Table1_Ureteropelvic junction obstruction in infants: Open or minimally invasive surgery? A systematic review and meta-analysis.doc

IntroductionThe historical gold standard treatment for ureteropelvic junction obstruction (UPJO) was the open Anderson–Hynes dismembered pyeloplasty (OP). Minimally invasive surgery (MIS) procedures, including laparoscopic pyeloplasty (LP) and robot-assisted laparoscopic pyeloplasty (RALP), have been reported to achieve better outcomes (i.e., decreased morbidity, reduced postoperative pain, superior esthetic results, and shortened length of hospital stay, LOS), with a success rate similar to OP. The main limitation of the MIS approach is the age and weight of patients, limiting these procedures to children >1 year. This study aims to evaluate the feasibility and benefits of MIS pyeloplasty compared to OP to surgically treat UPJO in children <1 year of age.
Materials and methodsA systematic review was independently performed by two authors. Papers comparing both techniques (MIS pyeloplasty vs. OP) in infants were included in the meta-analysis. Data (mean ± DS or percentage) were analyzed using Rev.Man 5.4 A p < 0.05 was considered significant.
ResultsNine studies (eight retrospective and one prospective) meet the inclusion criteria. A total of 3,145 pyeloplasties have been included, with 2,859 (90.9%) OP and 286 (9.1%) MIS. Age at operation was 4.9 ± 1.4 months in OP vs. 5.8 ± 2.2 months in MIS, p = ns. Weight at surgery was 6.4 ± 1.4 kg in OP vs. 6.9 ± 1.4 kg in MIS, p = ns. Operative time was 129.4 ± 24.1 min for OP vs. 144.0 ± 32.3 min for MIS, p < 0.001. LOS was 3.2 ± 1.9 days for OP vs. 2.2 ± 0.9 days for MIS, p < 0.01. Postoperative complications were present in 10.0 ± 12.9% of OP vs. 10.9 ± 11.6% in MIS, p = ns. Failure of surgery was 5.2 ± 3.5% for OP vs. 4.2 ± 3.3% for MIS, p = ns.
ConclusionThe development of miniaturized instruments and technical modifications has made MIS feasible and safe in infants and small children. MIS presented a longer operative time than OP. However, MIS seemed effective for treating UPJO in infants, showing shortened LOS compared to OP. No differences have been reported with regard to the incidence of postoperative complications and failure of pyeloplasty. Given the low quality of evidence of the meta-analysis according to the GRADE methodology, we would suggest limiting MIS procedures in infants to only those high-volume centers with experienced surgeons.

引言
肾盂输尿管连接部梗阻（ureteropelvic junction obstruction, UPJO）的传统金标准治疗术式为开放式安德森-海恩斯离断式肾盂成形术（open Anderson–Hynes dismembered pyeloplasty, OP）。现有研究显示，包括腹腔镜肾盂成形术（laparoscopic pyeloplasty, LP）与机器人辅助腹腔镜肾盂成形术（robot-assisted laparoscopic pyeloplasty, RALP）在内的微创手术（minimally invasive surgery, MIS）可获得更优疗效，具体表现为并发症发生率降低、术后疼痛减轻、美学效果更佳以及住院时长（length of hospital stay, LOS）缩短，且手术成功率与开放式术式相当。微创手术的主要局限在于患者的年龄与体重限制，目前仅可应用于1岁以上儿童。本研究旨在对比微创手术肾盂成形术与开放式术式治疗1岁以下儿童肾盂输尿管连接部梗阻的可行性与获益情况。

材料与方法
由两名研究者独立开展系统评价，纳入对比婴幼儿微创手术肾盂成形术与开放式术式的文献进行荟萃分析。采用RevMan 5.4软件对数据（均值±标准差或百分比）进行统计分析，以p<0.05为差异具有统计学意义。

结果
共纳入9项符合纳入标准的研究，其中8项为回顾性研究，1项为前瞻性研究。总计纳入3145例肾盂成形术病例，其中开放式术式2859例（占90.9%），微创手术286例（占9.1%）。开放式术式组患者的手术年龄为4.9±1.4个月，微创手术组为5.8±2.2个月，p值无统计学差异。手术时体重方面，开放式术式组为6.4±1.4kg，微创手术组为6.9±1.4kg，p值无统计学差异。手术时长方面，开放式术式组为129.4±24.1min，微创手术组为144.0±32.3min，p<0.001。住院时长方面，开放式术式组为3.2±1.9天，微创手术组为2.2±0.9天，p<0.01。术后并发症发生率方面，开放式术式组为10.0±12.9%，微创手术组为10.9±11.6%，p值无统计学差异。手术失败率方面，开放式术式组为5.2±3.5%，微创手术组为4.2±3.3%，p值无统计学差异。

结论
随着微型化手术器械的发展与手术技术的改良，微创手术已可安全应用于婴幼儿与低龄儿童群体。微创手术的手术时长较开放式术式更长，但用于治疗婴幼儿肾盂输尿管连接部梗阻同样有效，且住院时长较开放式术式更短。在术后并发症发生率与肾盂成形术失败率方面，两种术式未发现显著差异。鉴于本荟萃分析依据GRADE分级方法评估的证据质量较低，我们建议仅在具备经验丰富术者的高流量医疗中心开展婴幼儿微创手术肾盂成形术。