Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time, Length of Hospital Stay, Postoperative Complications, and Success Rate

Robotic-assisted laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction - How should success be determined?

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is characterised by stenosis of the ureteral lumen at the level of the renal pelvis and proximal ureter. At Haukeland University Hospital, robotic-assisted laparoscopic pyeloplasty (RLP) for UPJO has been performed since 2014. The aim of this study was to evaluate the results of the treatment and consider what determines treatment success.

MATERIALS AND METHODS

Retrospective review was performed of consecutive patients undergoing RLP between 2014-2022. Outcomes of interest included symptom relief, complication rates and renographic findings at follow-up. Treatment success was defined in terms of symptom improvement and/or improvement as well as relief of obstruction on renography.

RESULTS

In total, 95 RLPs were performed in 54 women and 41 men, with a mean age of 40 years (IQR: 21-58). Flank pain was the most frequent presenting complaint (n = 81, 85%) followed by infection (n = 33, 35%). More than one indication for surgery was present in 1/3 of the patients. Urodynamic relevant obstruction on renography was found in 62 patients (65%) preoperatively. Mean operative time was 123 minutes (range 60-270). Two patients experienced minor intraoperative complications. At three months follow-up, 91% of patients had symptom relief, and no obstruction on renography was recorded in 64%. There was no significant association between improvement in symptoms and renography findings at follow-up, p = 1.

CONCLUSIONS

RLP can deliver a high success rate in terms of symptom relief and few complications. There was no association between renography findings and symptom relief at follow-up. Success after surgery should be determined by symptom relief rather than renography findings.

A scoping review on chordee correction in boys with ventral congenital penile curvature and hypospadias

Introduction

Congenital penile curvature (PC), often concomitant with hypospadias, poses challenges in urology. Surgical correction techniques, including plication and corporotomy, lack standardized guidelines. This study aims to address the paucity of high-level evidence by comprehensively reviewing the outcomes of PC correction procedures in patients with and without hypospadias. This will inform clinical decision-making and provide insights for future research and meta-analyses.

Methods

We conducted this scoping review in accordance with the JBI Manual for Evidence Synthesis and PRISMA-ScR guidelines. An extensive literature search was performed and comparative studies published in English up to June 2023 were included. The studies were divided into three categories: PC without hypospadias, PC with hypospadias, and studies comparing two or more materials for covering the ventral corporotomy. Data extraction comprised author details, patient characteristics, study design, interventions, outcomes, and complications. Methodological quality was assessed using the Newcastle-Ottawa Scale.

Results

Forty-two studies were included in the review, which collectively comprised 3180 patients. Thirteen comparative studies reported the outcomes of surgery for congenital PC without hypospadias, 22 studies compared different techniques of PC correction in patients with hypospadias and 7 studies compared the type of materials for coverage following ventral corporotomy. In cases of PC without hypospadias, the most commonly reported surgery was the Nesbit's plication. For PC with hypospadias correction, the results of ventral corporotomy were superior to that of dorsal plication in most of the studies. The two-stage repair had better results when compared to the one-stage repair for patients with perineo-scrotal hypospadias. In studies comparing materials for coverage of ventral corporotomy, the tunica vaginalis flap or graft was utilized most commonly. The majority of the studies reported a success rate ranging from 85% to 100%. The methodological quality was high in all but four studies.

Conclusion

Plication procedures are generally preferred for PC without hypospadias, but they result in penile shortening. For those with hypospadias, corporotomy is associated with superior outcomes than plication, especially for those with severe curvature and redo procedures. For ventral corporotomy coverage, the tunica vaginalis flap or graft is the most commonly reported tissue in the literature.

Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study

BACKGROUND

Robot-assisted approach to UVJ is getting more and more used in pediatric patients.

METHODS

In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR).

RESULTS

Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery.

CONCLUSIONS

Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.

Single-Port vs Multiple-Port Robot-Assisted Laparoscopic Pyeloplasty for the Treatment of Ureteropelvic Junction Obstruction: A Systematic Review and Meta-Analysis

Background: Single-port robot-assisted pyeloplasty (SP-RP) has been performed in recent years. However, the advantages and disadvantages of SP-RP compared with multiple-port robot-assisted pyeloplasty (MP-RP) remain unclear. The purpose of this meta-analysis was to compare the safety and feasibility of the two technologies. Materials and Methods: Through a literature search using MEDLINE, EMBASE, and the Cochrane Library, studies comparing SP-RP and MP-RP were identified for meta-analysis. Comparisons of perioperative and postoperative outcomes between the groups were analyzed using weighted mean difference (WMD) and risk ratio. Results: Five retrospective cohort studies with 179 patients were included in this meta-analysis. The results showed that SP-RP was associated with shorter hospital stay (WMD: -0.6 minutes, 95% confidence interval [CI]: -1.19 to -0.02, p = 0.04), less postoperative pain (pain score, WMD: -0.84, 95% CI: -1.62 to -0.07, p = 0.03), and superior cosmetic appearance compared with MP-RP. In addition, no differences were found between the SP-RP and MP-RP groups in terms of operative time, blood loss, rate of complications, and recovery of renal function. Conclusion: SP-RP provided comparable effectiveness, safety, and superior outcomes in terms of cosmetic appearance and pain compared with MP-RP, which gives surgeons the confidence to adopt and promote these ultraminimal invasive surgeries.

Day Surgery in Children Undergoing Retroperitoneal Robot-assisted Laparoscopic Pyeloplasty: Is It Safe and Feasible?

Background

Robot-assisted pyeloplasty is the most frequently performed robotic procedure in children. A retroperitoneal approach limits surgical trauma and avoids peritoneal irritation. This led to the establishment of the criteria for day surgery (DS) and a related clinical care pathway.

Objective

To assess the feasibility and safety of DS in children undergoing retroperitoneal robot-assisted laparoscopic pyeloplasty (R-RALP).

Design setting and participants

We performed a bicentric prospective study (NCT03274050) over 2 yr involving the two major paediatric urology teaching hospitals in Paris. A clinical pathway and a prospective research protocol were specifically established.

Intervention

DS in selected children undergoing R-RALP.

Outcome measurements and statistical analysis

The primary outcomes were DS failure, 30-d complications, and readmission rates. The secondary outcomes included preoperative characteristics, perioperative parameters, and surgical outcomes. Quantitative variables were expressed as medians with interquartile ranges.

Results and limitations

Thirty-two children fulfilled specific inclusion criteria and were consecutively selected for DS following R-RALP. The median patient age was 7.6 yr (4.1-11.8) and weight 25 kg (14-45). The median console time was 137 min (108-167). There were no intraoperative complications or conversions. Six children were kept under observation overnight and discharged the following day due to persistent pain (n = 3), parental anxiety (n = 2), or a prolonged procedure (n = 1). The median duration of hospital stay of the 26 children in the DS setting was 12.7 h (12.2-13.2). During the 30-d period, there were four emergency room visits (15%) resulting in two patients requiring readmission (8%): one for febrile urinary tract infection (Clavien-Dindo II) and one child with no JJ stent for urinoma (Clavien-Dindo IIIb). Radiological studies confirmed improvement in dilatation for all cases with no recurrence (median follow-up: 15 mo).

Conclusions

This prospective case series is the first to demonstrate the feasibility and safety of DS in children undergoing R-RALP, obviating the need for routine inpatient care. Excellent results can be achieved by careful patient selection, a clear clinical pathway, and a dedicated team. Further evaluation is warranted to assess the cost effectiveness.

Patient summary

This study shows that day surgery after robotic pyeloplasty is both safe and effective in selected children.

Laparoscopic redo pyeloplasty with a buccal mucosal graft

Introduction

Redo pyeloplasty can be difficult due to scar tissue or fibrosis. Ureteral reconstruction with a buccal mucosal graft is performed safely and successfully, but most reports of ureteral reconstruction using a buccal mucosal graft are of robot-assisted surgery, with few reports of laparoscopic-assisted surgery. A case of laparoscopic-assisted redo pyeloplasty using a buccal mucosal graft is presented.

Case presentation

A 53-year-old woman was diagnosed with ureteropelvic junction obstruction, and a double-J stent was placed to relieve backache. She visited our hospital 6 months after double-J stent placement. Three months later, laparoscopic pyeloplasty was performed. At 2 months postoperatively, anatomic stenosis occurred. Holmium laser endoureterotomy and balloon dilation were performed; however, the anatomic stenosis recurred, and laparoscopic redo pyeloplasty with a buccal mucosal graft was performed. After redo pyeloplasty, obstruction was improved, and her symptoms disappeared.

Conclusion

This is the first case of using a buccal mucosal graft for laparoscopic pyeloplasty in Japan.

Laparoscopic versus robot-assisted pyeloplasty in infants and young children

OBJECTIVE

To compare the characteristics of conventional laparoscopic pyeloplasty (LP) and robotic-assisted laparoscopic pyeloplasty (RALP) in infants and young children with ureteropelvic junction obstruction (UPJO).

METHODS

We performed a retrospective study of patients (age: 0-36 months) who underwent dismembered pyeloplasty (Anderson-Hynes) with the fourth-generation RALP or traditional LP between April 2020 and December 2020.

RESULTS

A total of 33 patients with UPJO were enrolled: 12 underwent RALP (9 left side; 3 right side) and 21 underwent LP (18 left side; 3 right side). In the RALP group, the median patient age was 17 months (range: 5-36 months). In the LP group, the median patient age was 9 months (range: 2-36 months) (P = 0.182). The mean operation times were 120.25 ± 37.54 min (RALP) and 156.10 ± 51.11 min (LP) (P = 0.042), and the mean lengths of hospital stay were 6.42 ± 1.62 days (RALP) and 8.19 ± 2.25 days (LP) (P = 0.023). Removal of the drainage tube was performed after 3.08 ± 0.69 days (RALP) and after 4.76 ± 1.81 days (LP) (P = 0.001). The postoperative pain showed no significant difference. The mean hospitalization costs were 61464.75 ± 2800.53 yuan (RALP) and 22169.52 ± 3442.15 yuan (LP) (P < 0.001). The mean follow-up time was 10-18 months. Significant improvements in the anteroposterior diameter and parenchymal thickness were observed after surgery. Conversion to laparotomy was not performed. No short-term complications occurred during postoperative hospitalization and follow-up.

CONCLUSION

RALP has the advantages of less trauma and faster recovery. It can be safely and effectively performed in infants and young children, and its effectiveness is similar to that of traditional LP.

[COMPARING LAPAROSCOPIC AND ROBOT-ASSISTED PYELOPLASTY FOR URETERO-PELVIC JUNCTION OBSTRUCTION: INITIAL EXPERIENCE FROM A SINGLE CENTER]

(Objective) To compare the initial results of robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) for uretero-pelvic junction obstruction (UPJO). (Methods) Between April 2008 to October 2021, we identified 104 cases of UPJO where LP was performed and 18 cases where RALP was performed at our hospital. We retrospectively analyzed their perioperative outcomes. Furthermore, we recorded the operative times for each cases of LP and RALP. (Results) The median operative time for RALP was 141 minutes, which was significantly shorter than that for LP (204 minutes). No patient in the RALP group demonstrated any Clavien-Dindo complications (≥grade 3). During the observation period, improvement of symptoms was observed in all cases. The median suturing time in RALP was 38 minutes. Compared with the last 20 cases of LP, the time to expose the uretero-pelvic junction, the time of renal pelvis incision, and suturing time were significantly shorter in RALP. In addition, the console and suturing times were stable since the initial stage. In cases with a high grade of hydronephrosis, there was a large variation in the time to expose the uretero-pelvic junction and suture the renal pelvis and ureter in LP; however, this variation was smaller in RALP. (Conclusion) At our hospital, RALP for UPJO is considered to be a safe procedure. In the future, it is necessary to consider the long-term results and effectiveness of RALP.

Pyeloplasty with the Kangduo Surgical Robot vs the da Vinci Si Robotic System: Preliminary Results

Objective: To share our experience in robot-assisted pyeloplasty (RAP) with the Kangduo (KD) surgical robot vs the da Vinci Si (DV) robotic system (KD-RAP vs DV-RAP, respectively). Methods: From August 2019 to February 2021, 16 patients with ureteropelvic junction obstruction (UPJO) underwent KD-RAP and other 16 patients with UPJO accepted DV-RAP. All procedures were performed by the same surgeon. The perioperative results and follow-up data were prospectively collected and compared. Results: There was no conversion to open or laparoscopic surgery. The mean operation time was significantly longer in the KD-RAP group than the DV-RAP group (141 ± 28 minutes vs 118 ± 31 minutes, respectively, p = 0.04). The time per stitch was significantly longer in the KD-RAP group than the DV-RAP group (1.7 ± 0.5 minutes vs 1.4 ± 0.3 minutes, respectively, p = 0.05). No significant difference was noted in the estimated blood loss and the postoperative length of hospitalization. At a median follow-up of 19 (range 17-21) and 19.5 (range 14-33) months for the KD-RAP and DV-RAP groups, respectively, no difference was noted in the success rates between the KD-RAP and DV-RAP groups (93.75% and 100%, respectively; p = 0.31). Complications were comparable between the two groups (p = 0.54). One (6.3%) patient developed urinary infection, which responded well to oral antibiotics in KD-RAP group and 2 (12.5%) patients suffered from irritation symptoms of bladder, which improved after removal of Double-J stent in the DV-RAP group. Conclusions: The RAP with the use of the KD system was feasible, safe, and effective. The DV-RAP group showed advantage in the operation time and the time per stitch.

Acute abdominal pain localized in right iliac fossa: Not always acute appendicitis. A case of giant hydronephrosis in an 8-year-old boy and literature overview

Abdominal pain is a frequent complaint in children, leading them to seek medical attention. It can have several causes, though acute appendicitis is the most feared diagnosis when pain is localized in the right iliac fossa. We report a case of an 8-year-old boy with the complaint of acute abdominal pain, initially referred by his family doctor to a radiologist for an abdominal ultrasound (US) for suspected acute appendicitis. A fortuitous diagnosis of giant hydronephrosis (GH) was made upon admission, which showed the palpation of a huge poorly delineated abdominal mass that was probably missed at the previous examination by the general physician (GP). Uroscan confirmed the diagnosis of GH secondary to obstruction at the ureteropelvic junction. A renal MAG3 (mercaptuacetyltriglycine) scan showed revealed differential renal function (15%) on the right side, normal on the left side. Robot-assisted right pyeloplasty with the transposition of right lower polar vessels via trans-peritoneal laparoscopy was performed, and JJ probe left in-situ for a month. The boy is doing well and is under active follow-up. GH is rare; its diagnosis requires both meticulous examination and a high index of suspicion. Its management is uncodified but in children, pyeloplasty is preferred to nephrectomy.

A Comparison Between Laparoscopic and Robot-Assisted Laparoscopic Pyeloplasty in Patients with Ureteropelvic Junction Obstruction

Background

The aim of this study is to compare the results of laparoscopic pyeloplasty and robot-assisted laparoscopic pyeloplasty in patients with ureteropelvic junction obstruction.

Methods

Between March 2008 and May 2019, the patients who underwent retroperitoneal laparoscopic or robotic-assisted laparoscopic pyeloplasty in our institution were retrospectively reviewed.

Results

Thirteen patients underwent laparoscopically, and 12 patients underwent robotic surgery. The significant difference was found in median operative time between laparoscopic group (296 minutes) and robotic group (199 minutes) (P = 0.001). The median time for drain removal in laparoscopic group was longer than robotic group (3 vs. 2 days, respectively, P = 0.029).

Conclusion

Laparoscopic and robot-assisted laparoscopic pyeloplasty is safe and excellent success rates in patients with ureteropelvic junction obstruction. However, our experience study suggested that robotic surgery improves a total operative time, decreases drain removal time and less intraoperative blood loss than laparoscopic approach.

Retroperitoneal robotic-assisted laparoscopic pyeloplasty: A 10 year experience in a single institution

Introduction Pelvi-ureteric junction (PUJ) obstruction was traditionally treated with open pyeloplasty. In recent decades the development of minimally invasive techniques; including laparoscopic and later robotic surgery, has transformed treatment. The transperitoneal approach has most commonly been undertaken with few institutions reporting outcomes of the retroperitoneal approach. We report our 10 year experience of retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP). Methods A prospective database of 160 patients undergoing RALP between February 2010 and November 2019 was analysed. Data was recorded on demographics, operative details, complications and success rate. Success was determined as symptomatic improvement and/or an unobstructed renogram. Results 152 cases (95.0%) were performed using a retroperitoneal approach and 8 (5.0%) transperitoneal. Mean age was 45.317.4 years. Mean operating time was 139.445.6 minutes. A surgical drain was placed in 57 (71.3%) of the first 80 cases and 15 (18.8%) of the second 80 cases. Median hospital stay was 1 night (range 1-27). One case was converted to open pyeloplasty due to dense inflammatory tissue and one to robotic-assisted nephrectomy due to severe adhesions around the PUJ. There were no blood transfusions. There were 6 major (>grade 2 Clavien-Dindo) post-operative complications in 4 patients (2.5%). Two (1.3%) grade 3a complications: urine leak and pain after stent removal requiring nephrostomy. Three (1.9%) grade 3b complications: migrated stent requiring ureteroscopy, perirenal haematoma requiring open evacuation and stent re-insertion. One (0.6%) grade 4 complication requiring ventilatory support on intensive care. 18 patients received follow-up at an alternative hospital and 13 were lost to follow-up. Of the remaining cases 94.5% were successful. Conclusions R-RALP is a safe and effective treatment for PUJ obstruction allowing predictably rapid discharge from hospital without the need for a routine surgical drain. To our knowledge our study represents the largest single institution experience on RALP using a retroperitoneal approach.

Comparison between mini-laparoscopy, conventional laparoscopy and open approach for ureteropelvic junction obstruction treatment in children

INTRODUCTION

The aim of the study was to compare 3 mm mini-laparoscopy (mini LP), standard 5 mm laparoscopy (LP) and open surgery for pediatric pyeloplasty in a single center.

METHODS

Patients who underwent pyeloplasty from 1997 to 2017 at Hospital Sant Joan de Déu were prospectively collected. Demographic data, clinical, surgical and radiological variables were assessed. A multivariate logistic regression analysis was performed in order to identify risks for surgical complications, urinary leak and need for redo-surgery.

RESULTS

340 pyeloplasties were performed in this period: 197 open, 30 LP and 113 mini LP. Independent risk factors for surgical complications in a multivariate logistic regression model were: LP (vs mini LP, OR = 3.95; 95% CI: 1.13-13.8), higher differential renal function (each point more increases the risk 6%; 95% CI: 1-11%), older children (every year increases the risk 1.11 times; 95% CI: 1.002-1.225). Open surgery, pelvis diameter or the use of different stents were not risk factors. This model had an 80% PPV and a 92% NPV. LP (OR = 4.65; 95% CI: 1.08-19.96) and longer surgical time (OR = 1.014; 95% CI: 1.003-1.025) were independent risk factors for urinary leak. Higher pelvis diameter (OR = 0.93; 95% CI: 0.87-0.99) and the use of external stents were independent protective risk factors for urinary leak (OR = 0.09; 95% CI: 0.01-0.72). We have not found independent risk factors for redo-surgery in a multivariate logistic regression model.

CONCLUSION

mini LP can be safely and effectively used to perform pyeloplasty in pediatric patients of all ages.

Introduction of Pediatric Robot-Assisted Pyeloplasty in A Low-Volume Centre

(1) Background: This study investigated the introduction of pediatric robot-assisted pyeloplasty in a low-volume centre with reference to open pyeloplasty with regards to operative times, length of stay (LOS) and outcomes and cost analysis. (2) Methods: Data from 10 consecutive robot-assisted pyeloplasties was compared retrospectively to an age and weight matched cohort of open pyeloplasties operated on during two previous years. Operative times were analyzed in conjunction with LOS, outcomes and cost-analysis from patient records. (3) Results: Operative times remain longer in robot-assisted pyeloplasties (168 (IQR 68) vs. 141 (IQR 51) min), but patients are discharged from the hospital earlier and may return to daily activities earlier. In our hospital, the difference in LOS levels to some degree the cost difference between operations. (4) Conclusions: Robot-assisted pyeloplasty can be safely and economically introduced and maintained in a low-volume centre.

Resolution of hydronephrosis after pyeloplasty in children

BACKGROUND

There is still a lack of knowledge regarding the natural course of resolution of hydronephrosis after pyeloplasty, and no consensus exists on how resolution of hydronephrosis is defined or when resolution is expected to occur.

OBJECTIVE

To determine when resolution of hydronephrosis occurs following pyeloplasty, by type of obstruction and by surgical approach.

METHODS

This retrospective study included 125 children age <15 years treated with pyeloplasty and followed for two years with repeated ultrasound and MAG3 scan. Children with single kidneys, bilateral disease, and without hydronephrosis were excluded. Children with re-interventions were excluded in the evaluation of hydronephrosis but not in terms of success rate. Outcomes time to resolution of hydronephrosis (Anterior-Posterior diameter (APD) <10 mm or >50% reduction of APD) and 2-year success rate. Exposure was surgical approach and type of obstruction (intrinsic/extrinsic). Survival analysis was performed, adjusting for age, gender, year, laterality, preoperative renal function on MAG3, calyces dilatation and APD in the multivariable analysis.

RESULTS

At 12 months and 24 months follow-up, 90% and 93% had reached resolution, respectively. All children with persistent dilatation had improved drainage and stable or improved function on MAG3. There was no difference in time to resolution of hydronephrosis between open versus robotic-assisted laparoscopic surgery (adjusted HR 0.90, [0.54-1.52], p = 0.70), nor between different types of obstruction (aHR 0.84 [0.53-1.34], p = 0.47). Eight children had re-intervention, all identified within 3 months after primary surgery, and four had a postoperative drop on MAG3, giving a total success rate of 91% (121/135).

DISCUSSION

The vast majority of cases resolve and do so within 12 months from surgery. Since the improvement of hydronephrosis seems small between the first and second year after surgery, the value of follow-up beyond 12 months could be questioned. Based on the present study and previous literature we would recommend that children with persisting dilatation should continue their follow-up with ultrasound beyond 12 months. Children with complete resolution of their hydronephrosis at 12 months do not likely benefit from further follow-up. The same follow-up protocol should be applied, regardless of whether the obstruction is intrinsic or extrinsic in nature, or the surgery is performed with open or robotic-assisted approach. Overall, the definition of resolution of hydronephrosis varies in the literature and have impact on the results and may compromise comparisons.

CONCLUSION

Surgical approach or type of obstruction does not seem to affect time to resolution of hydronephrosis after pyeloplasty in children. Follow-up with ultrasound beyond 12 months does not seem to benefit children with complete resolution.

Robot-assisted laparoscopic ureteral reimplant: A single-center experience

Introduction:

Open ureteral reimplant has been the gold standard for management of lower ureteric strictures. With the widespread acceptance of robotic surgery, robotic-assisted laparoscopic ureteral reimplant (RALUR) is becoming the preferred choice for performing ureteral reimplant. We present our single-institution and single-surgeon experience of performing RALUR.

Materials and Methods:

We performed a retrospective analysis of 40 patients who underwent RALUR at our institute in the last 5 years. Demographic data were recorded along with presenting complaint and diagnosis. Intraoperative variables included operative and docking time, blood loss, intraoperative complications, technique, and procedure performed. Postoperative data that were analyzed included complications, hospital stay, and outcomes. Patient satisfaction score was calculated using a numerical scale of points 1–6.

Results:

The mean age of patients was 31.5 ± 9.8 years (r = 4–45). Male: female ratio was 3:5. The most common presenting symptom was flank pain, and the most common etiology was iatrogenic strictures in adults and congenital vesicoureteral reflux in children. The mean operative time and blood loss were 135.3 ± 45.1 min (r = 84–221) and 67.7 ± 31.4 ml (r = 32–118), respectively. There were no intraoperative complications and nil conversion to open surgery. The mean length of hospital stay was 4.5 ± 2.3 days (r = 3–9). Radiographic success was achieved in 41 out of 44 ureters. Eighty-five percent of the patients were completely satisfied with robotic approach and its outcomes.

Conclusion:

RALUR is a minimally invasive, safe, feasible, less morbid technique with good outcome.

Concomitant Treatment of Ureteropelvic Junction Obstruction Complicated by Renal Calculi with Laparoscopic Pyeloplasty and Pyelolithotomy via 19.5F Rigid Nephroscope: A Report of 12 Cases

OBJECTIVE

To introduce our experience of concomitant laparoscopic pyeloplasty (LP) and pyelolithotomy via 19.5 F rigid nephroscope to treat ureteropelvic junction obstruction (UPJO) complicated with renal calculi.

METHODS

The data of 42 patients with UPJO who underwent LP from June 2016 to August 2019 were retrospectively reviewed. Twelve patients with ipsilateral renal calculi underwent LP and concomitant pyelolithotomy via 19.5 F rigid nephroscope. Perioperative data of this group were compared with other 12 matched patients without calculi who underwent LP only.

RESULTS

Of 12 patients with renal calculi, only 4 patients had simple stone and the other 8 patients suffered complex stones. Anatomical solitary kidney was found in 2 patients. The mean diameter of the largest stone was 1.1 cm (ranged from 0.6 to 1.7). The mean operative time was 171 min, the mean time of nephroscopic management was 17.2 min, 7 patients received pyelolithotomy by forceps, 3 patients received pyelolithotomy and ultrasonic lithotripsy, 1 patient received ultrasonic lithotripsy, the mean number of stones retrieved was 8.9 (ranged from 0-53), in one case the calculus was inaccessible because it was located in a narrow neck caliceal diverticulum. Overall stone-free rate was 91.7% (11/12). No difference in operative time, postoperative hemoglobin drop, postoperative hospital stay and incidence of complications was observed between the 2 groups. At the mean follow-up of 17.9 months, no patients had obstruction or recurrent stones.

CONCLUSION

LP and concomitant pyelolithotomy via 19.5 F rigid nephroscope is a safe and feasible option to treat UPJO with renal calculi, with acceptable success rate and stone-free rate.

[A retrospective comparison of robotic assisted and conventional laparoscopic pyeloplasty in two centres]

Ziel

Wir verglichen in unserer retrospektiven Multicenterstudie die Ergebnisse der konventionell laparoskopischen Nierenbeckenplastik (L-NBP) mit denen der roboterassistierten Nierenbeckenplastik (R-NBP) nach Einführung des da Vinci X-Systems.

Methoden

Insgesamt wurden im definierten Zeitraum von Mai 2015 bis September 2019 76 Nierenbeckenplastiken an zwei unterschiedlichen Universitätskliniken durchgeführt. Für die Datenanalyse wurden 63 Patienten berücksichtigt, welche entweder eine L‑NBP (n = 27) oder eine R‑NBP (n = 36) nach Anderson und Hynse erhielten.

Ergebnisse

Das mediane Follow-up lag bei 22,5 (L-NBP) bzw. 12,7 (R-NBP) Monaten. Die statistische Analyse der Patientengruppen ergab bzgl. Alter, BMI, Geschlecht und betroffener Seite keinen statistischen Unterschied. Die Operationszeit war in der Gruppe der R‑NBP nicht statistisch signifikant kürzer (180 ± 72 vs. 159 ± 54 min, p = 0,194). Bezüglich postoperativer Major- bzw. Minor-Komplikationen nach Clavien-Dindo, Krankenhausaufenthaltsdauern (7,48 ± 2,86 vs. 6,33 ± 2,04 Tage) und Erfolgsrate ergab sich ebenso kein statistisch signifikanter Unterschied.

Schlussfolgerung

Unsere Daten zeigen keinen signifikanten Unterschied der beiden Gruppen bezogen auf die peri- und postoperativen Ergebnisse. Es konnte gezeigt werden, dass für den Patienten auch unmittelbar nach Implementierung eines robotischen Systems kein Nachteil entsteht.

Robotics in Pediatric Urology: Evolution and the Future

Almost 30 years have passed since the inception of minimally invasive surgery in urology and specifically in pediatric urology. Laparoscopy has now become an essential tool in the pediatric urologic armamentarium. The application of robot-assisted surgery in pediatrics has allowed for widespread utilization for common reconstructive procedures such as pyeloplasty and ureteral reimplantation. Understanding the implementation, technical considerations, and outcomes are critical for continued success and adoption. This has allowed for increased use in more complex urologic procedures such as redo pyeloplasty, dismembered ureteral reimplantation, catheterizable channel creation, and bladder augmentation.

Roboterassistierte (RA-)Kinderchirurgie: Nierenbeckenplastiken mit dem Da-Vinci-Roboter

Hintergrund

Im Ausland stellt die roboterassistierte (RA-)Chirurgie und hier besonders die RA-Urologie in der Kinderchirurgie bereits eine wichtige Alternative zu konventionellen Eingriffen (offen, laparoskopisch, laparoskopisch-assistiert) dar. Für Deutschland wurden dazu erst wenige Untersuchungen publiziert.

Ziel der Arbeit (Fragestellung)

Im Sinne einer vergleichenden Serie sollten die ersten Fälle von RA-Nierenbecken-Plastiken der Kinderchirurgie der Universitätsmedizin Göttingen im Vergleich zu konventionell laparoskopisch-assistierten (LAA) vor dem Hintergrund der internationalen Literatur evaluiert werden.

Material und Methoden

Es werden retrospektiv die ersten 13 RA und 14, unter Berücksichtigung des Patientenalters ausgewählte, konventionell LAA Anderson-Hynes-Plastiken hinsichtlich Operationsdauer, Krankenhausverweildauer, Alter der Patienten, Komplikationen und Rezidiven untersucht. Laparoskopisch-assistierte Operationen werden laparoskopisch durchgeführt, lediglich die Anlage der Anastomose erfolgt über einen kleinen Flankenschnitt extrakorporal. Roboterassistierte Eingriffe verlaufen gänzlich laparoskopisch.

Ergebnisse

Für die Operationsdauer ergab sich kein signifikanter Unterschied (111,54 min vs. 117,64 min). Die Liegezeit fiel für RA-Eingriffe signifikant kürzer aus (5,85 Tage vs. 10,0 Tage). Die Altersverteilung ergab für die RA-Kohorte ein Mittel von 52,23 Monaten und für die LAA 30,29 Monate. Die Komplikationsrate betrug 15,38 % (Harntransportstörung, paralytischer Ileus und Dislokation des PDK sowie Omentumprolaps), die Rezidivrate 7,69 % für die RA Eingriffe. Für die LAA operierten Patienten und Patientinnen lagen die Werte bei 7,14 % (Dislokation der Doppel-J-Schiene nach kranial) und 14,28 %.

Diskussion

Die ersten RA-Nierenbecken-Plastiken unserer Klinik wiesen im internationalen Vergleich ähnliche Werte für Operationsdauer, Komplikations- sowie Rezidivrate auf. Es zeigten sich ein ähnliches Outcome für beide Operationsverfahren und keine signifikante Zeitersparnis durch Verwendung des OP-Roboters. Im Gegensatz dazu fiel die Krankenhausverweildauer nach RA-Eingriffen signifikant kürzer aus als nach LAA-Operationen. In der internationalen Literatur finden sich jedoch auch insgesamt kürzere Liegezeiten. Insgesamt stellen RA-Nierenbecken-Plastiken eine wertvolle Alterative zu LAA-Verfahren dar.

Robotic dismembered pyeloplasty surgical simulation using a 3D-printed silicone-based model: development, face validation and crowdsourced learning outcomes assessment

Ureteropelvic junction obstruction (UPJO) is an uncommonly encountered pathology, posing a challenge for resident training. We describe the development and face validation of a robotic pyeloplasty simulation using a 3D-printed silicone-based model of UPJO for surgical training, in combination with crowdsourced scoring to objectively assess performance and learning outcomes. The organs were created using 3D modeling software and printed using a silicone-based material by Lazarus 3D, LLC. They were secured in a laparoscopic box trainer and the robotic system was docked. Eight residents and three faculty each performed two robotic-assisted right dismembered pyeloplasties on separate occaisions. Face validity was evaluated on a 5-point Likert scale. Crowd-Sourced Assessment of Technical Skills (C-SATS Inc.) scored surgical performance using the Global Evaluative Assessment of Robotic Skills (GEARS) criteria, based on video review of each simulation. All participants completed the simulation twice with fully patent anastomoses. Average time to complete the first and second trials was 44.4 min and 43.2 min, respectively. The average GEARS score was 17.1 and 17.6 for the first and second trials respectively. Participants improved on average in all 5 GEARS categories, with significant improvement in depth perception (p = 0.006). The model received mean scores (out of 5) of 4.36 for aesthetics, 4.18 for overall feel, 3.55 for realism, 4.72 for usability, and 4.72 for suturability. Residents had a significant increase in confidence between initial and final surveys on a 5-point Likert Scale: 1.63 vs. 2.38 (p = 0.03). Using 3D-printed silicone-based models, participants completed robotic-assisted dismembered pyeloplasties for training and skill acquisition. We demonstrated face validity of the simulation, which was also found to improve participant speed and significantly improve resident confidence. Crowdsourced assessment demonstrated significant improvement in depth perception.

Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances. Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures. Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame. Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

Outcomes Following Primary Realignment Versus Suprapubic Cystostomy with Delayed Urethroplasty for Pelvic Fracture-Associated Posterior Urethral Injury: A Systematic Review with Meta-Analysis

Objective

Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU.

Methods

PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9).

Results

From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82).

Conclusion

For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.

Comparison of open, laparoscopic and robot-assisted pyeloplasty for pelviureteric junction obstruction in adult patients

Ureteropelvic junction obstruction (UPJO) is a frequently found congenital abnormality of the upper urinary tract treated with pyeloplasty. We hereby report a study to compare open pyeloplasty (OP), laparoscopic pyeloplasty (LP) and robotic assisted pyeloplasty (RAP) for UPJO in terms of functional and perioperative outcomes. 102 patients who underwent Anderson-Hynes dismembered pyeloplasty for UPJO were divided into three groups based on type of surgical techniques utilized as follows: OP (Group A; n = 34), LP (Group B; n = 34), and RAP (Group C; n = 34). Preoperative, intraoperative and postoperative data were recorded. The mean operative time was significantly more in the Group B (187.76 min) than the Group A (132.06 ± 30.1 min) and Group C (136.76 ± 25.1 min) (p < .001). Mean blood loss was more in OP group 86.47 ± 29. 35 ml versus 42.94 ± 20. 77 ml in RAP and 45.59 ± 20. 3 ml in the LP group (p < .001). The LP was found to be much tiring. Mean surgeon fatigue index (SFI) calculated was 7 ± 1.1 in the LP group compared to 4.12 ± 1.1 in RAP group and the difference was statistically significant (p< .001). Average VAS score in the first 2 days postoperatively was 6.66±1.58 in the OP group compared to 4.29 ± 1.16 in RAP group and 4.29 ± 1.31 in the LP group (p < 0.001). Pyeloplasty has a similar success rate and efficacy irrespective of the technique utilized. RAP improves the surgeons QOL (quality of life) and the fatigue scores, which is useful for surgeon longevity. RAP has become widely favorite and can be considered the approach of choice in the management of UPJO wherever infrastructure and finances allow.

Recent advances in urologic surgical techniques for pyeloplasty

Pyeloplasty is one of the most common urological reconstructive interventions. Since the presentation of the first open pyeloplasty by Anderson and Hynes in 1949, the management of ureteropelvic junction obstruction has dramatically developed. The most immense progress was made in the 1990s with the introduction of laparoscopy. A multitude of new minimal surgical techniques have been introduced since then. In the last few years, the innovations were based on refinement of already-existing techniques and technology. With this aim, single-port surgery, three-dimensional vision for laparoscopy, robotic technology, and alternative techniques for creating the anastomosis-like fibrin glue have been introduced. This unsystematic review is timely, and the scientific interest is to present and discuss some of the latest advances in surgical techniques and different approaches for the intra- and post-operative management in pyeloplasty. To the best of our knowledge, this is the only review looking at the recent advances in urological surgical techniques for pyeloplasty during the last few years with a focus on new technology and surgical techniques.

Balloon dilation for failed pyeloplasty in children?

Objective:

Pyeloplasty is considered the gold standard treatment for ureteropelvic junction obstruction (UPJO). However, the failure rate of pyeloplasty is as high as 10% and repeat pyeloplasty is more difficult. This study aimed to evaluate the efficacy of balloon dilatation for failed pyeloplasty in children.

Materials and Methods:

Between 2011 and 2017, 15 patients, aged 6 months to 14 years, were treated with balloon dilation for restenosis of UPJO after a failed pyeloplasty. Ultrasound and intravenous urography were used to evaluate the primary outcome. Success was defined as the relief of symptoms and improvement of hydronephrosis, which was identified by ultrasound at the last follow-up.

Results:

All patients successfully completed the operation, 13 patients by retrograde approach and 2 patients by antegrade approach. Thirteen patients were followed for a median of 15 (4 to 57) months and 2 patients were lost to follow-up. Resolution of the hydronephrosis was observed in 5 cases. The anteroposterior diameter (APD) of the pelvis decreased by an average of 12.4 ± 14.4mm. Eight patients needed another surgery. The average postoperative hospital stay was 1.78 ± 1.4 days. Two patients experienced fever after balloon dilation. No other complications were found.

Conclusions:

Balloon dilatation surgery is safe for children, but it is not recommended for failed pyeloplasty in that group of patients, owing to the low success rate.

Current Concepts in Pediatric Robotic Assisted Pyeloplasty

Robotic surgery in pediatric urology has been gaining popularity since its introduction almost two decades ago. Robotic assisted pyeloplasty is the most common robotic procedure performed in pediatric urology. Advances in robotic technology, instrumentation, patient care and surgical expertise have allowed the correction of ureteropelvic junction (UPJ) obstruction in most patients using this minimally invasive technique. The excellent experience with robotic assisted pyeloplasty has challenged other approaches as a new standard for the treatment of UPJ obstruction. In this review, we will describe the technique as it relates to the different robotic platforms, review the surgical experience and compare its results to other surgical approaches. Also, we will discuss patient and parent satisfaction, cost and financial considerations, along with evaluating the future of robotic surgery in the treatment of UPJ obstruction.

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.

Implementation of Robotic Surgery in a Pediatric Hospital: Lessons Learned

BACKGROUND

Since the late 1980s, minimally invasive surgery (MIS) has been one of the fastest growing approaches for surgical procedures. However, its development has reached a plateau. One of the reasons is the difficulty to operate on more complex cases, such as neonatal procedures. Some experts report outstanding outcomes for complex operations, but not all surgeons may be able to achieve the same results. Is robotic surgery (RS) a solution?

METHODS

To answer this question, we reviewed the current indications of RS for the pediatric population and the steps needed to incorporate the robotic surgical system in a children's hospital. We reported our experience and presented our first results and the encountered problems.

RESULTS

After a year and a half of experience with RS, several lessons were learned: (1) the current robotic surgical system cannot yet be considered a replacement to conventional MIS, (2) docking is less time consuming than expected, (3) postoperative pain is significantly decreased, (4) the absence of haptic feedback is still a matter of concern, and (5) costs can be afforded by sharing the RS with adult surgeons.

CONCLUSIONS

Based on our experience, the advantages seem to outweigh the drawbacks as it encourages team building and increases overall comfort for the surgeon. However, the current literature fails to prove that RS gives better results for pediatric patients. New advances in technology will probably help to overcome the encountered difficulties and the high costs.

Laparoscopic versus open pyeloplasty: a multi-institutional prospective study

INTRODUCTION

To prospectively compare the perioperative and functional outcomes of laparoscopic (LP) and open pyeloplasty (OP) in three academic institutions.

MATERIAL AND METHODS

Between September 2012 and September 2016, 102 patients with primary uteropelvic junction obstruction (UPJO) underwent pyeloplasty (51 LP and OP for the other 51 patients). Demographic data, perioperative parameters, including operative time, estimated blood loss, complications, length of hospital stay, and functional outcome were compared, and SF-8 Health Survey scoring was recorded for each group.Patients were followed up by ultrasound (US) and /or intravenous urography (IVU) at 3, 6 and 12 months. A MAG-3 renal scan was performed at 3 months postoperatively.

RESULTS

The mean operative time was significantly shorter in the open group (153.2 ±42 min vs. 219.8 ±46 min; P <0.001). Compared to OP, the mean postoperative analgesia (Diclofenac) requirement was significantly less in the LP group (101.1 ±36 mg vs. 459.1 ±123 mg; P <0.001). The median hospital stay was significantly shorter for LP (2.7 ±1.8 days vs. 9.09 ±7.3 days; P <0.001). The median follow-up period was 19.7 months (12-28 months). The success rate was 96.1% in the OP group and 94.1% in the LP group.

CONCLUSIONS

In spite of being a technically demanding procedure, LP offers faster recovery and higher patient satisfaction. In our hands, OP still has a shorter operative time and relatively lower retreatment rate.

Robotic-assisted versus laparoscopic cholecystectomy for benign gallbladder diseases: a systematic review and meta-analysis

BACKGROUND

Robotic surgery, an emerging technology, has some potential advantages in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted cholecystectomy (RAC) is still a controversial issue on its comparative merit compared with conventional laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the safety and efficacy of RAC compared with LC for benign gallbladder disease.

METHODS

A systematic literature search was conducted using the PubMed, EMBASE, and Cochrane Library databases (from their inception to December 2017) to obtain comparative studies assessing the safety and efficacy between RAC and LC. The quality of the literature was assessed, and the data analyzed using R software, random effects models were applied.

RESULTS

Twenty-six studies, including 5 RCTs and 21 NRCSs (3 prospective plus 18 retrospective), were included. A total of 4004 patients were included, of which 1833 patients (46%) underwent RAC and 2171 patients (54%) underwent LC. No significant differences were found in intraoperative complications, postoperative complications, readmission rate, hospital stay, estimated blood loss, and conversion rate between RAC and LC groups. However, RAC was related to longer operative time compared with LC (MD = 12.04 min, 95% CI 7.26-16.82) in RCT group, which was consistent with NRCS group; RAC also had a higher rate of incisional hernia in NRCS group (RR = 3.06, 95% CI 1.42-6.57), and one RCT reported that RAC was similar to LC (RR = 7.00, 95% CI 0.38-129.84).

CONCLUSIONS

The RAC was not found to be more effective or safer than LC for benign gallbladder diseases, which indicated that RAC is a developing procedure instead of replacing LC at once. Given the higher costs, the current evidence is in favor of LC in cholecystectomy.

The Feasibility of Laparoscopic Surgery in Gynecologic Oncology for Obese and Morbidly Obese Patients

Background

Surgical interventions are the mainstay of treatment for many gynecological cancers. Although minimally invasive surgery offers many potential advantages, performing laparoscopic pelvic surgery in obese patients remains challenging. To overcome this, many centers have shifted their practice to robotic surgery; however, the high costs associated with robotic surgery are concerning and limit its use.

Objective

This study aimed to examine the feasibility of performing laparoscopic gynecologic oncology procedures in obese and morbidly obese patients.

Materials and Methods

This retrospective study evaluated patients who underwent laparoscopic surgeries by a gynecologic oncologist from January 2012 to June 2016 at a designated gynecologic oncology center. Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2), obese (BMI 30–39.9 kg/m2), and morbidly obese (BMI ≥ 40 kg/m2). Intra and postoperative complications and outcomes were recorded. Group differences were computed with Kruskal-Wallis nonparametric test (continuous) or Fisher exact test (categorical).

Results

Of 497 patients, 288 were nonobese (58%), 162 obese (33%), and 47 morbidly obese (9%). Complex surgical procedures were performed in 57.4% of obese patients and 55.3% of morbidly obese patients. Although morbidly obese and obese patients had longer operative times (mean of 181 and 166 minutes vs 144 minutes,P= 0.014), conversion from laparoscopy to laparotomy occurred in 9.05% of all patients, with no group differences. Low intraoperative (9%–11%) and severe postoperative (2.41%) complication rates were observed overall, with no group differences. There was no statistically significant difference in the rate of emergency room visits 30 days postoperation between the 3 BMI groups (P= 0.6108). Average length of postoperative stay was statistically significant (P= 0.0003) but was low overall (1–2 days). Hospital readmission rates were low, with the lowest rate among morbidly obese patients (2.13%).

Conclusions

Our data suggest that laparoscopic gynecologic-oncology procedures for obese patients are feasible and safe.

Robot-assisted laparoscopic pyeloplasty: a single-centre experience

BACKGROUND

Ureteropelvic junction obstruction (UPJO) is characterised by an obstruction compromising the passage of urine from the renal pelvis into the ureter, and can be corrected by Robot-Assisted Laparoscopic Pyeloplasty (RALP). We aimed to evaluate the surgical outcomes of RALP, and examine the rates of true pain resolution following the procedure.

METHODS

We retrospectively explored the records of all patients who underwent RALP between April 2005 and January 2017. Measures of success were defined as the prevention of deterioration in split renal function and resolution of obstruction, and the resolution or improvement in subjective pain levels.

RESULTS

83 patients were included in this series. Mean patient age was 40.8 years. 38 patients had a left sided RALP, whilst 45 underwent RALP on the right. Crossing vessels were identified in 53.0% of patients. Mean operative time was 148.0 min. 68 patients had pain as their presenting feature. Following RALP, the pain resolved in 69.2% (n = 47), improved in 26.5% (n = 18), and remained the same in 4.4% (n = 3). 11.8% (n = 8) of patients required referral to other specialities for pain management. Success from a radiological perspective of cleared obstruction and arrest of deteriorating renal function was 97.6%.

CONCLUSIONS

Our individual outcomes demonstrate a high success rate regarding resolution of obstruction and preventing deterioration in renal function. We also report that a number of patients, who despite meeting the radiological criteria to undergo RALP, had alternate underlying causes for their pain symptoms. For this reason, we propose that the primary measure of success for RALP should be based on renal function and radiological outcomes, rather than the outcomes relating to pain. Both surgeons and patients should be aware that whilst RALP is a highly successful procedure, persistence of pain may be due to overlapping clinical conditions which can be managed by a multidisciplinary approach.

Robotics in urology

Twenty years after it was introduced, robotic surgery has become more commonplace in urology – we examine its current uses and controversies

Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: A systematic review and meta-analysis

Importance

This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery (RLS) and conventional laparoscopic surgery (CLS) based on randomly-controlled trials (RCTs).

Objectives

We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure.

Evidence review

A search was conducted for RCTs in PubMed, EMBASE, and Cochrane databases from 1981 to 2016. Among a total of 1,517 articles, 27 clinical reports with a mean sample size of 65 patients per report (32.7 patients who underwent RLS and 32.5 who underwent CLS), met the inclusion criteria.

Findings

CLS shows significant advantages in total operative time, net operative time, total complication rate, and operative cost (p < 0.05 in all cases), whereas the estimated blood loss was less in RLS (p < 0.05). As subgroup analyses, conversion rate on colectomy and length of hospital stay on hysterectomy statistically favors RLS (p < 0.05).

Conclusions

Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Operative time and total complication rate are significantly more favorable with CLS.

Does antegrade JJ stenting affect the total operative time during laparoscopic pyeloplasty?

OBJECTIVE

We aimed to show the effect of retrograde JJ stenting and intraoperative antegrade JJ stenting techniques on operative time in patients who underwent laparoscopic pyeloplasty.

MATERIAL AND METHODS

A total of 34 patients were retrospectively investigated (15 male and 19 female) with ureteropelvic junction obstruction. Of the patients stentized under local anesthesia preoperatively, as a part of surgery, 15 were retrogradely stentized at the beginning of the procedure (Group 1), and 19 were antegradely stentized during the procedure (Group 2). A transperitoneal dismembered pyeloplasty technique was performed in all patients. The two groups were retrospectively compared in terms of complications, the mean total operative time, and the mean stenting times.

RESULTS

The mean ages of the patients were 31.5±15.5 and 33.2±15.5 years (p=0.09), and the mean body mass indexes were 25.8±5.6 and 26.2.3±8.4 kg/m2 in Group 1 and Group 2, respectively. The mean total operative times were 128.9±38.9 min and 112.7±21.9 min (p=0.04); the mean stenting times were 12.6±5.4 min and 3.5±2.4 min (p=0.02); and the mean rates of catheterization-to-total surgery times were 0.1 and 0.03 (p=0.01) in Group 1 and 2, respectively. The mean hospital stays and the mean anastomosis times were similar between the two groups (p>0.05).

CONCLUSION

Antegrade JJ stenting during laparoscopic pyeloplasty significantly decreased the total operative time.

The Comparative Effectiveness of Treatments for Ureteropelvic Junction Obstruction

OBJECTIVE

To examine the effectiveness of the 3 primary treatments for ureteropelvic junction obstruction (ie, open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy) as assessed by failure rates.

MATERIALS AND METHODS

Using MarketScan data, we identified adults (ages 18-64 years) who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was failure (ie, need for a secondary procedure). We fit a Cox proportional hazards model to examine the effects of different patient, regional, and provider characteristics on treatment failure. We then implemented a survival analysis framework to examine the failure-free probability for each treatment.

RESULTS

We identified 1125 minimally invasive pyeloplasties, 775 open pyeloplasties, and 1315 endopyelotomies with failure rates of 7%, 9%, and 15%, respectively. Compared with endopyelotomy, minimally invasive pyeloplasty was associated with a lower risk of treatment failure (adjusted hazards ratio [aHR] 0.52; 95% confidence interval [CI], 0.39-0.69). Minimally invasive and open pyeloplasties had similar failure rates. Compared with open pyeloplasty, endopyelotomy was associated with a higher risk of treatment failure (aHR 1.78; 95% CI, 1.33-2.37). The average length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P <.001).

CONCLUSION

Endopyelotomy has the highest failure rate, yet it remains a common treatment for ureteropelvic junction obstruction. Future research should examine to what extent patients and physicians are driving the use of endopyelotomy.

Global minimally invasive pyeloplasty study in children: Results from the Pediatric Urology Expert Group of the European Association of Urology Young Academic Urologists working party

INTRODUCTION

Minimally invasive pyeloplasty (MIP) for ureteropelvic junction (UPJ) obstruction in children has gained popularity over the past decade as an alternative to open surgery. The present study aimed to identify the factors affecting complication rates of MIP in children, and to compare the outcomes of laparoscopic (LP) and robotic-assisted laparoscopic pyeloplasty (RALP).

MATERIALS AND METHODS

The perioperative data of 783 pediatric patients (<18 years old) from 15 academic centers who underwent either LP or RALP with an Anderson Hynes dismembered pyeloplasty technique were retrospectively evaluated. Redo cases and patients with anatomic renal abnormalities were excluded. Demographics and operative data, including procedural factors, were collected. Complications were classified according to the Satava and modified Clavien systems. Failure was defined as any of the following: obstructive parameters on diuretic renal scintigraphy, decline in renal function, progressive hydronephrosis, or symptom relapse. Univariate and multivariate analysis were applied to identify factors affecting the complication rates. All parameters were compared between LP and RALP.

RESULTS

A total of 575 children met the inclusion criteria. Laparoscopy, increased operative time, prolonged hospital stay, ureteral stenting technique, and time required for stenting were factors influencing complication rates on univariate analysis. None of those factors remained significant on multivariate analysis. Mean follow-up was 12.8 ± 9.8 months for RALP and 45.2 ± 33.8 months for LP (P = 0.001). Hospital stay and time for stenting were shorter for robotic pyeloplasty (P < 0.05 for both). Success rates were similar between RALP and LP (99.5% vs 97.3%, P = 0.11). The intraoperative complication rate was comparable between RALP and LP (3.8% vs 7.4%, P = 0.06). However, the postoperative complication rate was significantly higher in the LP group (3.2% for RALP and 7.7% for LP, P = 0.02). All complications were of no greater severity than Satava Grade IIa and Clavien Grade IIIb.

DISCUSSION

This was the largest multicenter series of LP and RALP in the pediatric population. Limitations of the study included the retrospective design and lack of surgical experience as a confounder.

CONCLUSIONS

Both minimally invasive approaches that were studied were safe and highly effective in treating UPJ obstruction in children in many centers globally. However, shorter hospitalization time and lower postoperative complication rates with RALP were noted. The aims of the study were met.

Comparing the efficacy and safety between robotic-assisted versus open pyeloplasty in children: a systemic review and meta-analysis

OBJECTIVE

This manuscript is mainly to systemically review the published reports that compared the efficacy and safety of robotic-assisted (RP) versus open pyeloplasty (OP) in children with ureteropelvic junction obstruction (UPJO).

METHODS

We did a systemic search in the PubMed(®) for all randomized controlled trials or comparative studies that compared the surgical results of robotic versus open pyeloplasty in children with UPJO. Two of the authors (Hsu and Chang) independently did the literature search, quality assessment, and data extraction. The obtained data were analyzed with Cochrane Collaboration Review Manager (RevMan(®), version 5.3). The end points of the analysis and review included age, operative time, hospital stay, costs, complications, and success rate.

RESULTS

In total, seven comparative trials and three studies using national database met the criteria that comprised 20,691 (RP:OP = 1956:18,735) patients in the meta-analysis. Most studies reported median value of patient age, operative time, and hospital stay. Only a small proportion of studies could be included for meta-analysis. The enrolled trials revealed that RP was more frequently performed in older children, required longer operative time, and shorter hospital stay. The postoperative success rate was comparable (RR = 0.99, 95 CI 0.94-1.04). Comparing with OP, there was a significant higher complication rate (RR = 1.29, 95 CI 1.10-1.51) and higher costs in the RP group.

CONCLUSION

Robotic-assisted pyeloplasty may be a promising alternative minimal invasive surgery for UPJO in children if the higher complication rates and higher costs in the RP can be overcome in the near future.

Comparison of surgical and functional outcomes of open, laparoscopic and robotic pyeloplasty for the treatment of ureteropelvic junction obstruction

OBJECTIVE

To compare the surgical and functional outcomes of open, laparoscopic and robotic dismembered pyeloplasty for the treatment of patients with ureteropelvic junction obstruction (UPJO).

MATERIAL AND METHODS

Between 2007 and 2012, a total of 56 patients underwent conventional open (Group 1; n=25), laparoscopic (Group 2; n=16), and robotic (Group 3; n=15) dismembered pyeloplasty operations. Preoperative evaluation was performed using urinalysis, urine culture, blood biochemistry, urinary ultra-sound, intravenous pyelogram (IVP) (optional) and Mercaptoacetyltriglycine (MAG-3) renal scan. The mean operation time, estimated blood loss, drain removal time, narcotic analgesic requirements, length of hospital stay and functional outcomes were compared among groups. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) v. 20 (IBM, Armonk, NY, USA) software, and statistically significant differences were determined using a p value <0.05.

RESULTS

The mean age of the patients was 30 years in Group 1, 34.3 years in Group 2 and 32.9 years in Group 3. The mean operation time was 127, 130 and 114 min (p=0.32), and the estimated blood loss was 105, 31 and 28 mL, respectively (p=0.001). The drain was removed after 4.36 (±1.3), 2.33 (±0.6) and 1.8 (±0.6) days after surgery (p<0.001), and the mean hospital stay was 4.14 (±1.8), 2.8 (±0.75) and 2 (±1) days, respectively (p<0.001). Narcotic analgesic requirement was significantly higher in Group 1 compared with Groups 2 and 3 (p=0.02). The radiographic and symptomatic success rates were 96% in Group 1, 93.75% in Group 2 and 93.3% in Group 3.

CONCLUSION

Laparoscopic and robotic pyeloplasty are feasible, effective, reliable and minimally invasive treatment approaches for the treatment of UPJO as compared with open dismembered pyeloplasty.