This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited. © 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. http://SIUJ.org https://orcid.org/0000-0002-0354-0024 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 311310 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 http://SUIJ.org http://SIUJ.org http://SIUJ.org 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 Ra nd om s eq ue nc e ge ne ra tio n (s el ec tio n bi as ) A llo ca tio n co nc ea lm en t ( se le ct io n bi as ) Bl in di ng o f p ar tic ip an ts a nd p er so nn el (p er fo rm an ce b ia s) Bl in di ng o f o ut co m e as se ss m en t ( de te ct io n bi as ) In co m pl et e ou tc om e da ta (a tt rit io n bi as ) Se le ct iv e re po rt in g (re po rt in g bi as ) O th er b ia s 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 El ig ib il it y Identi�cation of studies via databases and registers Id en ti �c at io n In cl 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 313312 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 http://SIUJ.org http://SIUJ.org 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. 315314 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 http://SIUJ.org http://SIUJ.org 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) 317316 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 http://SIUJ.org http://SIUJ.org 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 http://SIUJ.org http://SIUJ.org 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/ s43159-022-00164-5 320 SIUJ • Volume 4, Number 4 • July 2023 SIUJ.ORG REVIEW http://SIUJ.org