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© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ.ORG SIUJ  •  Volume 4, Number 4  •  July 2023

Key Words Competing Interests Article Information

Pyeloplasty, laparoscopy, minimally 
invasive surgical procedures, open surgery, 
pelvicoureteric junction obstruction

None declared. Received on November 16, 2022 
Accepted on February 19, 2023

This article has been peer reviewed. 
Soc Int Urol J. 2023;4(4):309–320

DOI: 10.48083/ILKV8446

309

REVIEW

Laparoscopic Versus Open Pyeloplasty for 
Pelvicoureteric Junction Obstruction:  
A Systematic Review and Meta-Analysis

Benjamin Charles Buckland,1,3* Kevin Tree,2 Harry Narroway,4 Sean Heywood,3  
Tharindu Senanayake,5 Marcus Handmer3

1 The University of Sydney, School of Public Health, Sydney, Australia 2 Urology Department, Dubbo Base Hospital, Dubbo, Australia 3 Urology Department, John Hunter 
Hospital, Newcastle, Australia 4 Department of Surgery, Gosford Hospital, Gosford, Australia 5 Department of Surgery, John Hunter Hospital, Newcastle, Australia 

Abstract

Objectives To compare outcomes of laparoscopic versus open pyeloplasty for the management of pelvicoureteric 
junction obstruction (PUJO) using a systematic review and meta-analysis.
In September 2022, electronic database searches were conducted using the Cochrane Library, the Cochrane Central 
Register of Controlled Trials, EMBASE, MEDLINE, clinical trial registries, and relevant conferences to identify 
relevant abstracts and presentations.

Methods Prospective randomized controlled trials comparing laparoscopic to open pyeloplasty for PUJO were 
included in the review. There were no restrictions on date or language. All populations were included. The authors 
performed data extraction and risk of bias assessment using the risk of bias tool. Meta-analysis was performed using 
RevMan software.

Results Six prospective randomized controlled trials involving 335 participants were included in the analysis. 
Six studies included data on the failure rate, with a slight favouring of open pyeloplasty compared to laparoscopic 
pyeloplasty, although this was not statistically significant (odds ratio [OR], 1.39; 95% confidence interval  
[CI] 0.50 to 3.83).
Five studies compared operative time, with open pyeloplasty found to have shorter times across all studies (mean 
difference [MD], 54.97 minutes; 95% CI 47.08 to 62.85).
Based on 5 studies, laparoscopic pyeloplasty has a shorter hospital stay (MD, 4.12 days; 95% CI 3.64 to 4.59).
Two studies compared postoperative analgesia requirements, showing a lower diclofenac requirement in the 
laparoscopic group (MD, 330.08 mg; 95% CI 298.05 to 362.11 mg).
One study compared blood loss intraoperatively and found no significant difference between the groups (MD, 
8.52 mL; 95% CI -2.49 to 19.53).
Based on 4 studies, laparoscopic pyeloplasty may result in slightly higher complication rates postoperatively (OR, 1.49; 
95% CI 0.53 to 4.18); however, there was no statistically significant difference.
No subgroup analyses were conducted.

Conclusions Limited, low-quality evidence from small-scale trials suggests that laparoscopic pyeloplasty has 
improved outcomes in terms of shorter hospital stays and reduced postoperative pain compared to open pyeloplasty. 
Open pyeloplasty, on the other hand, had a shorter operative time. Failure rate, complication rate, and blood loss were 
comparable between the 2 approaches.

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extraction form to independently extract the following 
information. Any discrepancies not resolved between 
the 2 authors were adjudicated with the help of a third 
author (H.N.).

This review included all studies, regardless of whether 
they reported the outcomes of interest. The primary 
outcome assessed was the failure of pyeloplasty, while 
the secondary outcomes were length of stay, analgesia 
requirement, length of operation, estimated blood loss, 
surgical complications, and cosmetic appearance.

In addition to these outcomes of interest, data on 
various other variables was sought, including study 
design, protocol, country/context, language, dates of 
study, inclusion criteria of participants, exclusion criteria 
of participants, number of participants per group, exper-
imental and control intervention, and funding source.

Study risk of bias assessment
Two authors (B.B. and S.H.) independently conducted a 
risk of bias assessment using the Cochrane Risk of Bias 
tool (RoB 1.0)[13]. Each author evaluated the criteria 
listed below as low risk, unclear risk, or high risk. Any 
discrepancies in judgment between the authors (B.B. and 
S.H.) were discussed and resolved, and a third author 
(T.S.) was introduced to adjudicate on any differences 
that remained unresolved.

Criteria assessed:
• Random sequence generation (selection bias)
• Allocation concealment (selection bias)
• Blinding of participants and personnel  

(performance bias)
• Blinding of outcome assessment (detection bias)
• Incomplete outcome data (attrition bias)
• Selective reporting (reporting bias)
• Other sources of bias

We evaluated selection bias on a trial-by-trial basis by 
examining the methods of randomization and alloca-
tion concealment. Similarly, we assessed performance 
bias on a trial-by-trial basis by examining the methods 
used to blind participants and personnel to the interven-
tion received.

For each outcome within each trial, we assessed 
outcome and reporting bias. We then categorized the 
outcomes into objective (not susceptible to detection 
bias) and subjective (susceptible to detection bias).

We planned to perform a primary analysis using only 
the studies with a low risk of bias and then a sensitivity 
analysis.

Effect measures and synthesis methods
We reported continuous outcome data measures as 

mean differences (MDs) with 95% confidence intervals 
(95% CI) and dichotomous outcome measures as a 
risk ratio (RR) with 95% CI. Given the difference in 
populations, paediatric and adult populations were 
synthesized separately.

We summarized the data using a random effects 
model and interpreted the results by considering the 
whole distribution of effects in the random‐effects meta‐
analyses. Additionally, our statistical analyses followed 
the guidelines outlined the  Cochrane Handbook for 
Systematic Reviews of Interventions. For dichotomous 
outcomes, we used the Mantel‐Haenszel method; for 
continuous outcomes, we used the inverse variance 
method. We used Review Manager 5 (RevMan 5) soft-
ware to perform all the analyses.

Missing data: We had planned to contact the study 
authors for any missing data and intended to use an 
intention-to-treat analysis. However, no missing data 
were reported, and thus no imputation was necessary by 
the authors.

Statistical heterogeneity: We assessed heterogeneity 
both graphically, by interpreting forest plots, and statis-
tically using the I2 statistic. A value of I2 over 75% indi-
cated significant heterogeneity between studies.

Subgroup analysis: No subgroup analysis was planned.

Certainty assessment
The employed the GRADE approach to assess the quality 
of evidence generated by this systematic review. The 
GRADE Guideline Development Tool was used to make 
the summary of findings table.

Results
The initial search strategy identified 1561 records from 
electronic databases, with an additional 8 records 
were identified from conference abstracts and 22 
from citation searching of other sources (Figure 1). 
After removing duplicates, we screened 1168 records, 
excluding 1010 based on the title and abstract screening. 
We screened 158 full articles for suitability. Of these, 
119 were excluded due to incorrect study type and 34 
were excluded due to wrong intervention. We included 
5 studies based on eligibility criteria and identified 
an additional study (Garg 2014[14]) through other 
searching methods.

Study characteristics
The baseline characteristics and demographics of 
participants are included in Table 1.

Risk of bias assessment
Please refer to Figures 2, and 3, as well as the study 
characteristics section. The completed Risk of Bias tool 
can be found in Online Appendix 1.

Introduction

Pelvicoureteric junction obstruction (PUJO) is a 
common cause of hydronephrosis in children and adults. 
The prevalence of this condition has risen recently 
due to the increased efficacy and hence widespread 
use of antenatal screening. Approximately one in 
1000 newborns has PUJO, with a male predominance 
(2:1)[1]. PUJO is most frequently caused by a stenotic 
segment of the ureter at the pelvicoureteric junction 
(PUJ), creating a functional obstruction. Less common 
causes of pelvicoureteric junction obstruction include 
crossing vessels, fibrosis, anatomical variants, and 
fibroepithelial polyps[2]. In adults, acquired stenosis of 
the PUJ can be caused by upper tract infections, stones, 
trauma (such as instrumentation), or ischemia and can 
culminate in reactive fibrosis and an annular stricture. 
Upon presentation, symptoms typically include flank 
or abdominal pain due to increased pressure within the 
kidney, which can lead to kidney damage[3].

In approximately 60% to 70% of cases, patients do 
not require surgical management, with hydronephro-
sis resolving spontaneously[4]. However, patients who 
experience significant symptoms or impairment in 
renal function may require surgical management. Open 
pyeloplasty (OP) is considered the gold standard of treat-
ment for symptomatic PUJO[5]. However, there has 
been a trend toward minimally invasive techniques with 
advancements in technology. Minimally invasive proce-
dures such as robot-assisted laparoscopic pyeloplasty 
(LP) can theoretically improve efficiency and effective-
ness[6]. These may include a reduced risk for significant 
bleeding, smaller incisions, decreased pain, improved 
cosmetic outcomes, lower risk for postoperative infec-
tions, and shorter hospital stays[7]. A study reported an 
increase in the use of minimally invasive pyeloplasty 
from 2.4% to 55.3% of all pyeloplasty procedures 
conducted between 1998 and 2009[8].

Despite the increasing popularity of laparoscopic 
approaches, there is a lack of high-quality evidence 
directly comparing OP to LP. Systematic reviews have 
been conducted comparing different laparoscopic 
approaches to pyeloplasty[9], LP versus OP in chil-

dren[10], or LP versus robotic-assisted LP in infants[11], 
or have predominantly included retrospective stud-
ies[12]. To date, there has not been a systematic review 
of prospective studies comparing LP to OP. This system-
atic review aims to identify and analyze randomized 
controlled trials (RCTs) to assess the use of laparoscopic 
pyeloplasty in patients of all ages with PUJO.

Methods
Eligibility criteria
We included all prospective RCTs and excluded all other 
study designs. We evaluated laparoscopic pyeloplasty 
compared to open pyeloplasty in children and adults 
with a diagnosis of PULO who had not previously 
received any surgical management.

Information sources
In July 2022, we conducted electronic searches of the 
Cochrane Library and the Cochrane Central Register 
of Controlled Trials, MEDLINE, and EMBASE Ovid 
(see Online Appendix 1 for search strategy), with 
no restrictions on date or language. We reviewed 
trials registries for unpublished studies, including the 
Australia and New Zealand Clinical Trials Registry, 
International Clinical Trials Registry (World Health 
Organization), and Clinicaltrials.gov. Additionally, we 
reached out to experts in urology to identify critical 
studies and ongoing research. We searched for abstracts 
presented at the European Association of Urology 
(EAU) annual meetings, the British Association 
of Urological Surgeons (BAUS), and the American 
Urological Association (AUA) between 2019 and 2021. 
We conducted a manual search of the reference lists of 
included studies to identify any additional research.

Selection process
Two authors (B.B. and T.S.) reviewed all identified 
studies using Rayyan, a software program designed to 
screen potential studies. All studies identified in the 
search strategy were screened by title and abstract. 
Two review authors (B.B. and T.S.) independently 
conducted a thorough evaluation of the full text of all 
potentially relevant studies and categorized them as 
excluded, included, ongoing, or awaiting classification. 
The authors documented reasons for excluding specific 
studies. In the case of any discrepancies between the 
authors, a third author (H.N.) was involved to discuss 
and adjudicate any inconsistencies. This process is 
highlighted in the PRISMA flow diagram. A Cohen’s 
Unweighted Kappa score of 0.92 was calculated, 
indicating strong agreement between the reviewers and 
hence strong inter-rater reliability.

Data collection process/items
One author (B.B.) developed a dedicated data extraction 
form. Two authors (B.B. and S.H.) used this data 

Abbreviations 
CI confidence interval
LP laparoscopic pyeloplasty
MD mean difference
OP open pyeloplasty 
PUJO pelvicoureteric junction obstruction 
RCTs randomized controlled trials 
RR risk ratio

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risk of bias in 5 studies, resulting in overall high risk. 
In one study (Gatti 2017[16]), the operating surgeon 
completed all follow-up, leading to high risk of bias.

Incomplete outcome data
No studies reported incomplete data, indicating low risk 
of bias for all 6 studies.

Selective reporting
No studies included a published protocol. All outcomes 
appeared to be reported appropriately and logically as 
RCTs. Given that there was no protocol to compare, all 6 
studies were judged as unclear risk of bias.

Other potential bias
No studies included any disclaimer or declaration 
regarding conflicts of interest or funding.

Publication bias
No publication bias was observed. A funnel plot was not 
feasible due to the low number of included studies.

Results of synthesis
Primary outcome—failure rate
All 6 studies included data on the failure rate of 
pyeloplasty (total, 304: LP, 148; OP, 156) (Figure 4). 
However, there were no events in Srinivas[17], making 
the risk ratio not estimable. In the adult population, LP 
likely results in no greater risk for failure compared to 
OP (RR, 1.23; 95% CI 0.32 to 4.72). There was no statical 
heterogeneity (I2=0%) among the included studies. 
Similar results were seen in the paediatric population 
(RR, 1.44; 95% CI 0.25 to 8.24).

Secondary outcomes
Operative time: Five studies included data on operative 
time (total, 304: LP, 148; OP, 156) (Figure 5). In adults, 

FIGURE 2. 

Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentage across all 
included studies.

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other bias

0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

FIGURE 3. 

Risk of bias summary: review authors’ judgments about 
each risk of bias item for each included study.

Bansal 2011

Garg 2014

Gatti 2017

Mohammed 2017

Ravish 2007

Srinivas 2011
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Allocation
Random sequence generation
Four studies did not report the method of randomization 
used. One study (Garg 2014[14]) reported an adequate 
ra ndomization met hod. Anot her study (Rav ish 
2007[15]) reported using alternative allocation, putting 
it at a high risk of bias.

Allocation concealment
Five studies were rated as unclear risk of bias because of 
insufficient information. The study by Ravish et al. was 

FIGURE 1. 

Study flow diagram

Additional records identi�ed 
through other sources

(n = 30)

Records after duplicates removed
(n = 1168)

Records screened
(n = 1168)

Records excluded
(n = 1010)

Full-text articles assessed 
for eligibility

(n = 158))

Full-text articles excluded,
 with reasons 

(n = 152)
Incorrect study type (n = 119)
Incorrect intervention (n = 34)

Studies included in qualitative 
synthesis

(n = 6)

S
cr

ee
ni

ng
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ib

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it

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Identi�cation of studies via databases and registers

Id
en

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In

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ud

ed

Studies included in quantitative 
synthesis (meta-analysis)

(n = 6)

Records identi�ed through 
database searching

(n = 1561)

rated at a high risk of selection bias because of a poor 
randomization technique.

Blinding
Blinding of participants and personnel

We judged all 6 studies at high risk of bias due to the 
nature of the intervention.

Blinding of outcome assessment

Objective outcomes were assessed as being low risk of 
bias, while subjective outcomes were assessed as high 

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TABLE 1. 

Baseline characteristics

Study Name
Bansal et al.[21] Garg et al.[14] Gatti et al.[16] Mohammed et al.[22] Ravish et al.[15] Srinivas et al.[17]

LP OP LP OP LP OP LP OP LP OP LP OP

Age 
(median in years)

31.64 29.58 27.27 23.47 6.8 7.6 NR NR 31.64 29.58 20.42 22.83

Left Sided % 42.90% 47.10% 70% 56.70% 66% 69% NR NR 42.90% 47.10% 53.33% 46.60%

Gender (male %) 60.70% 58.80% 50% 56.70% NR NR NR NR 60.70% 58.80% 73.30% 73.30%

BMI 
(Kg/m2) ± SD 

NR NR NR NR NR NR 28.4 ± 3.25 30.4 ± 3.5 NR NR NR NR

Sample size 62 60 98 55 29 30

Intervention 
(number)

Laparoscopic pyeloplasty (n = 28) Laparoscopic pyeloplasty (n = 30) Laparoscopic pyeloplasty (n = 50) Laparoscopic pyeloplasty (n = 25) Laparoscopic pyeloplasty (n = 28) Laparoscopic pyeloplasty (n = 15)

Control (number) Open pyeloplasty (n = 34) Open pyeloplasty (n = 30) Open pyeloplasty (n = 48) Open pyeloplasty (n = 30) Open pyeloplasty (n = 34) Open pyeloplasty (n = 15)

Follow-up 33–34 months 3 months 16 weeks 12 months 3 months 3 months

Study design Prospective RCT Prospective RCT Prospective RCT Prospective RCT Prospective RCT Prospective RCT

Protocol No No No No No No

Country/context India/single centre India/single centre USA/not reported Germany/not reported India/single centre India/single centre

Language English English English English English English

Dates of study 2004–2007 August 2011 – July 2013 2005–2014 August 2010 – August 2014 2004-2007 April 2004 – March 2005

Inclusion 
criteria of 
participants

Symptomatic OR worsening renal 
function, radiographic evidence of PUJO

Diagnosis of PUJO
PUJO, under 18 years of age

Indications for surgery

Overweight/obese 
(BMI > 25 kg/m2)

PUJO

Symptomatic OR worsening renal function
radiographic evidence of 

PUJO

Primary PUJO including symptomatic and 
asymptomatic patients

Exclusion 
criteria of 
participants

No information reported

<18 years of age
Renal function <15% Coagulopathy

Spinal deformity
Cardiopulmonary compromise

Refusal of randomization

Previous pyeloplasty No information reported No information reported

Secondary PUJO
Urinary tract infection

Redo pyeloplasty’s Contraindications to surgery 
or laparoscopic surgery

Long segment PUJO 

Demographics  
(LP vs OP)

Median age in years – 31.64 vs 29.58

Male sex (%) – 60.7% vs 58.8%

left-sided operation (%) –  
42.9% vs 47.1%

Median age in years – 27.27 vs 23.47

Male sex (%) – 50% vs 56.7%

Left-sided operation (%) – 70% vs 56.7%

Median age in years – 6.8 vs 7.6

Male sex (%) – no information

Left-sided operation (%) – 66% vs 69%

Mean hydronephrosis grade – 3.5 vs 3.5

Mean BMI (kg/m2)  
28.4 ± 3.25 vs 30.4 ± 3.5

Median age in years - 31.64 vs 29.58
Male sex (%) – 60.7% vs 58.8%

Left-sided operation (%) – 42.9% vs 47.1%

Median age in years – 20.42 vs 22.83
Male sex (%) – 73.3% vs 73.3%

Left-sided operation (%) – 53.33% vs 46.6%

Experimental 
intervention

Laparoscopic pyeloplasty (n = 28) Laparoscopic pyeloplasty (n = 30) Laparoscopic pyeloplasty (n = 50) Laparoscopic pyeloplasty (n = 25) Laparoscopic pyeloplasty (n = 28) Laparoscopic pyeloplasty (n = 15)

Control 
intervention

Open pyeloplasty (n = 34) Open pyeloplasty (n = 30) Open pyeloplasty (n = 48) Open pyeloplasty (n =30) Open pyeloplasty (n = 34) Open pyeloplasty (n = 15)

Primary outcome Success of procedure Success of procedure Success of procedure Success of procedure Success of procedure Postoperative pain score

Definition of 
successful 
pyeloplasty

No recurrence of PUJO or conversion to 
OP intraoperatively

Recurrence of PUJO postoperatively No information
Recurrence of PUJO on

MAG 3 scan at 3 months
Recurrence of PUJO on follow up imaging No information

Secondary 
outcome

Operation time
Analgesic requirement
Length of hospital stay

Operation time
Analgesic requirement
Length of hospital stay

Estimated blood loss Mean Hb drop 
postoperatively Success rate

Day of drain removal post operatively

Cost analysis 
Length of operation

Length of stay
Analgesic use

Operation time
Analgesic requirement
Length of hospital stay

Haemoglobin loss

Operation time
Analgesic requirement
Length of hospital stay

Postoperative functionality score

Funding No information No information No information No information No information No information No information

Declaration 
of conflict of 
interests

No information No information No information No information No information No information

LP: laparoscopic pyeloplasty, OP: open pyeloplasty.

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data to short-term outcomes. Long-term outcomes 
are important for choosing a surgical approach in all 
populations, however.

A key finding of this systematic review is the lack of 
high-quality studies endorsing the use of laparoscopic 
pyeloplasty over open pyeloplasty.

LP likely results in little to no difference in failure rate, 
complication rate, intraoperative blood loss, or short-
term pain in both adult and paediatric populations.  

FIGURE 6. 

Forest plot for length of stay (days)

FIGURE 7.

Forest plot for complications

FIGURE 8.

Forest plot for postoperative diclofenac use (mg)

The laparoscopic approach likely has shorter hospital 
stays, decreased analgesic requirements, and improved 
pain at 7 days postoperatively. LP likely has longer oper-
ative times compared to OP.

The results of this systematic review highlight that the 
key clinical benefits of using a laparoscopic technique 
are a shorter length of stay and improved pain compared 
to OP. However, there is no significant difference in fail-
ure rates or complications between the 2 techniques. As 
such, patients can be counselled that LP may slightly 

LP likely results in a longer operative time of 66 minutes 
compared to OP (MD, 66.48 minutes; 95% CI 19.54 to 
113.41). There is significant statistical heterogeneity 
(I2=96%). There was a smaller difference in the 
paediatric population of 17 minutes (MD, 17.00; 95% CI 
3.04 to 30.96).

Length of stay: Five studies included data on length of 
stay (total, 304: LP, 148; OP, 156) (Figure 6). LP likely 
reduces hospital stay by 3 days in adults (MD, -3.55; 95% 
CI -1.52 to -5.58). There is substantial statistical hetero-
geneity (I2=92%). There was no difference in the paedi-
atric group (MD, -0.10; 95% CI -4.58 to 4.37).

Complications: Four studies included data on compli-
cations (total, 269: LP, 123; OP, 126) (Figure 7). LP likely 
results in no difference in complication rates in adults 
(RR, 1.24; 95% CI 0.48 to 3.23). There is no significant 
statistical heterogeneity (I2= 0%). Similar results were 
seen in children (RR, 2.88; 95% CI 0.12 to 69.07).

Analgesia requirements: Two studies included data on 
this analgesia requirements (total, 122: LP, 58; OP, 64) 
(Figure 8). LP is likely to have a lower analgesia post-

operative requirement (MD, -364.66; 95% CI -776.90 
to 47.58). There is significant statistical heterogeneity 
(I2=99%).

Blood loss: One study included data on blood loss (total, 
60: LP, 30; OP, 30) (Figure 9). LP likely results in little to 
no difference in blood loss (in millilitres) (MD, 8.52 mL; 
95% CI -2.49 to 19.53). There was no data on blood loss 
for the paediatric population.

Cosmetic outcome: No studies included data on 
cosmetic outcome.

No subgroup analysis or sensitivity analysis was 
performed.

Summary of findings is shown in Table 2.

Discussion
Key findings
The review is based of 6 randomized controlled trials, 
all of which had relatively small sample sizes and 
events rates. Additionally, most studies had a relatively 
short follow-up period of 3 months, which limits the 

FIGURE 4. 

Forest plot for failure rate in laparoscopic versus open pyeloplasty

FIGURE 5. 

Forest plot for operative time (minutes)

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improve recovery times and postoperative pain, but 
there is no significant difference in outcomes of either 
failure rates or complications. LP and OP are equivalent 
in these outcomes in both populations.

Comparison with existing knowledge
Previous systematic reviews comparing laparoscopic 
to open pyeloplasty have included only retrospective 
studies[12], focused on specific populations such as 
children[10], or compared other approaches such as 
robotic-assisted or retroperitoneal approaches[9,11]. Mei 
et al. had similar results in the paediatric population, 
with LP having shorted hospital stays without an 
increased risk for complications or failure of the 
pyeloplasty[10]. Huang et al. reported a shorter hospital 
stay and lower complication rate with LP compared to 
OP in children[18].

Strengths and limitations
This review employed a broad search strateg y of 
numerous data sources to search for RCTs regardless of 
publication status and language. Despite this, there is a 
possibility of missing published studies in a language 
other than English, studies published in non‐indexed 
journals, or studies not yet published.

This study only included randomized controlled 
trials, the gold-standard study type for an intervention 
such as LP compared to OP.

The quality of evidence was consistently downgraded 
for all studies included in this review due to the stud-
ies’ intrinsic limitations. Given the surgical nature of 

the intervention, these studies are prone to selection 
bias from poor allocation concealment and lack of 
blinding[19]. Overall, all studies included in this review 
are at high risk of bias, and the results should be inter-
preted with caution.

An ongoing challenge in assessing new or evolving 
surgical techniques is accounting for user experience 
and the surgical learning curve[20]. Surgical outcomes 
are dependent on the experience of the surgeon, the 
number of procedures performed, and the centre’s expe-
rience. Other specific factors that may affect outcomes 
for pyeloplasty include stent and drain placement, which 
were not assessed. Thus, this review cannot account for 
any of these factors, which may influence outcomes.

Implication for practice
This systematic review highlights the minor benefits 
offered by laparoscopic pyeloplasty. In practice, these 
minor benefits are unlikely to outweigh the surgeon’s 
preference of approach based on their training, 
experience, and available resources. However, it 
emphasizes the importance of urologists in training to 
learn the laparoscopic approach for pyeloplasty.

Implication for research
Overall, this review has shown that LP may have some 
minor advantages over OP, but the evidence is of low 
quality. Further research could focus on larger sample 
sizes, with longer-term follow-up of participants. With 
the introduction of robotically assisted pyeloplasty, this 
approach could also be investigated with large RCTs.

References

1. Morris RK, Kilby MD. Congenital urinary tract obstruction. Best 
Pract Res Clin Obstet Gynaecol.2008;22(1):97–122. doi: 10.1016/j.
bpobgyn.2007.08.007. PMID: 17904905.

2. Woodward M, Frank D. Postnatal management of antenatal 
hydronephrosis. BJU Int.2002; 89(2):149–156. doi: 10.1046/j.1464-
4096.2001.woodward.2578.x. PMID: 11849184.

3. González R, Schimke CM. Ureteropelvic junction obstruction in 
infants and children. Pediatr Clin North Am.2001;48(6):1505–1518. 
doi: 10.1016/s0031-3955(05)70388-6. PMID: 11732127.

4. Chertin B, Pollack A, Koulikov D, Rabinowitz R, Hain D, Hadas-Halpren 
I, et al. Conservative treatment of ureteropelvic junction obstruction 
in children with antenatal diagnosis of hydronephrosis: lessons 
learned after 16 years of follow-up. Eur Urol.2006;49(4):734–738. 
doi: 10.1016/j.eururo.2006.01.046. PMID: 16504374.

5. Anderson JC; Hynes W. Retrocaval ureter; a case diagnosed 
pre-operatively and treated successfully by a plastic operation. Br 
J Urol.1949;21(3):209–214. doi: 10.1111/j.1464-410x.1949.tb10773.x. 
PMID: 18148283.

6. Carr BM, Lyon JA, Romeiser J, Talamini M, Shroyer ALW. Laparoscopic 
versus open surgery: a systematic review evaluating Cochrane 
systematic reviews. Surg Endosc.2019;33(6):1693–1709. doi: 10.1007/
s00464-018-6532-2. PMID: 30357523.

7. Mandal A, Robertson S. Laparoscopic surgery advantages. In: News 
Medical Life Sciences.2019.

8. Sukumar S, Sun M, Karakiewicz PI, Friedman AA, Chun FK, Sammon J, 
et al. National trends and disparities in the use of minimally invasive 
adult pyeloplast y. J Urol.2012;188(3):913 –918. doi: 10.1016/j.
juro.2012.05.013. PMID: 22819404.

9. Ji F, Chen L, Wu C, Li J, Hang Y, Yan B. Meta-analysis of the 
efficacy of laparoscopic pyeloplasty for ureteropelvic junction 
obstruction via retroperitoneal and transperitoneal approaches. 
Front Pediatr.2021;9:707266. doi: 10.3389/fped.2021.707266. PMID: 
34395345; PMCID: PMC8357990.

10. Mei H, Pu J, Yang C, Zhang H, Zheng L, Tong Q. Laparoscopic versus 
open pyeloplasty for ureteropelvic junction obstruction in children: a 
systematic review and meta-analysis. J Endourol.2011;25(5):727–736. 
doi: 10.1089/end.2010.0544. PMID: 21476861.

FIGURE 9.

Forest plot for blood loss (mL)

TABLE 2. 

Summary of findings: Laparoscopic Pyeloplasty compared to Open Pyeloplasty for Pelvicoureteric  
Junction Obstruction

Outcomes

Anticipated absolute effects* 
(95% CI)

Relative
effect

(95% CI)

No of
participants

(studies)

Certainty of
the evidence

(GRADE)
Comments

Risk with
Open

Pyeloplasty

Risk with 
Laparoscopic
Pyeloplasty

Failure Rate 38 per 1000
50 per 1000
(17 to 146)

RR 1.31
(0.45 to 3.79)

304
(6 RCTs) Moderate

Operative
Time

MD 56 Minutes more
(13.88 more to 98.91 

more)
—

304
(5 RCTs) Moderate

Length of
Stay

MD 3.18 days fewer
(5.13 fewer to 

1.24 fewer)
—

304
(5 RCTs) Moderate

Complications 48 per 1000
63 per 1000
(25 to 159)

RR 1.33
(0.53 to 3.33)

249
(4 RCTs) Moderate

Analgesia
Requirement

(Postoperative
Diclofenac

requirement)

MD 364.66 mg lower
(776.9 lower to 47.58 

higher)
—

122
(2 RCTs) Low

Blood Loss
MD 8.52 mLs higher
(2.49 lower to 19.53 

higher)
—

60
(1 RCT) Low

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of 
the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.

Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a 
possibility that it is substantially different.

Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

319318 SIUJ.ORG SIUJ  •  Volume 4, Number 4  •  July 2023SIUJ  •  Volume 4, Number 4  •  July 2023 SIUJ.ORG

REVIEW Laparoscopic Versus Open Pyeloplasty for Pelvicoureteric Junction Obstruction: A Systematic Review and Meta-Analysis

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11. Chandrasekharam V VS, Babu R. A systematic review and meta-
analysis of conventional laparoscopic versus robot-assisted 
laparoscopic pyeloplasty in infants. J Pediatr Urol.2021;17(4):502–510. 
doi: 10.1016/j.jpurol.2021.03.009. PMID: 33812779.

12. Uhlig A, Uhlig J, Trojan L, Hinterthaner M, von Hammerstein-Equord A, 
Strauss A. Surgical approaches for treatment of ureteropelvic junction 
obstruction - a systematic review and network meta-analysis. BMC 
Urol.2019;19(1):112. doi: 10.1186/s12894-019-0544-7. PMID: 31711468; 
PMCID: PMC6849262.

13. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron 
I, et al. RoB 2: a revised tool for assessing risk of bias in randomised 
trials. BMJ.2019;366:l4898. doi: 10.1136/bmj.l4898. PMID: 31462531.

14. Garg M, Singh V, Sinha RJ, Sankhwar SN. Prospective randomized 
comparison of retroperitoneoscopic vs open pyeloplast y with 
minimal incision: subjective and objective assessment in adults. 
Urology.2014;83(4):805 –811. doi: 10.1016/j.urology.2013.11.024. 
PMID: 24485998.

15. Ravish IR, Nerli RB, Reddy MN, Amarkhed SS. Laparoscopic pyeloplasty 
compared with open pyeloplast y in children. J Endourol.2007 
Aug;21(8):897-902. doi: 10.1089/end.2006.0411. PMID: 17867949 
Clinical Trial.

16. Gat ti JM, Amstutz SP, Bowlin PR, Stephany HA, Murphy JP. 
Laparoscopic vs open pyeloplasty in children: results of a randomized, 
prospective, controlled trial. J Urol.2017 Mar;197(3 Pt 1):792-797. doi: 
10.1016/j.juro.2016.10.056. Epub 2016 Oct 17.

17. Srinivas KK, Uppin IV, Nerle RB. A prospective randomized controlled 
trial complains open pyeloplasty and laparoscopic pyeloplasty for 
ureteropelvic junction obstruction (UPJO): subjective outcome. J Clin 
Diagn Res.2011;5(8):1601–1605.

18. Huang Y, Wu Y, Shan W, Zeng L, Huang L. An updated meta-analysis 
of laparoscopic versus open pyeloplasty for ureteropelvic junction 
obstruction in children. Int J Clin Exp Med.2015;8(4):4922–4931. PMID: 
26131065; PMCID: PMC4483847.

19. McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised trials in 
surgery: problems and possible solutions. BMJ.2002;324(7351):1448–
1451. doi: 10.1136/bmj.324.7351.1448. PMID: 12065273; PMCID: 
PMC1123389.

20. Dahm P. Envisioning an IDEAL future for urological innovation. BJU 
Int.2016;117(3):387–388. doi: 10.1111/bju.13129. PMID: 25810303.

21. Bansal P, Gupta A, Mongha R, Narayan S, Das RK, Bera M, Chakraborty 
SC, Kundu AK. Laparoscopic versus open pyeloplasty: comparison of 
two surgical approaches- a single centre experience of three years. 
Indian J Surg. 2011 Aug;73(4):264-7. doi: 10.1007/s12262-011-0237-2. 
Epub 2011 Apr 26. PMID: 22851839; PMCID: PMC3144340.

22. Mohamed HE, EL-Asmar KM, Hassan TA , ELShafei EA, Soliman 
MH, Allam AM. Feasibility, safety and effectiveness of laparoscopic 
transperitoneal pyeloplasty in children: Ain Shams University early 
experience. Ann Pediatr Surg.2022;18(26). https://doi.org/10.1186/
s43159-022-00164-5

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