Robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction: comparison between pediatric and adult patients-Japanese series

A Comparative Analysis of Robot-Assisted Laparoscopic Pyeloplasty in Pediatric and Adult Patients: Does Age Matter?

We investigated factors that affect the surgical outcomes of robotic pyeloplasty by comparing the surgical results of pediatric and adult patients with ureteropelvic junction stricture (UPJO). We retrospectively reviewed patients who underwent robotic pyeloplasty for UPJO between January 2013 and February 2022. The patients were categorized into two groups: the pediatric (≤18 years) and adult (>18 years) groups. The perioperative and postoperative outcomes and surgical complications were comparatively analyzed. Prognostic factors for predicting surgical failure were analyzed with multivariable logistic regression analysis. The pediatric group showed longer total operation and console times. The mean pain score was lower in the pediatric group than in the adult group on days 1 and 2 after surgery. The average amount of morphine used in the pediatric group was lower during postoperative days 0−2. No differences in the length of hospital stay, incidence of surgical failure, and incidence of urolithiasis requiring treatment after robotic pyeloplasty were observed between the groups. The only factor that predicted surgical failure was a history of urolithiasis before surgery. The results showed that age did not affect the surgical outcome.

Robotic surgery in pediatric urology: Current status

Robot-assisted laparoscopic surgery (RALS) has been increasingly embraced in the fields of adult and pediatric urology, especially in North America and Europe. The advantages of a stable magnified 3-D view, tremor filtering, and motion scaling allow for precise intracorporeal exposure and suturing. Because most surgeries are performed as reconstructive rather than excision procedures, the robotic platform is particularly feasible for the field of pediatric urology. In this review, we summarize the recent viewpoints on RALS, such as pyeloplasty, ureteral reimplantation, bladder neck reconstruction, bladder neck sling, appendicovesicostomy, bladder diverticulectomy, and treatments for ureterocele or ectopic ureters, and we also critically summarize the current status of the literature. Based on our initial experience, RALS is technically feasible for pediatric patients and may be achieved with comparable surgical outcomes. RALS is also associated with reduced morbidity compared to open surgery to conventional laparoscopic surgery. This evolution will offer an alternative in the treatment pediatric patients, along with improved care and patient quality of life. Further large case series and randomized controlled trials that investigate the robotic platform's technological improvements will help to expand indications of RALS in the field of pediatric urology.

New steps of robot-assisted radical prostatectomy using the extraperitoneal approach: a propensity-score matched comparison between extraperitoneal and transperitoneal approach in Japanese patients

Background

Robot-assisted radical prostatectomy (RARP) is commonly performed using the transperitoneal (TP) approach with six trocars over an 8-cm distance in the steep Trendelenburg position. In this study, we investigated the feasibility and the benefit of using the extraperitoneal (EP) approach with six trocars over a 4-cm distance in a flat or 5° Trendelenburg position. We also introduced four new steps to the surgical procedure and compared the surgical results and complications between the EP and TP approach using propensity score matching.

Methods

Between August 2012 and August 2016, 200 consecutive patients without any physical restrictions underwent RARP with the EP approach in a less than 5° Trendelenburg position, and 428 consecutive patients underwent RARP with the TP approach in a steep Trendelenburg position. Four new steps to RARP using the EP approach were developed: 1) arranging six trocars; 2) creating the EP space using laparoscopic forceps; 3) holding the separated prostate in the EP space outside the robotic view; and 4) preventing a postoperative inguinal hernia. Clinicopathological results and complications were compared between the EP and TP approaches using propensity score matching. Propensity scores were calculated for each patient using multivariate logistic regression based on the preoperative covariates.

Results

All 200 patients safely underwent RARP using the EP approach. The mean volume of estimated blood loss and duration of indwelling urethral catheter use were significantly lower with the EP approach than the TP approach (139.9 vs 184.9 mL, p = 0.03 and 5.6 vs 7.7 days, p < 0.01, respectively). No significant differences in the positive surgical margin were observed. None of the patients developed an inguinal hernia postoperatively after we introduced this technique.

Conclusions

The EP approach to RARP was safely performed regardless of patient physique or contraindications to a steep Trendelenburg position. Our method, which involved using the EP approach to perform RARP, can decrease the amount of perioperative blood loss, the duration of indwelling urethral catheter use, and the incidence of postoperative inguinal hernia development.