings (MeSH): (pyeloplasty) AND ((laparoscopic) OR (robotic) OR (open)) AND ((Ureteropelvic junction obstruction) OR (pelviureteric junction obstruction)) AND ((child) OR (p?ediatric)) AND (outcome). The search was conducted from inception of the databases to the 5^th of February 2026. The detailed search strategy per database can be seen in Table S1. No language filters were applied. Initial screening was conducted using Rayyan, an artificial intelligence (AI)-powered platform designed to enhance the speed and accuracy of systematic review reporting. Identified articles were uploaded to Rayyan to streamline the process, enabling reviewers to remove duplicate studies and screen the remaining studies for relevance. The AI technology itself did not influence any decisions (16). All inclusion and exclusion decisions were made independently by two human reviewers, with disagreements resolved by a third author; Rayyan was used exclusively for deduplication and workflow management.

Inclusion and exclusion criteria

Studies that investigated children under the age of 16 years with PUJO who underwent a dismembered pyeloplasty (singular pathology or procedure) were included. Studies with redo cases, concomitant renal anomalies, or multiple procedures were excluded. Non-comparative case series or studies with a sample size of fewer than 10 total patients were excluded; non-comparative cohort studies of ≥10 patients were eligible for narrative synthesis only and were not included in quantitative pooling. Case reports, letters to the editor, expert opinions, reviews, and conference abstracts were excluded. Furthermore, studies that included patients older than 16 years of age were excluded, and unpublished studies were not sought. The detailed eligibility criteria outlined by the PICOS (Participants, Interventions, Comparisons, Outcomes, Study design) framework can be found in Table S2. Age-stratified comparative data were inconsistently reported across the included studies; therefore, all paediatric age groups were analysed together, and potential age-related selection effects are addressed in the discussion. The study was prospectively registered with the PROSPERO database (CRD42023456779).

Study appraisal and synthesis

Initial title and abstract and subsequent full-text screening of articles was undertaken by two authors (P.N. and N.C.) blinded to each other’s decisions. Any conflicts between the two researchers were arbitrated in a meeting by a third author (N.Z.) or resolved by consensus. At the full-text review stage, reasons for exclusion were recorded and reported in the PRISMA flow diagram (Figure 1).

Figure 1 PRISMA 2020 flow diagram for new systematic reviews.

Data extraction

Data extraction was undertaken by a minimum of two authors per study (P.N., N.C., A.C.), with any conflicts resolved through discussion and consensus. Extracted data were compiled in a predefined Excel spreadsheet capturing the baseline characteristics of each study (title, author name, year of publication, centre, country, and source of funding) and patient characteristics (age, sex, weight, body mass index, side, aetiology, preoperative and postoperative data and imaging results, operative technique, number of ports, use of drains or stents or nephrostomies, and postoperative success and complications).

Risk of bias assessment

The quality of the included studies and the risk of bias (RoB) were assessed independently by two authors (P.N., N.C.) using the RoB 2 tool for the included randomised controlled trial (RCT), the Newcastle-Ottawa Scale for comparative studies, and the JBI critical appraisal tool for the studies that underwent narrative synthesis, and any disagreements were resolved by consensus (17). This system of scoring is split into three main sections: selection, comparability, and outcome. Each of the sections contains subquestions that assess the quality of the research methodology at the study level. Studies scoring ≥7 stars were classified as low RoB, 4–6 as moderate, and ≤3 as high RoB. A sensitivity analysis was not performed, as the majority of the included studies scored high and were deemed low RoB (Figures S1-S3). The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. GRADE provides an overall assessment of evidence quality, integrating qualitative bias evaluation (18,19).

Statistical analysis

Three pairwise comparisons were made due to the nature of our research question: OP vs. LP, LP vs. RALP, and OP vs. RALP. Pairwise meta-analyses were conducted for each outcome of interest, as there were three or more studies with the same comparator and control groups with sufficient homogeneity. For continuous outcomes (operative time, LOS), effect sizes were expressed as mean differences (MDs) and corresponding 95% confidence intervals (CI). They were pooled using a generic inverse-variance method under a random-effects model owing to the anticipated clinical heterogeneity.

For binary outcomes (minor and major complications, operative success), pooled odds ratios (ORs) and their 95% CIs were calculated using the Mantel-Haenszel method (20). I² was used to assess statistical heterogeneity and inter-study variation. Conventional I² measurements of 25%, 50%, and 75% suggest inconsistency at low, moderate, and high levels, respectively (21). Given that fewer than 10 studies contributed to any individual pooled comparison, subgroup analysis, meta-regression, and formal publication bias testing (funnel plots, Egger’s test) were not performed, as these methods are considered unreliable below this threshold. A random-effects model was applied unless there was low statistical heterogeneity, in which case a fixed-effect model was applied. The meta-analysis was performed using Review Manager 5.4 (Cochrane Collaboration, Oxford, UK).

For the 25 single-arm studies, a meta-analysis of proportions was not undertaken. These studies lacked internal comparators and were highly heterogeneous in case-mix, follow-up duration, and outcome definitions. Pooling single-arm data and comparing the resulting proportions across surgical approaches would have potentially led to biased and clinically misleading inferences. This represents a protocol deviation, which we judged necessary to preserve methodological rigour (22).

Results

Study selection results

The initial literature search yielded 971 articles. Following deduplication and the removal of 443 articles, 528 studies underwent title and abstract screening. Of these, 110 studies were assessed at the full-text review stage. Overall, 38 studies were deemed eligible for inclusion (Figure 1).

Included studies and characteristics

Out of the 38 included studies, 13 were pooled in the meta-analysis; two studies were a triplicate comparison of OP, LP, and RALP. Eleven studies directly compared two forms of pyeloplasty: five OP vs. LP comparisons, four LP vs. RALP comparisons, and two OP vs. RALP comparisons. Not all studies reported every outcome. One randomised controlled trial comparing all three techniques was identified, and the remaining 12 comparative studies were retrospective cohort designs. No prospective comparative studies were identified. The availability of comparative data differed by outcome and surgical approach. Operative time and LOS were available for meta-analysis for LP vs. OP and RALP vs. LP. However, no studies provided extractable data for these outcomes for OP vs. RALP. In contrast, minor complications, major complications, and operative success were reported across all three surgical approaches. Consequently, the number of studies contributing to each meta-analysis varied by outcome and comparison, as reflected in the forest plots (Figures 2,3) and summarised in Table 1.

Figure 2 Meta-analysis of outcomes. (A) operative time (min); (B) length of hospital stay (days); (C) minor postoperative complications (CD I–II). CD, Clavien-Dindo classification; CI, confidence interval; LP, laparoscopic pyeloplasty; OP, open pyeloplasty; RALP, robot-assisted laparoscopic pyeloplasty; SD, standard deviation.

Figure 3 Meta-analysis of outcomes. (A) major postoperative complications (CD III–V); (B) operative success. CD, Clavien-Dindo classification; CI, confidence interval; LP, laparoscopic pyeloplasty; OP, open pyeloplasty; RALP, robot-assisted laparoscopic pyeloplasty.

The remaining 25 studies did not directly compare two different forms of pyeloplasty or were cohort studies. They were unable to be included in the meta-analysis and underwent a narrative synthesis instead.

Risk of bias assessment

The RoB assessment of the included RCT was performed using the RoB 2 tool (Figure S1) (60). RoB assessments of the comparative studies in the meta-analysis were performed using the Newcastle-Ottawa Scale RoB tool (Figure S2) (17). Individual study-level RoB was predominantly low across domains for the included RCTs, comparative cohort studies, and non-comparative studies, with occasional ‘some concerns’ or ‘unclear’ ratings, most frequently in domains relating to comparability/confounder adjustment and completeness of outcome reporting. The JBI critical appraisal tool was used to assess the non-comparative studies undergoing narrative synthesis (Figure S3) (61).

Synthesis of results of outcomes following dismembered pyeloplasty: meta-analysis

Operative time

Operative time was reported in studies comparing OP versus LP and LP versus RALP (Figure 2A). Pooled analysis demonstrated a significantly longer operative time for LP compared with OP (MD, 21.58 min, 95% CI: 4.28–38.88) (P=0.01). However, heterogeneity between studies was considerable (I²=92%, P<0.00001). No statistically significant difference in operative time was observed between LP and RALP; however, CIs were wide (MD, −1.92 min, 95% CI: −45.57 to 41.72) (P=0.93). Data heterogeneity was also significant (I²=96%, P<0.00001). The wide CIs observed in the LP versus RALP comparisons likely reflect the small sample sizes within the subgroups and the substantial inter-study variability, limiting the precision of the pooled estimates. Operative time could not be compared between OP and RALP, as there was insufficient directly comparable data. These findings should be interpreted cautiously, as high heterogeneity and limited direct comparisons restrict inference regarding procedural efficiency.

LOS

Five studies reported suitable data for pooled analysis comparing the LOS (Figure 2B) of OP compared to LP. LP had a significantly shorter LOS when compared to OP (MD, −2.33 days, 95% CI: −4.61 to −0.05) (P=0.04). Considerable heterogeneity was demonstrated between the studies (I²=97%, P<0.00001). RALP showed a significantly reduced LOS when compared to LP (MD, −0.89, 95% CI: −1.35 to −0.36) (P=0.0007) with moderate heterogeneity between the three studies (I²=75%, P=0.003).

Minor complications

The complications were tabulated according to the Clavien-Dindo classification and divided into minor (Clavien-Dindo I–II) and major (III–V). Pooled analysis of studies comparing OP and LP and reporting minor complications (Figure 2C) showed no significant difference between the two approaches (OR, 95% CI: 0.74, 0.41–1.35) (P=0.33) (I²=5%, P=0.38). OP compared to RALP demonstrated no significant differences in minor complication occurrence (OR, 95% CI: 0.40, 0.07–2.39) (P=0.31), with considerable data heterogeneity noted between the pooled studies (I²=76%, P=0.005). Similarly, there was no significant difference in minor complication rate when RALP was compared to LP (OR, 95% CI: 0.63, 0.27–1.44) (P=0.27) (I²=0%, P=0.98).

Major complications

Pooled analysis for studies that reported major complications showed comparable results between Clavien-Dindo III–IV amongst surgical techniques, and no Clavien-Dindo V complications were reported in the included studies. OP compared to LP showed no significant difference in major complications (Figure 3A) (OR, 95% CI: 1.02, 0.41–2.54) (P=0.96) (I²=0%, P=0.70). OP compared to RALP demonstrated comparable rates of major complications (OR, 95% CI: 1.60, 0.52–4.92) (P=0.41), but the analysed studies showed some heterogeneity (I²=32%, P=0.22). Lastly, when LP was compared to RALP, no significant difference in major complications was noted (OR, 95% CI: 1.17, 0.32–4.25) (P=0.82), with no significant heterogeneity demonstrated between the studies (I²=0%, P=0.57).

Operative success

Operative success was defined by most studies as radiological improvement in drainage and/or reduction in hydronephrosis, with or without symptom resolution. Although definitions varied slightly across studies, all studies reported operative success as a binary outcome, which enabled pooled analysis. No significant differences in operative success were observed between OP and LP approaches (OR, 95% CI: 1.06, 0.47–2.39) (Figure 3B). Compared to LP, RALP showed significantly improved success rates (OR, 95% CI: 2.78, 1.09–7.11) (P=0.03), and no heterogeneity was demonstrated between the studies (I²=0%, P=0.98). OP did not reveal a statistically significant operative success rate when compared to RALP (OR, 95% CI: 0.78, 0.30–1.99).

Narrative synthesis

Twenty-five studies that did not directly compare two or more surgical methods of dismembered pyeloplasty were unsuitable for quantitative pooling in a meta-analysis and therefore underwent a narrative synthesis (8,36-59). These cohort studies predominantly evaluated outcomes following either open, laparoscopic, or robotic pyeloplasty in children under the age of 16 years. Study designs were mainly retrospective with variable follow-up duration from 3 months (40) to 7.9 years (46). Sample sizes varied widely from 20 patients (52) to 200 patients (51), and most were single-centre experiences.

Radiological and symptomatic improvement or need for redo pyeloplasty were primary criteria defining operative success. Success rates across most single-arm or single-modality studies were uniformly high, typically exceeding 90%, irrespective of surgical approach (8,36,37,39,41,43-51,53-58). Most studies showed comparable and infrequent minor and major postoperative complications amongst surgical techniques.

Infants and RALP

The use of robotic surgery in infants was limited due to instrument size and the reduced working space resulting from the small abdomen of these patients (9,29). For the purposes of this review, infants were defined as children under the age of 12 months. Andolfi et al. described 100% operative success in a series of 44 infants, under the age of 12 months, that underwent RALP (47). This demonstrates that RALP is safe in the infant population. No conversions from a robotic to open approach and very few complications were reported (47). Minor complications included urinary tract infection (2%) and postoperative ileus (9%) (47). An omental hernia was reported in 4.5% of patients and was the only major (Clavien-Dindo III) complication (47). Li et al. compared the outcomes of infants under the age of 3 months that underwent a RALP to those aged from 3 months to 3 years (43). Comparable postoperative complications and operative success were reported, demonstrating the safety of RALP in this very low weight cohort (5.67±0.75 kg) (43).

GRADE certainty of evidence

Although most included studies were judged to be at low RoB, the overall certainty of evidence, assessed using the GRADE approach, ranged from low to very low across outcomes (Table S3). The “serious” RoB domain rating applied during GRADE assessment reflects the predominantly retrospective, non-randomised design of the comparative studies, consistent with GRADE methodology for observational evidence, rather than poor conduct or reporting within individual studies. Certainty was downgraded primarily due to the predominance of observational study designs, substantial clinical and methodological heterogeneity, indirectness related to variation in age groups and surgical techniques, imprecision of pooled estimates, and a likely risk of publication bias inherent to predominantly single-centre surgical series. Operative time was rated as very low certainty due to marked heterogeneity and imprecision. LOS, complication rates, and operative success were rated as low certainty.

Discussion

Principal findings

This systematic review extracted data from 38 studies (3,159 patients) on PUJO using different surgical approaches, with 13 included in a meta-analysis (1,275 patients). OP and LP showed comparable success rates and all three approaches had similar complication profiles. However, RALP has an improved success rate when compared to LP. This finding was consistent across the four contributing studies, with no observed statistical heterogeneity, supporting the reliability of the pooled estimate despite the overall low GRADE certainty for this outcome, which reflects the small number of studies and observational study design rather than inconsistency between them. RALP was also associated with a significantly shorter LOS compared to LP, and LP had a shorter LOS when compared to OP. However, whilst no significant differences in operative time were demonstrated between LP and RALP, the CIs were wide. This reflects the limited sample sizes and inter-study variability. Importantly, operative time could not be compared between OP and RALP due to the lack of data. As such, while differences in operative duration exist, the available evidence does not support conclusions regarding increased operative efficiency with minimally invasive approaches. Notably, the longer operative time observed with LP relative to OP did not correspond to worse safety or efficacy outcomes, and RALP’s improved operative success and shorter LOS relative to LP were not accompanied by any increase in complication rates, suggesting these procedural differences do not translate into a safety trade-off.

The narrative synthesis of non-comparative studies further supported the findings of the meta-analysis, demonstrating consistently high success rates and low rates of major complications across all modalities. Collectively, these results suggest that minimally invasive approaches can offer equivalent efficacy, with potential LOS advantages over traditional open repair. These findings should be interpreted with caution in the context of age-related selection patterns, as younger infants more commonly present with intrinsic obstruction suitable for any approach, while older children can have a higher incidence of crossing vessels that may influence the choice of surgical technique (62).

Our analysis demonstrated that all three surgical techniques achieve consistently high success rates, reaffirming the operative effectiveness and safety in treating paediatric PUJO. Results suggest that while the overall outcomes are equivalent, minimally invasive surgery, particularly RALP, may offer advantages, particularly in LOS. RALP was associated with a significantly shorter LOS compared to LP, reflecting quicker recovery and reduced morbidity.

Operative time remained longest for LP. Operative time differed significantly only in comparisons between OP and LP, with LP demonstrating longer operative duration. No significant difference in operative time was identified between LP and RALP, and operative time could not be compared between OP and RALP due to the lack of data. As such, conclusions regarding the relative operative efficiency of RALP cannot be drawn from the available evidence. The observed variability in operative time likely reflects differences in study design and surgeon experience rather than procedural efficiency.

These findings highlight that RALP, given the shorter LOS and cosmetic considerations, may influence decision-making in selected centres with available resources and expertise (63).

These results are consistent with previous systematic reviews and meta-analyses that have reported the outcomes of minimally invasive pyeloplasty in paediatric patients. Earlier systematic reviews by Cundy et al. and Esposito et al. similarly reported equivalent success and complication rates among open, laparoscopic, and robotic pyeloplasties (9,12). Many of these earlier reviews were limited by small sample sizes and the inclusion of early robotic series, which may reflect the learning curve associated with the new technology. The present review expands on this evidence by including all contemporary studies capturing the advances in the field. A contemporaneous systematic review restricted to infants and toddlers under 3 years or 15 kg similarly reported shorter hospital stay with RALP compared with LP, but did not find a statistically significant difference in operative success between approaches, in contrast to the significant advantage observed in our broader paediatric cohort (64). This discrepancy may reflect differences in age range, sample size, or the specific studies contributing to each pooled estimate, and underscores the need for larger, age-stratified prospective comparisons to clarify whether RALP’s success advantage is consistent across the full paediatric age spectrum or specific to older children. Consequently, a more accurate representation of current clinical outcomes is reported and supports the growing body of evidence which demonstrates that RALP is a safe and effective alternative to OP or LP in children.

Strengths and limitations

This review has notable strengths including a systematic approach, a rigorous methodology, compliance with the PRISMA checklist, and RoB assessment of individual studies to ensure the generation of meaningful findings. However, there were some limitations due to the large heterogeneity among the included studies, particularly for operative time and LOS. The precision of several pooled estimates, particularly within the LP versus RALP comparisons, was limited by small sample sizes and substantial inter-study heterogeneity, resulting in wide CIs that reduce the certainty of these findings. Similarly, the limited number of studies per comparison precluded formal assessment of publication bias; the likely presence of such bias was instead incorporated qualitatively into the GRADE certainty downgrading. Furthermore, summarising outcomes across the full paediatric age spectrum may introduce clinical selection bias, as infants and older children may differ in PUJO aetiology and subsequent suitability for specific open or minimally invasive approaches (62). The limited age-stratified data in the included studies prevented subgroup meta-analyses, and this should be considered when interpreting pooled estimates. This variability is not uncommon in surgical meta-analyses and likely reflects clinical and methodological differences among the included studies. Geographical and temporal differences added additional levels of variability. While high heterogeneity limits the precision of the pooled estimates, it mirrors real-world surgical practice. Pyeloplasty studies for PUJO demonstrate marked variability in patient demographics, surgeon experience, and methodological approaches. Moreover, a search in languages other than English was not performed and may have introduced a small language bias. Chinese-language databases (CNKI, Wanfang) were not searched, which may have excluded relevant data from high-volume Asian robotic centres despite the inclusion of several English-language studies from these regions. Although single-arm studies constitute a substantial part of the paediatric pyeloplasty literature, we deliberately avoided proportional meta-analysis due to marked clinical and methodological heterogeneity, which may limit the comprehensiveness of quantitative synthesis.

Implications for clinical practice

The results reinforce that minimally invasive pyeloplasty, LP or RALP, offers success rates equivalent to OP with the added benefits of reduced length of hospitalisation. However, in some healthcare systems, the costs and accessibility of robotic equipment remain barriers (2). In this context, LP continues to be a cost-effective and reliable alternative (2). Patient selection and surgeon expertise should guide the choice of procedure rather than availability of technology alone. The learning curve associated with robotic proficiency, as demonstrated in included cumulative sum (CUSUM) analyses (35,48), suggests that RALP’s outcome advantages may be most reliably realised in centres with established robotic programmes and sufficient case volume; in resource-limited settings without robotic access, LP remains a safe and effective default, while OP retains a role where laparoscopic expertise is also unavailable.

Implications for future research

Most studies included in this review were retrospective in nature. Future research should focus on the limitations of the current evidence base. High-quality prospective observational studies comparing OP, LP, and RALP are needed to better define outcomes and cost-effectiveness. Uniform definitions of operative success and reporting complications using the Clavien-Dindo classification are necessary to facilitate data synthesis across studies. Furthermore, as technology evolves, smaller instruments, paediatric-specific robotic platforms, and single-port systems may assist the extension and application of RALP to younger and smaller patients. International collaborations and registries could play a role in standardising reporting of data and the provision of paediatric robotic care. As the primary literature expands, future updates of this review should incorporate meta-regression and formal publication bias testing to formally characterise sources of heterogeneity.

Conclusions

To summarise, this systematic review and meta-analysis demonstrated improved operative success of RALP when compared to LP and similar complication rates among open, laparoscopic, and robot-assisted laparoscopic pyeloplasty in children. Minimally invasive approaches were associated with shorter hospital LOS, and operative time was shorter with open compared to laparoscopic approaches. These findings support the safety and efficacy of all three approaches, with the choice of technique best guided by patient factors, surgeon expertise, and resource availability. Further high-quality prospective observational studies are required in the future to establish longer-term outcome data to guide and advance paediatric urological practice.

Acknowledgments

The authors appreciated the help of the Patricia Bowen Library & Knowledge Service, Isleworth, London, UK.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0252/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0252/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0252/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study did not involve primary data collection from human participants and was based entirely on previously published, aggregate data; as such, formal ethical approval and individual informed consent were not required.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Prasad G, Anand S, Yadav DK, et al. Assessment of ureteric jets as a supportive diagnostic modality for unilateral pelvi-ureteric junction obstruction and its utility in follow-up: A pilot study. J Pediatr Urol 2024;20:1093-8. [Crossref] [PubMed]
2. Nikolinakos P, Chatzikrachtis N, Donkov I, et al. Robotic pyeloplasty: Technological global panacea or geo-surgical nightmare?. Arch Ital Urol Androl 2024;96:12263. [Crossref] [PubMed]
3. O'Sullivan NJ, Anderson S. Pelviureteric junction obstruction in adults: A systematic review of the literature. Curr Urol 2023;17:86-91. [Crossref] [PubMed]
4. Cascini V, Lauriti G, Di Renzo D, et al. Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and meta-analysis. Front Pediatr 2022;10:1052440. [Crossref] [PubMed]
5. Poulakis V, Witzsch U, Schultheiss D, et al. History of ureteropelvic junction obstruction repair (pyeloplasty). From Trendelenburg (1886) to the present. Urologe A 2004;43:1544-59. [Article in German]. [Crossref] [PubMed]
6. Wahyudi I, Tendi W, Rahman F, et al. Minimal Invasive Treatment in Pelvic-Ureteric Junction Obstruction: A Comprehensive Review. Res Rep Urol 2021;13:573-80. [Crossref] [PubMed]
7. Cundy TP, Shetty K, Clark J, et al. The first decade of robotic surgery in children. J Pediatr Surg 2013;48:858-65. [Crossref] [PubMed]
8. Broch A, Paye-Jaouen A, Bruneau B, et al. Day Surgery in Children Undergoing Retroperitoneal Robot-assisted Laparoscopic Pyeloplasty: Is It Safe and Feasible?. Eur Urol Open Sci 2023;51:55-61. [Crossref] [PubMed]
9. Esposito C, Cerulo M, Lepore B, et al. Robotic-assisted pyeloplasty in children: a systematic review of the literature. J Robot Surg 2023;17:1239-46. [Crossref] [PubMed]
10. Autorino R, Eden C, El-Ghoneimi A, et al. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: a systematic review and meta-analysis. Eur Urol 2014;65:430-52. [Crossref] [PubMed]
11. Ortiz-Seller D, Panach-Navarrete J, Valls-González L, et al. Comparison between open and minimally invasive pyeloplasty in infants: A systematic review and meta-analysis. J Pediatr Urol 2024;20:244-52. [Crossref] [PubMed]
12. Cundy TP, Harling L, Hughes-Hallett A, et al. Meta-analysis of robot-assisted vs conventional laparoscopic and open pyeloplasty in children. BJU Int 2014;114:582-94. [Crossref] [PubMed]
13. Greenwald D, Mohanty A, Andolfi C, et al. Systematic Review and Meta-Analysis of Pediatric Robot-Assisted Laparoscopic Pyeloplasty. J Endourol 2022;36:448-61. [Crossref] [PubMed]
14. Chandrasekharam VVS, Babu R. A systematic review and metaanalysis of open, conventional laparoscopic and robot-assisted laparoscopic techniques for re-do pyeloplasty for recurrent uretero pelvic junction obstruction in children. J Pediatr Urol 2022;18:642-9. [Crossref] [PubMed]
15. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. [Crossref] [PubMed]
16. Nikolinakos P, Chatzikrachtis N, Chatterjee A, et al. Comparison of outcomes of open, laparoscopic and robot-assisted laparoscopic pyeloplasty in children with ureteropelvic junction obstruction: protocol for a systematic review and meta-analysis. BMJ Open 2024;14:e087519. [Crossref] [PubMed]
17. GA Wells, B Shea, D O’Connell, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [Internet]. [cited 2025 Apr 10]. Available online: https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
18. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6. [Crossref] [PubMed]
19. Atkins D, Eccles M, Flottorp S, et al. Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group. BMC Health Serv Res 2004;4:38. [Crossref] [PubMed]
20. MANTEL N, HAENSZEL W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959;22:719-48. [PubMed]
21. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-60. [Crossref] [PubMed]
22. Barker TH, Migliavaca CB, Stein C, et al. Conducting proportional meta-analysis in different types of systematic reviews: a guide for synthesisers of evidence. BMC Med Res Methodol 2021;21:189.
23. Jia J, Meng Q, Zhang M, et al. A comparative study on the Efficacy of Retroperitoneoscopic Pyeloplasty and Open Surgery for Ureteropelvic Junction Obstruction in Children. Pak J Med Sci 2021;37:1768-74. [Crossref] [PubMed]
24. Braga LH, Lorenzo AJ, Bägli DJ, et al. Comparison of flank, dorsal lumbotomy and laparoscopic approaches for dismembered pyeloplasty in children older than 3 years with ureteropelvic junction obstruction. J Urol 2010;183:306-11. [Crossref] [PubMed]
25. Langreen S, Ludwikowski B, Dingemann J, et al. Laparoscopic pyeloplasty in neonates and infants is safe and efficient. Front Pediatr 2024;12:1397614. [Crossref] [PubMed]
26. Masieri L, Sforza S, Cini C, et al. Minilaparoscopic Versus Open Pyeloplasty in Children Less Than 1 Year. J Laparoendosc Adv Surg Tech A 2019;29:970-5. [Crossref] [PubMed]
27. Cui X, He YB, Huang WH, et al. Mini-laparoscopic pyeloplasty to treat UPJO in infants. Minim Invasive Ther Allied Technol 2022;31:473-8. [Crossref] [PubMed]
28. Andolfi C, Lombardo AM, Aizen J, et al. 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 J Urol 2022;40:1049-56. [Crossref] [PubMed]
29. Bansal D, Cost NG, DeFoor WR Jr, et al. Infant robotic pyeloplasty: comparison with an open cohort. J Pediatr Urol 2014;10:380-5. [Crossref] [PubMed]
30. Aghababian A, Abdulfattah S, Eftekharzadeh S, et al. Comparison of open and robot-assisted repair for ureteropelvic junction obstruction: Outcomes and direct costs from a single-institution. J Pediatr Urol 2025;21:1254-9. [Crossref] [PubMed]
31. Sun L, Zhao D, Shen Y, et al. Laparoscopic versus robot-assisted pyeloplasty in infants and young children. Asian J Surg 2023;46:868-73. [Crossref] [PubMed]
32. Wong YS, Pang KKY, Tam YH. Comparing Robot-Assisted Laparoscopic Pyeloplasty vs. Laparoscopic Pyeloplasty in Infants Aged 12 Months or Less. Front Pediatr 2021;9:647139. [Crossref] [PubMed]
33. Patel A, Pickhardt MW, Littlejohn N, et al. Shortened operative time for pediatric robotic versus laparoscopic dismembered pyeloplasty. Can J Urol 2016;23:8308-11. [PubMed]
34. Sharma G, Kundra A, Sharma S, et al. Is open pyeloplasty still a practical option for pediatric patients in resource-limited settings compared to laparoscopic and robotic approaches?. Pediatr Surg Int 2025;42:19. [Crossref] [PubMed]
35. Shu B, Zhang S, Gao J, et al. Da Vinci robotic assisted pyeloplasty versus laparoscopic pyeloplasty in newborns under 3 months. Sci Rep 2025;15:28435. [Crossref] [PubMed]
36. Nasser FM, Shouman AM, ElSheemy MS, et al. Dismembered Pyeloplasty in Infants 6 Months Old or Younger With and Without External Trans-anastomotic Nephrostent: A Prospective Randomized Study. Urology 2017;101:38-44. [Crossref] [PubMed]
37. Kawal T, Srinivasan AK, Shrivastava D, et al. Pediatric robotic-assisted laparoscopic pyeloplasty: Does age matter?. J Pediatr Urol 2018;14:540.e1-6. [Crossref] [PubMed]
38. Abdelwahab M, Abdelaziz A, Aboulela W, et al. One week stenting after pediatric laparoscopic pyeloplasty; is it enough?. J Pediatr Urol 2020;16:98.e1-6. [Crossref] [PubMed]
39. Sarhan O, Al Awwad A, Al Otay A, et al. Comparison between internal double J and external pyeloureteral stents in open pediatric pyeloplasty: A multicenter study. J Pediatr Urol 2021;17:511.e1-7. [Crossref] [PubMed]
40. Nagdeve NG, Bhingare PD, Sarawade P. A Randomized Control Trial Comparing Outcome after Stented and Nonstented Anderson-Hynes Dismembered Pyeloplasty. J Indian Assoc Pediatr Surg 2018;23:186-91. [Crossref] [PubMed]
41. Zaragoza-Torres RI, Cruz-Méndez Á, Baltazar-González JA, et al. Outcome of the treatment of hydronephrosis due to congenital ureteropelvic stenosis according to age at surgery. Bol Med Hosp Infant Mex 2021;78:536-43. [Crossref] [PubMed]
42. Radford A, Turner A, Ashraf J, et al. Robotic Pyeloplasty in Children: A "Barbed" Shortcut. J Laparoendosc Adv Surg Tech A 2018;28:486-9. [Crossref] [PubMed]
43. Li W, She X, Chen C, et al. Robot-Assisted Laparoscopic Pyeloplasty in Infants Under 3 Months: Single-Institution Study Findings, Safety Measures, and Success Strategies. J Endourol 2025;39:470-6. [Crossref] [PubMed]
44. Simforoosh N, Abedi A, Hosseini Sharifi SH, et al. Comparison of surgical outcomes and cosmetic results between standard and mini laparoscopic pyeloplasty in children younger than 1 year of age. J Pediatr Urol 2014;10:819-23. [Crossref] [PubMed]
45. Blanc T, Abbo O, Vatta F, et al. Transperitoneal Versus Retroperitoneal Robotic-assisted Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children. A Multicentre, Prospective Study. Eur Urol Open Sci 2022;41:134-40. [Crossref] [PubMed]
46. Cundy TP, Gattas NE, White AD, et al. Learning curve evaluation using cumulative summation analysis-a clinical example of pediatric robot-assisted laparoscopic pyeloplasty. J Pediatr Surg 2015;50:1368-73. [Crossref] [PubMed]
47. Andolfi C, Rodríguez VM, Galansky L, et al. Infant Robot-assisted Laparoscopic Pyeloplasty: Outcomes at a Single Institution, and Tips for Safety and Success. Eur Urol 2021;80:621-31. [Crossref] [PubMed]
48. Badawy H, Saad A, Fahmy A, et al. Prospective evaluation of retroperitoneal laparoscopic pyeloplasty in children in the first 2 years of life: Is age a risk factor for conversion?. J Pediatr Urol 2017;13:511.e1-4. [Crossref] [PubMed]
49. Liu D, Zhou H, Ma L, et al. Transumbilical multi-port laparoscopic pyeloplasty versus transumbilical single-site laparoscopic pyeloplasty for ureteropelvic junction obstruction in children: A retrospectively comparative study. J Pediatr Urol 2017;13:618.e1-5. [Crossref] [PubMed]
50. Sharifiaghdas F, Mirzaei M, Daneshpajooh A, et al. Minimally invasive open dismembered pyeloplasty technique: Miniature incision, muscle-splitting dissection, and nopelvis reduction in children. Asian J Urol 2019;6:290-3. [Crossref] [PubMed]
51. Hassan N, Trivedi BUS, Sivakumar K, et al. Outcome of Dismembered Pyeloplasty in Children with Unilateral Pelviureteric Junction Obstruction: A Retrospective Observational Study. JCDR 2023. doi:10.7860/JCDR/2023/62423.18420.
52. Erol İ, Karamık K, İslamoğlu ME, et al. Outcomes of infants undergoing laparoscopic pyeloplasty: A single-center experience. Urologia 2019;86:27-31. [Crossref] [PubMed]
53. Vauth F, Zöhrer P, Girtner F, et al. Open Pyeloplasty in Infants under 1 Year-Proven or Meaningless?. Children (Basel) 2023;10:257. [Crossref] [PubMed]
54. Ciftci H, Akin Y, Savas M, et al. Functional Results of Laparoscopic Pyeloplasty in Children: Single Institute Experience in Long Term. Urol Int 2016;97:148-52. [Crossref] [PubMed]
55. Lu L, Zhang B, Tang L, et al. Comparison of the safety and efficacy of laparoscopic single-incision triangulated umbilical surgery pyeloplasty with traditional three-hole surgery in a pediatric tertiary center. Int J Urol 2025;32:73-8. [Crossref] [PubMed]
56. Zhou H, Sun N, Zhang X, et al. Transumbilical laparoendoscopic single-site pyeloplasty in infants and children: initial experience and short-term outcome. Pediatr Surg Int 2012;28:321-5. [Crossref] [PubMed]
57. Casale P, Lambert S. Prospective analysis of completely stentless robot-assisted pyeloplasty in children. J Robot Surg 2010;3:215-7. [Crossref] [PubMed]
58. Huang Y, Zhang W, Song H, et al. Preliminary results of feasibility, safety and efficacy of robotic assisted laparoscopic pyeloplasty with the SHURUI single-port robotic surgical platform in children. J Robot Surg 2025;19:128. [Crossref] [PubMed]
59. Mattioli G, Cipriani MS, Calevo MG, et al. Learning curve in robotic surgery for ureteropelvic junction obstruction in children: how to best define a reliable learning process through CUSUM analysis. Front Surg 2025;12:1693109. [Crossref] [PubMed]
60. Chandler J, McKenzie J, Boutron I, et al. Cochrane Methods 2016. Wiley; 2016 Oct [cited 2026 Feb 23]. Available online: http://doi.wiley.com/10.1002/14651858.CD201601.
61. Munn Z, Barker TH, Moola S, et al. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth 2020;18:2127-33. [Crossref] [PubMed]
62. Zhao D, Sun L, Tao C, et al. Ureteropelvic Junction Obstruction Caused by Crossing Vessels in Infants and Young Children. J Pediatr Surg 2024;59:1835-40. [Crossref] [PubMed]
63. Freilich DA, Penna FJ, Nelson CP, et al. Parental satisfaction after open versus robot assisted laparoscopic pyeloplasty: results from modified Glasgow Children's Benefit Inventory Survey. J Urol 2010;183:704-8. [Crossref] [PubMed]
64. Szyduczyński M, Korneliussen J, Jażdżewska A, et al. Comparative Outcomes of Robot-Assisted and Laparoscopic Pyeloplasty in Infants and Toddlers: A Systematic Review and Meta-Analysis. Children (Basel) 2026;13:728. [Crossref] [PubMed]