Combined Pyeloplasty and Flexible Endoscopic Management in Children with Ureteropelvic Junction Obstruction and Urolithiasis: A Systematic Review

<title>Abstract</title> <p>Background: Concurrent ureteropelvic junction obstruction (UPJO) and renal calculi in children remain challenging to manage. This systematic review evaluated the efficacy and safety of simultaneous flexible endoscopic stone extraction during laparoscopic or robot-assisted pyeloplasty in paediatric patients with concurrent UPJO and urolithiasis. Methods: The study protocol was registered in PROSPERO (CRD420261402551). A systematic search was conducted according to the PRISMA 2020 guidelines. Studies involving paediatric patients who underwent simultaneous laparoscopic or robot-assisted pyeloplasty with flexible endoscopic stone management were included. Study quality was assessed via the Joanna Briggs Institute Critical Appraisal Tool and Newcastle‒Ottawa Scale. Results: Five studies involving 46 paediatric patients (mean age, 7.4 years) were included. Most procedures use an antegrade flexible endoscopic approach with Holmium laser lithotripsy. The mean operative time was 214 minutes. The initial stone-free rate after the primary procedure was 88.1% (37/42), increasing to 97.8% (41/42) following secondary interventions. The overall complication rate was 9.5% (4/42 patients), complications included transient urinary leakage managed with double-J stent placement (Clavien-Dindo IIIa) in three patients (Jia et al.) and residual stone fragments requiring secondary ureterorenoscopy (Clavien-Dindo IIIb) in three patients (Esposito et al.), alongside minor postoperative events, including hematuria and urinary tract infection (Clavien-Dindo II). No major intraoperative complications, postoperative anastomotic strictures, or stone recurrences were documented during a mean follow-up of 16.4 months. Conclusions: Simultaneous minimally invasive pyeloplasty with flexible endoscopic stone extraction appears to be a safe and effective single-stage approach for paediatric patients with concurrent UPJO and nephrolithiasis. This technique provides high stone clearance rates with low morbidity while avoiding more invasive staged procedures. Further prospective studies with larger cohorts are needed to validate long-term outcomes.</p>