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Manunta A, Peyronnet B, Olivari-Philiponnet C, Chartier-Kastler E, Saussine C, Phé V, Robain G, Denys P, Even A, Samson E, Grise P, Karsenty G, Hascoet J, Castel-Lacanal E, Charvier K, Guinet-Lacoste A, Chesnel C, Amarenco G, Haffner F, Haddad M, Le Normand L, Perrouin-Verbe MA, Perrouin-Verbe B, De Seze M, Ruffion A, Gamé X. [Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]. Prog Urol 2023; 33:178-197. [PMID: 36609138 DOI: 10.1016/j.purol.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/10/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population. MATERIALS AND METHODS National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached. RESULTS Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible). CONCLUSION Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.
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Affiliation(s)
- A Manunta
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France
| | - B Peyronnet
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France.
| | | | - E Chartier-Kastler
- Service d'Urologie, GH Pitié-Salpétrière, APHP, Paris, France; Sorbonne Université, Paris, France; Service de médecine physique et réadaptation, Hôpital Raymond-Poincaré, APHP, Garches, France
| | - C Saussine
- Service d'urologie, les hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - V Phé
- Service d'urologie, Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - G Robain
- Service de médecine physique et réadaptation, Hôpital Rotschild, APHP, Paris, France
| | - P Denys
- Service de médecine physique et réadaptation, Hôpital Raymond-Poincaré, APHP, Garches, France; Faculté de médecine Paris Ouest, Université de Versailles-Saint-Quentin-en-Yvelines, Garches, France
| | - A Even
- Service de médecine physique et réadaptation, Hôpital Raymond-Poincaré, APHP, Garches, France; Faculté de médecine Paris Ouest, Université de Versailles-Saint-Quentin-en-Yvelines, Garches, France
| | - E Samson
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France
| | - P Grise
- Service d'urologie, CHU Rouen, Rouen, France
| | - G Karsenty
- Aix-Marseille Université, urologie et transplantation rénale, Hôpital La Conception, AP-HM, Marseille, France
| | - J Hascoet
- Centre de référence Spina Bifida-Dysraphismes, CHU Pontchaillou, Rennes, France
| | - E Castel-Lacanal
- CHU Toulouse, service de médecine physique et de réadaptation et ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - K Charvier
- Service de médecine physique et réadaptation, Hôpital Henry-Gabrielle, Hospices civils de Lyon, Saint-Genis-Laval, France
| | - A Guinet-Lacoste
- Sorbonne Université, GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, AP-HP, Hôpital Tenon, 75020 Paris, France
| | - C Chesnel
- Sorbonne Université, GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, AP-HP, Hôpital Tenon, 75020 Paris, France; Service de neuro-urologie et explorations périnéales, Hôpital Tenon, AP-HP, Paris, France
| | - G Amarenco
- Sorbonne Université, GRC 001, GREEN Groupe de recherche clinique en neuro-urologie, AP-HP, Hôpital Tenon, 75020 Paris, France; Service de neuro-urologie et explorations périnéales, Hôpital Tenon, AP-HP, Paris, France
| | - F Haffner
- ASBH, Association nationale Spina Bifida et Handicaps associés, 94420 Le Plessis Trevise, France
| | - M Haddad
- Service de chirurgie viscérale et urologie pédiatrique, AP-HM, Marseille, France
| | - L Le Normand
- Service d'urologie, CHU de Nantes, Nantes, France
| | | | - B Perrouin-Verbe
- Service de médecine physique et réadaptation, CHU de Nantes, Nantes, France
| | - M De Seze
- Spécialiste en médecine physique et de réadaptation, Clinique St.-Augustin, Bordeaux, France
| | - A Ruffion
- Service d'urologie, Hospices civils de Lyon, Lyon, France
| | - X Gamé
- Département d'urologie, transplantation rénale et andrologie, CHU Rangueil, Université Paul-Sabatier, Toulouse, France
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2
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Affiliation(s)
- Parviz Hajiyev
- The University of Chicago Comer Children's Hospital, Chicago, Illinois, USA.
| | - Mohan S Gundeti
- The University of Chicago Comer Children's Hospital, Chicago, Illinois, USA
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Mei H, Tang S. Robotic-assisted surgery in the pediatric surgeons' world: Current situation and future prospectives. Front Pediatr 2023; 11:1120831. [PMID: 36865692 PMCID: PMC9971628 DOI: 10.3389/fped.2023.1120831] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023] Open
Abstract
Robotic-assisted surgery has been fully embraced by surgeons for the adult population; however, its acceptance is too slow in the world of pediatric surgeons. It is largely due to the technical limitations and the inherent high cost associated with it. In the past two decades, indeed, there has been considerable advancement in pediatric robotic surgery. A large number of surgical procedures were performed on children with the assistance of robots, even with comparative success rates to standard laparoscopy. As a newly developing field, it still has many challenges and obstacles. This work is centered on the current status and progression of pediatric robotic surgery as well as the future perspectives in the field of pediatric surgery.
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Affiliation(s)
- Hong Mei
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shaotao Tang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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4
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Open bladder augmentation ileocystoplasty, appendicovesicostomy creation, and bladder neck reconstruction. UROLOGY VIDEO JOURNAL 2022. [DOI: 10.1016/j.urolvj.2022.100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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5
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Brownlee EM, Slack M. The Role of the Versius Surgical Robotic System in the Paediatric Population. CHILDREN 2022; 9:children9060805. [PMID: 35740742 PMCID: PMC9222178 DOI: 10.3390/children9060805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 12/05/2022]
Abstract
The uptake of robot-assisted surgery has continuously grown since its advent in the 1990s. While robot-assisted surgery is well-established in adult surgery, the rate of uptake in paediatric surgical centres has been slower. The advantages of a robot-assisted system, such as improved visibility, dexterity, and ergonomics, could make it a superior choice over the traditional laparoscopic approach. However, its implementation in the paediatric surgery arena has been limited primarily due to the unavailability of appropriately sized instruments as per paediatric body habitus, therefore, requiring more technologically advanced systems. The Versius surgical robotic system is a new modular platform that offers several benefits such as articulated instruments which pass through conventional 5 mm ports, compact arms for easier manoeuvrability and patient access, the ability to mimic conventional port placements, and adaptive machine learning concepts. Prior to its introduction to paediatric surgery, it needs to go through a careful pre-clinical and clinical research program.
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Affiliation(s)
- Ewan M. Brownlee
- Department of Paediatric Surgery and Urology, Southampton Children’s Hospital, University Hospital Southampton, Southampton SO16 6YD, UK;
| | - Mark Slack
- Clinical School, University of Cambridge, Cambridge CB2 2QQ, UK
- CMR Surgical Ltd., 1EBP, Milton Rd, Cambridge CB24 9NG, UK
- Correspondence: ; Tel.: +44-1223-755300 or +44-7766024389
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Management of the Transitional Urology Patient: the Role of the Adult Reconstructive Urologist. Curr Urol Rep 2021; 22:15. [PMID: 33534013 DOI: 10.1007/s11934-021-01035-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Patients with congenital urologic conditions present unique challenges as adults. Herein, we review the literature relevant to the adult reconstructive urologist confronted with complex surgical concerns affecting their patients with a history of hypospadias, spina bifida, and other syndromes affecting the genitourinary tract. RECENT FINDINGS Urethral stricture disease related to hypospadias is complex, but successful urethroplasty and penile curvature correction can be achieved with an anatomically minded approach. Multiple urinary diversion techniques can be considered in a patient-centered approach to bladder management in the adult spina bifida patient, but complications are common and revision surgeries are frequently required. Strong evidence is lacking for most surgical techniques in this population, but experiences reported by pediatric and adult urologists with genitourinary reconstruction training can help foster consensus in decision-making. Urologists trained in genitourinary reconstruction may be uniquely positioned to care for the transitional urology patient as they enter adolescence and adulthood.
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Abstract
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.
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Affiliation(s)
- Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Arun Srinivasan
- Division of Urology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Mittal S, Srinivasan A, Bowen D, Fischer KM, Shah J, Weiss DA, Long CJ, Shukla AR. Utilization of Robot-assisted Surgery for the Treatment of Primary Obstructed Megaureters in Children. Urology 2020; 149:216-221. [PMID: 33129867 DOI: 10.1016/j.urology.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the technical aspects of robot assisted laparoscopic ureteral reimplantation (RALUR) for the management of primary obstructive megaureter (POM) and report initial outcomes, safety, and feasibility of the procedure. METHODS Using an IRB- approved robotic surgery registry, we performed a retrospective chart review of patients undergoing RALUR for POM between April 2009 and May 2019. RESULTS A total of 18 patients underwent RALUR using a modified Lich-Gregoir technique for management of POM and 7 (38.9%) of these underwent intracorporeal ureteral tapering at the time of surgery. At median follow up of 27.5 (IQR 11-50) months, no patient required reoperation for recurrent obstruction and all patients had improvement in hydronephrosis postoperatively. 30-day complications were low with 1 Grade I, 2 Grade II and 1 Grade III Clavien-Dindo complication. The most common issue postoperatively was febrile urinary tract infection, occurring in 6 patients (33.3%), at an average of 3.2 months after surgery. Increased operative time was the only significant difference between the tapered verses nontapered group. CONCLUSION We present the largest series of RALUR for POM to date. Based upon our initial experience with this technique we believe it is technically feasible and reproducible with good outcomes and low complication rates. Future studies are needed to track long-term outcomes and better understand indications for and the utility of ureteral tapering as well as how to minimize febrile UTIs postoperatively. Additional follow up is needed to determine the efficacy of RALUR as compared to open ureteral reimplantation for POM.
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Affiliation(s)
- Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA.
| | - Arun Srinivasan
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Diana Bowen
- Department of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL
| | - Katherine M Fischer
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Jay Shah
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA
| | - Dana A Weiss
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Christopher J Long
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
| | - Aseem R Shukla
- Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA; Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3(rd) Floor West Pavilion, Philadelphia, PA
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9
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Galansky L, Andolfi C, Adamic B, Gundeti MS. Continent Cutaneous Catheterizable Channels in Pediatric Patients: A Decade of Experience with Open and Robotic Approaches in a Single Center. Eur Urol 2020; 79:866-878. [PMID: 32868139 DOI: 10.1016/j.eururo.2020.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/11/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND To allow patients with bladder and bowel dysfunctions to achieve social continence, continent catheterizable channels (CCCs) are effective alternatives to intermittent self-catheterization and enema. OBJECTIVE We aimed to describe our progressive advancement from open to robotic construction of CCCs, reporting outcomes and comparing the two approaches. DESIGN, SETTING, AND PARTICIPANTS We retrospectively reviewed electronic medical records of pediatric patients who underwent construction of CCCs between 2008 and 2019. The inclusion criteria were age ≤18 yr, and CCCs with or without bladder augmentation or bladder neck surgery. We compared open versus robotic approaches for demographics, and intra- and postoperative outcomes; operative time was calculated as incision-to-closure time. SURGICAL PROCEDURE Channels performed were appendicovesicostomy (APV), Monti with tapered ileum, and antegrade colonic enema (ACE). A Monti channel with tapered ileum was preferred to a spiral Monti or double Monti, as it has more robust blood supply and it was performed only with an open approach. MEASUREMENTS The primary outcome was success rate, defined as postoperative stomal continence. Stomal incontinence was defined as the presence of urine leakage noted by caregivers or patients and confirmed by the surgeon. Secondary outcomes were stomal stenosis (supra- and subfascial), incontinence, need for surgical revision, and surgical site infection. RESULTS AND LIMITATIONS A total of 69 patients were included in the study, with 35 open and 34 robotic procedures. The robotic approach showed a significant decrease in length of hospital stay (LOS) compared with the open approach. Six primary subfascial revisions were performed in five patients--three Monti, two ACE, and one APV. Continence rates were 91.4% and 91.2% for open and robotic approaches, respectively. CONCLUSIONS Robotic surgery for CCCs showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach. Additionally, due to its minimally invasive nature, it offers advantages such as decreased postoperative pain, LOS, and time to full diet, and better cosmesis. PATIENT SUMMARY Robotic surgery for continent catheterizable channels showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach.
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Affiliation(s)
- Logan Galansky
- Pediatric Urology, Section of Urology, Department of Surgery, UCMC and Comer Children's Hospital, The University of Chicago Biological Sciences Division and Pritzker School of Medicine, Chicago, IL, USA
| | - Ciro Andolfi
- Pediatric Urology, Section of Urology, Department of Surgery, UCMC and Comer Children's Hospital, The University of Chicago Biological Sciences Division and Pritzker School of Medicine, Chicago, IL, USA.
| | - Brittany Adamic
- Pediatric Urology, Section of Urology, Department of Surgery, UCMC and Comer Children's Hospital, The University of Chicago Biological Sciences Division and Pritzker School of Medicine, Chicago, IL, USA
| | - Mohan S Gundeti
- Pediatric Urology, Section of Urology, Department of Surgery, UCMC and Comer Children's Hospital, The University of Chicago Biological Sciences Division and Pritzker School of Medicine, Chicago, IL, USA
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Osumah TS, Granberg CF, Butaney M, Gearman DJ, Ahmed M, Gargollo PC. Robot-Assisted Laparoscopic Urachal Excision Using Hidden Incision Endoscopic Surgery Technique in Pediatric Patients. J Endourol 2020; 35:937-943. [PMID: 32013581 DOI: 10.1089/end.2019.0525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction: Although laparoscopic urachal excision in children has been well reported, there are limited data on a robot-assisted surgery (RAS) approach. The hidden incision endoscopic surgery (HIdES) technique is an established method of eliminating visible scars following a number of RAS urologic procedures. We report our experience of using a robotic approach to treat urachal anomalies in children, and we present the first description of utilizing the HIdES port configuration for this procedure. Materials and Methods: We retrospectively reviewed pediatric patients who underwent resection of a urachal remnant at our institution from 2013 to 2018. Surgical techniques were either the traditional open approach (OA) or RAS. HIdES trocar placement configuration was employed in all robotic cases. Patient demographics, perioperative data, pathology reports, and outcomes were abstracted and compared. Results: Twenty-three patients underwent a urachal remnant resection in the study period (RAS: 14 patients vs OA: 9 patients). RAS patients were older (8.5 vs 2.0 years, p = 0.031) and weighed more than OA patients (36.1 vs 13.9 kg, p = 0.063). Median operative time for RAS was longer than OA operative time (136 vs 33 minutes, p < 0.01). Fewer RAS patients were outpatient compared with OA (7.1% vs 66.7%, p < 0.01), but with a median length of stay of 1 day (0-1 day). Two patients (14.3%) in the RAS group experienced postoperative complications within 1 week of the procedure compared with 1 (11.1%) in the OA group. There was no significant difference in blood loss, postoperative narcotic requirements, or duration of follow-up between both groups. Conclusion: RAS is a safe and feasible alternative to open surgery for urachal anomalies. Complete excision can be achieved by using HIdES port configuration, allowing for excellent cosmetic outcomes that are superior to traditional surgical scars without limitation to essential surgical ergonomics.
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Affiliation(s)
| | | | - Mohit Butaney
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamed Ahmed
- Department of Urology, Mayo Clinic, Rochester, Minnesota
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Adamic B, Kirkire L, Andolfi C, Labbate C, Aizen J, Gundeti M. Robot‐assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in children: Step‐by‐step and modifications to UChicago technique. BJUI COMPASS 2020; 1:32-40. [PMID: 35474913 PMCID: PMC8988522 DOI: 10.1002/bco2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/12/2020] [Accepted: 01/12/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Brittany Adamic
- Pediatric Urology Section of Urology Department of Surgery Comer Children's Hospital The University of Chicago Pritzker School of Medicine Chicago IL USA
| | - Lakshmi Kirkire
- The University of Chicago Pritzker School of Medicine Chicago IL USA
| | - Ciro Andolfi
- Pediatric Urology Section of Urology Department of Surgery Comer Children's Hospital The University of Chicago Pritzker School of Medicine Chicago IL USA
| | - Craig Labbate
- Pediatric Urology Section of Urology Department of Surgery Comer Children's Hospital The University of Chicago Pritzker School of Medicine Chicago IL USA
| | - Joshua Aizen
- Pediatric Urology Section of Urology Department of Surgery Comer Children's Hospital The University of Chicago Pritzker School of Medicine Chicago IL USA
| | - Mohan Gundeti
- Pediatric Urology Section of Urology Department of Surgery Comer Children's Hospital The University of Chicago Pritzker School of Medicine Chicago IL USA
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12
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Kim JK, Chua ME, Ming JM, Farhat WA, Koyle MA, Lorenzo AJ. Impact of previous abdominal surgery on the outcome of laparoscopy-assisted open appendicovesicostomy (Mitrofanoff) creation in children: a comparative study. J Pediatr Urol 2019; 15:662.e1-662.e7. [PMID: 31591049 DOI: 10.1016/j.jpurol.2019.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION AND OBJECTIVE For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children. MATERIALS AND METHODS A research ethics board-approved retrospective review was performed to assess peri-operative outcomes among pediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS <1 year ago) and extent (ventriculoperitoneal (VP) shunt vs non-VP shunt PAS) to assess their peri-operative outcomes. Fisher's exact test and Mann-Whitney U test were used to determine statistical significance. RESULTS Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8-14.0) and 9.9 years (4.2-14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n = 3, 20.0%; n = 9, 47.4%). The median follow-up period was 25.9 (IQR 7.7-47.2) months and 28.0 (IQR 13.0-53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes. DISCUSSION Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS. CONCLUSION Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS.
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Affiliation(s)
- Jin K Kim
- Division of Urology, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada.
| | - Michael E Chua
- Division of Urology, The Hospital for Sick Children, Toronto, Canada; Institute of Urology, St. Luke's Medical Center, Quezon City, Philippines
| | - Jessica M Ming
- Division of Urology, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Walid A Farhat
- Department of Urology, University of Wisconsin, Madison, WI, USA
| | - Martin A Koyle
- Division of Urology, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Armando J Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, Canada; Department of Surgery, University of Toronto, Toronto, Canada
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Abstract
Cystectomy and urinary bladder substitution are rare in children but may be necessary in some cases of bladder exstrophy, in the setting of malignancy, or in other settings in which the bladder is severely dysfunctional. This article details advances in surgical techniques in creating continent urinary diversions in this specialized pediatric population.
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Affiliation(s)
- Jennifer E Reifsnyder
- Division of Pediatric Urology, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, 11040, USA
| | - Moneer K Hanna
- Division of Pediatric Urology, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY, 10065, USA
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Barashi NS, Rodriguez MV, Packiam VT, Gundeti MS. Bladder Reconstruction with Bowel: Robot-Assisted Laparoscopic Ileocystoplasty with Mitrofanoff Appendicovesicostomy in Pediatric Patients. J Endourol 2019; 32:S119-S126. [PMID: 29774817 DOI: 10.1089/end.2017.0720] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Neurogenic bladder occur as a consequence of several conditions, most commonly posterior urethral valves syndrome, spina bifida, tethered cord, sacral agenesis, and Arnold-Chiari malformation. It is characterized by diminished bladder capacity and/or reduced compliance, associated with high-pressure voiding that can lead to deterioration of renal function if left untreated. When medical management fails, bladder reconstruction with bowel (aumentation ileocystoplasty) becomes the treatment of choice for these patients. In most cases, it is accompanied by the creation of a continent catheterizable channel, with the appendix being the most commonly used conduit (Mitrofanoff appendicovesicostomy). Conventional open surgery has proven to be an efficient and safe approach in these patients. However, robot-assisted surgery not only offers a cosmetic advantage, but also results in a shorter hospital stay, less postoperative pain, and even decreased number of adhesions (as shown in porcine models). Nevertheless, the complexity of this technique has limited the wide adoption of this approach. We seek to provide a technical guide to robot-assisted laparoscopic ileocystoplasty and Mitrofanoff appendicovesicostomy in pediatric patients, as well as a critical review of literature about the perioperative care of these patients.
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Affiliation(s)
- Nimrod S Barashi
- Section of Urology, Department of Surgery, University of Chicago Medical Center , Chicago, Illinois
| | - Maria Veronica Rodriguez
- Section of Urology, Department of Surgery, University of Chicago Medical Center , Chicago, Illinois
| | - Vignesh T Packiam
- Section of Urology, Department of Surgery, University of Chicago Medical Center , Chicago, Illinois
| | - Mohan S Gundeti
- Section of Urology, Department of Surgery, University of Chicago Medical Center , Chicago, Illinois
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Gargollo PC, White LA. Robotic-assisted bladder neck procedures in children with neurogenic bladder. World J Urol 2019; 38:1855-1864. [PMID: 31471741 DOI: 10.1007/s00345-019-02912-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/09/2019] [Indexed: 01/23/2023] Open
Abstract
PURPOSE To review the current status of robotic-assisted laparoscopic surgical techniques for bladder neck procedures in children with incontinence secondary to neurogenic bladder. METHODS A comprehensive review of the literature on robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 25 years. These data were subsequently compared to published series of open bladder neck procedures and published results from robotic-assisted bladder neck reconstruction series completed at our institution. RESULTS The principle bladder neck procedures for incontinence in pediatric patients with neurogenic bladder include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure, and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including low interoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation. CONCLUSIONS Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with the previous open abdominal surgery.
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Affiliation(s)
- Patricio C Gargollo
- Division of Pediatric Urology, Mayo Clinic and Mayo Medical School, Rochester, MN, USA
| | - Lindsay A White
- Mayo Clinic and Mayo Clinic School of Graduate Medical Education, Rochester, MN, USA.
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Su H, Wu S, Wang Y, Peng S. Robot-assisted laparoscopic augmentation ileocystoplasty and excision of an intraperitoneal mass: a case report. J Int Med Res 2019; 47:3444-3452. [PMID: 31179780 PMCID: PMC6683881 DOI: 10.1177/0300060519852845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This case is reported to introduce an advanced surgical technique and share our experience with surgeons. Methods A 53-year-old man was admitted to the Department of Urology of The Second Xiangya Hospital with complaints of frequent urination and dysuria in June 2018. He had been diagnosed with genitourinary tuberculosis and left renal dysfunction at another hospital and had undergone left nephrectomy 6 months previously. At our institution, intravenous urography showed a normally functioning right solitary kidney. Computed tomography indicated a high-density mass in the abdominal cavity. At the patient’s request, robot-assisted laparoscopic augmentation ileocystoplasty and excision of the intraperitoneal mass was performed. Results The surgery was performed using a completely intracorporeal technique. The procedure was completed in 240 minutes, and the patient was discharged on postoperative day 11. At the 2-month follow-up, ultrasound examination showed that the maximal bladder capacity had increased to 1000 mL. Intravenous urography revealed no urine leakage, and filling of the bladder was satisfactory. Conclusions With the development of robot-assisted surgery, robotic surgery can be successfully used for less frequently performed operations.
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Affiliation(s)
- Hao Su
- 1 Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Shuiqing Wu
- 1 Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yinhuai Wang
- 1 Department of Urology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Shiqi Peng
- 2 Department of Plastic and Cosmetic Surgery, The First Affiliated Hospital of Hunan Normal University, Hunan Normal University, Changsha, Hunan 410005, China
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Kim C. Robotic Urologic Surgery in Infants: Results and Complications. Front Pediatr 2019; 7:187. [PMID: 31139606 PMCID: PMC6527797 DOI: 10.3389/fped.2019.00187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022] Open
Abstract
Over the last 30 years, robotic surgery has evolved into the preferred surgical approach for many operative cases. Robotics has been associated with lower pain scales, shorter hospitalizations, and improved cosmesis (1, 2). However, its acceptance in pediatrics have been hampered by longer operative times, smaller working space, and limited fine surgical instruments. Many find these challenges even more pronounced when performing robotic surgery in infants (i.e., children <1 year old). Although the data in infants is less robust, many studies have shown benefits similar to the adult population. Specifically, multiple reports of robotic surgery in infants have shown lower postoperative analgesic use. Additionally, hospital stays are shorter, which may lead to quicker return to work for parents and guardians. Multiple reports have shown low complication rates of robotic surgery in infants. When complications have occurred, they are usually Clavien Grade 1 and 2, with occasional grade 3. Often the complications are not from the robotic technique, but are linked to other factors such as the ureteral stents (3, 4). Most importantly, the success rates of surgery are comparable to open surgery. This chapter will review indications for the most common urologic robotic surgeries performed in infants. Also, we will review reported results and complications of robotic surgery in children, with specific attention to the infant population. However, data focused only on infants is limited. Many studies have some infant patients, but their results are often mixed with all pediatric patients.
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Affiliation(s)
- Christina Kim
- Department of Urology, University of Wisconsin-Madison, Madison, AL, United States
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Robotic Surgery as Applied to Functional and Reconstructive Urology. Eur Urol Focus 2019; 5:322-328. [DOI: 10.1016/j.euf.2019.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/11/2019] [Accepted: 06/26/2019] [Indexed: 11/19/2022]
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Andolfi C, Kumar R, Boysen WR, Gundeti MS. Current Status of Robotic Surgery in Pediatric Urology. J Laparoendosc Adv Surg Tech A 2019; 29:159-166. [DOI: 10.1089/lap.2018.0745] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Ciro Andolfi
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Rana Kumar
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - William R. Boysen
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Mohan S. Gundeti
- Pediatric Urology, Section of Urology, Department of Surgery, Comer Children's Hospital, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
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Navarrete Arellano M, Garibay González F. Robot-Assisted Laparoscopic and Thoracoscopic Surgery: Prospective Series of 186 Pediatric Surgeries. Front Pediatr 2019; 7:200. [PMID: 31179254 PMCID: PMC6537604 DOI: 10.3389/fped.2019.00200] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/30/2019] [Indexed: 12/13/2022] Open
Abstract
Objective: We present the applications and experiences of robot-assisted laparoscopic and thoracoscopic surgery (RALTS) in pediatric surgery. Materials and Methods: A prospective, observational, and longitudinal study was conducted from March 2015 to March 2018 that involved a non-random sample of a pediatric population that was treated with RALTS. The parameters examined were: gender, age, weight, height, diagnoses, surgical technique, elapsed time of console surgery, estimated bleeding, need for hemotransfusion, complications, surgical conversions, postoperative hospital stay, and follow-up. The Clavien-Dindo classification of complications was used. The surgical system used was the da Vinci model, Si version (Intuitive Surgical, Inc., Sunnyvale, CA. U.S.A), with measures of central tendency. Results: In a 36-months period, 186 RALTS cases were performed, in 147 pediatric patients and an adult; 53.23% were male, and the remaining were female. The average age was 83 months, ranging from 3.5 to 204 months, plus one adult patient of 63 years. The stature was an average of 116.6 cm, with a range of 55-185 cm; the average weight was 26.9 kg, with a range of 5-102 kg; the smallest patient at 3.5 months was 55 cm in stature and weighed 5.5 kg. We performed 41 different surgical techniques, grouped in 4 areas: urological 91, gastrointestinal and hepatobiliary (GI-HB) 84, thoracic 6, and oncological 5. The console surgery time was 137.2 min on average, ranging from 10 to 780 min. Surgeon 1 performed 154 operations (82.8%), and the remainder were performed by Surgeon 2, with a conversion rate of 3.76%. The most commonly performed surgeries were: pyeloplasty, fundoplication, diaphragmatic plication, and removal of benign tumors, by area. Hemotransfusion was performed for 4.83%, and complications occurred in 2.68%. The average postoperative stay was 2.58 days, and the average follow-up was 23.5 months. The results of the 4 areas were analyzed in detail. Conclusion: RALTS is safe and effective in children. An enormous variety of surgeries can be safely performed, including complex hepatobiliary, and thoracic surgery in small children. There are few published prospective series describing RALTS in the pediatric population, and most only describe urological surgery. It is important to offer children the advantages and safety of minimal invasion with robotic assistance; however, this procedure has only been slowly accepted and utilized for children. It is possible to implement a robust program of pediatric robotic surgery where multiple procedures are performed.
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Affiliation(s)
| | - Francisco Garibay González
- Department of Pediatrics, Hospital Militar de Especialidades de la Mujer y Neonatología, SEDENA, Mexico City, Mexico
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Sheth KR, Koh CJ. The Future of Robotic Surgery in Pediatric Urology: Upcoming Technology and Evolution Within the Field. Front Pediatr 2019; 7:259. [PMID: 31312621 PMCID: PMC6614201 DOI: 10.3389/fped.2019.00259] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/06/2019] [Indexed: 12/22/2022] Open
Abstract
Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.
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Affiliation(s)
- Kunj R Sheth
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States
| | - Chester J Koh
- Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States.,Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States
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Subramaniam R. Robotic Approach to Creation of Continent Catheterisable Channels-Technical Steps, Current Status, and Review of Outcomes. Front Pediatr 2019; 7:1. [PMID: 30719432 PMCID: PMC6348248 DOI: 10.3389/fped.2019.00001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/03/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose: To report the current status of Robotic approach to creation of Catheterisable channel (CC) with the author's personal experience compared to published literature on technical steps, follow up, and outcomes. Methods: CC data was extracted from the prospective database set up for all Robotic pediatric urology procedures performed by the author at his institution. A literature search was then performed to look at the evidence base. Results: Eighteen consecutive cases (8M:7F) of Robotic approach to creation of CC was identified and included. All attempted cases were successfully completed without any conversion to open approach. Median age at surgery was 10.75 years (IQR 6.9-16.5); Median OT 197 min (IQR 131-295) with concomitant procedures in 4 cases. Appendix was used in 14 cases as CC conduit and distal ureter in 4 cases. Median Length of stay (LOS) was 2.75 days (IQR 2-6) and Median FU 27.3 m. Whilst FU duration is comparable to published series, average OT and LOS was much lower in this series. The LOS in this robotic series is much lower than the author's experience with open approach (2.75 vs. 5.8 days). No major complications postoperatively except for one exit site wound infection managed conservatively. None of the CC have been revised in this series and all channels are patent with 12 F or 14 F admissible catheter size. There were no cases of incontinence related to technique of creation of CC and no incidence of exit site stomal stenosis with use of ACE stopper until channel matures and Clean intermittent catheterisation (CIC) is established. Conclusion: Robotic approach to CC is feasible, safe with excellent outcomes and minimum morbidity. Robotic complex bladder reconstructive surgery offers some advantages to children compared to open approach but is only currently performed in few tertiary centers with expertise.
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Affiliation(s)
- Ramnath Subramaniam
- Consultant Paediatric Urologist, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Department of Paediatric Urology, University of Leeds, Leeds, United Kingdom.,Department of Paediatric Urology, University of Ghent, Ghent, Belgium
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Gargollo PC, White LA. Robotic-Assisted Bladder Neck Procedures for Incontinence in Pediatric Patients. Front Pediatr 2019; 7:172. [PMID: 31134167 PMCID: PMC6514215 DOI: 10.3389/fped.2019.00172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/12/2019] [Indexed: 11/13/2022] Open
Abstract
Purpose: To review the current status of bladder neck procedures for incontinence in pediatric patients, focusing on the increasing role of robotic-assisted laparoscopic surgical techniques. Methods: A comprehensive review of the literature on open and robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 20 years. This data was subsequently compared with published results from robotic-assisted bladder neck reconstruction series completed at our institution. Results: The principal bladder neck procedures for incontinence in pediatric patients include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including: low intraoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation. Conclusions: Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with previous open abdominal surgery.
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Affiliation(s)
- Patricio C Gargollo
- Division of Pediatric Urology, The Mayo Clinic and Mayo Medical School, Rochester, MN, United States
| | - Lindsay A White
- The University of Washington School of Medicine, Seattle, WA, United States
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Abstract
As the frontiers of minimally invasive surgery (MIS) continue to expand, the availability and implementation of new technology in pediatric urology are increasing. MIS is already an integral part of pediatric urology, but there is still much more potential change to come as both recent and upcoming advances in laparoscopic and robotic surgery are surveyed.
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25
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Abstract
A review of the current status of robotic surgery use in paediatrics.
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Affiliation(s)
- Joshua Cave
- Chelsea and Westminster NHS Foundation Trust
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26
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Pal RP, Koupparis AJ. Expanding the indications of robotic surgery in urology: A systematic review of the literature. Arab J Urol 2018; 16:270-284. [PMID: 30147957 PMCID: PMC6105341 DOI: 10.1016/j.aju.2018.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities. Methods A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis. Results In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques. Conclusion Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.
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Key Words
- (L)(R)RP, (laparoscopic)(retropubic)radical prostatectomy
- (L)(RA) PN, (laparoscopic)(robot-assisted) partial nephrectomy
- (L-)(O-)(R-) RPLND, (laparoscopic)(open)(robot-assisted) retroperitoneal lymph node dissection
- (O)(L)(RA)SP, (open)(laparoscopic)(robot-assisted)simple prostatectomy
- (RA)RC, (robot-assisted) radical cystectomy
- (S)UI, (stress) urinary incontinence
- (s)RALP, (salvage)robot-assisted laparoscopic prostatectomy
- AUS, artificial urinary sphincter
- HoLEP, holmium laser enucleation of the prostate
- ICUD, intracorporeal urinary diversion
- LOS, length of hospital stay
- MIS, minimally invasive surgery
- PCNL, percutaneous nephrolithotomy
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RAI, robot-assisted augmentation ileocystoplasty
- RAS, robot-assisted surgery
- RCT, randomised controlled trial
- RNL, robot-assisted nephrolithotomy
- RPL, robot-assisted pyelolithotomy
- Robot-assisted surgery
- Robotic surgery
- Urology
- sRRP, salvage RRP
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Affiliation(s)
- Raj P Pal
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
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Abstract
PURPOSE OF REVIEW In this review, we summarize research that has evaluated the role of laparoendoscopic single-site (LESS) and robotic surgery in pediatric urology, highlighting new and/or controversial ideas. RECENT FINDINGS The newest research developments over the last several years are studies that address generalizability of these techniques, ideal patient factors, extrapolation to more complex surgeries, and comparative studies to more traditional techniques to define the associated costs and benefits, as well as patient-centered outcomes. Specifically in the field of LESS, addressing the limitations of suboptimal vision, instrument crowding, and loss of triangulation have been a focus. The literature is now replete with new applications for robotic surgery as well as descriptions of the specific technical challenges inherent to pediatrics. Robotic surgery and LESS are areas of growth in pediatric urology that allow continual innovation and expansion of technology within a surgeon's armamentarium.
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Abstract
Pediatric urinary diversion is performed for a unique set of indications with many options to consider. Although surgical intervention has decreased in necessity overall due to advances in expectant management, it remains an important tool. There are many options and various factors to consider in choosing the right type of diversion for an individual and these patients require lifelong follow-up with a pediatric urologist and eventually an adult urologist. This article provides a detailed review of the most relevant techniques used by pediatric urologists for urinary diversion.
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Affiliation(s)
- Jeffrey D Browning
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213, USA
| | - Heidi A Stephany
- Department of Urology, University of California, Irvine and Children's Hospital of Orange County, 505 S. Main Street, Orange, CA 92868, USA.
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Role of Robotics in Children: A brave New World! Eur Urol Focus 2017; 3:172-180. [PMID: 28889938 DOI: 10.1016/j.euf.2017.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/31/2017] [Accepted: 08/31/2017] [Indexed: 12/11/2022]
Abstract
CONTEXT The key in the evolution towards minimally invasive surgery is the availability of appropriate equipment, especially when procedures involve children. While robotic procedures in adults continue to struggle to prove measurable advantages compared with open or classical laparoscopic ones, the use of the robotic platform (RP) in pediatric urology is steadily increasing. OBJECTIVE To review the contemporary literature regarding the use of robotic-assisted (RA) urologic interventions in children. EVIDENCE ACQUISITION A nonsystematic review of the literature was conducted through PubMed database between 2002 and 2017, with an emphasis on large series. EVIDENCE SYNTHESIS A few major challenges must be considered before using the RP in children: anesthesia, placement of trocars, and technical difficulties related to small space. To date, only the robot-assisted pyeloplasty is recognized as safe and efficient with an equivalent outcome compared to the open or classical laparoscopy; this was supported by large multicentric studies, which are not available for most of the other procedures. CONCLUSIONS RA procedure in children has been proven safe and effective. Still in its infancy, further data over time is likely to prove different RA procedures to be equivalent to open or laparoscopy in terms of outcome. PATIENT SUMMARY The advent of the robotic platform means an evolution towards minimizing surgical trauma for the child. Currently, the available platforms designed for adults are adapted to work in children. However, it might be expected in the future that new technologies will improve the technical possibilities to improve the robotic platform for minimally invasive surgery in children. To date, a few applications are considered safe and efficient (in experienced hands), considering that the team has to be aware of some challenges to overcome regarding anesthesia, material, and technique adaptation to the patient. The most accepted robotic applications in children comprises of the robot-assisted pyeloplasty, hemi-nephrectomy, and ureteric reimplantation.
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Gor RA, Elliott SP. Surgical Management of Neurogenic Lower Urinary Tract Dysfunction. Urol Clin North Am 2017; 44:475-490. [DOI: 10.1016/j.ucl.2017.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Madec FX, Hedhli O, Perrouin-Verbe MA, Levesque A, Le Normand L, Rigaud J. Feasibility, Morbidity, and Functional Results of Supratrigonal Cystectomy with Augmentation Ileocystoplasty by Combined Robot-Assisted Laparoscopy and Mini-Laparotomy Approach. J Endourol 2017; 31:655-660. [PMID: 28467725 DOI: 10.1089/end.2017.0107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Evaluation of the feasibility, morbidity, learning curve, and functional results of robotic supratrigonal cystectomy with augmentation ileocystoplasty (RSCAI). MATERIALS AND METHODS RSCAI was performed in 19 patients between 2012 and 2016. Thirteen patients (66.4%) presented refractory detrusor overactivity or impaired compliance and 6 patients (31.6%) had painful bladder syndrome. A combined robot-assisted laparoscopy and mini-laparotomy approach was performed. Early (<30 days) and late (>30 days) complications were reported according to the Clavien-Dindo classification. Functional results were analyzed according to the surgical indication. RESULTS Mean total operating time was 288.7 ± 92.1 minutes. Mean intraoperative blood loss was 147.4 ± 144.8 mL. Mean length of hospital stay in the surgical ward was 9.4 ± 3.7 days. Mean duration of bladder drainage was 23.3 ± 4.1 days. For surgeons who regularly performed robot-assisted laparoscopy, the learning curve of this technique, as assessed by the operating time, required almost five operations. No major (Clavien-Dindo >2) early (0%) or late (0%) postoperative complication was observed. Early minor complications were observed in 47.4% of cases, usually consisting of pyelonephritis (21.1%). Late minor complications (10.5%) were Clavien-Dindo grade I. Mean follow-up was 13.6 ± 10.1 months. The majority of patients (94.7%) obtained functional improvement of their disease in terms of pain, functional bladder capacity, or bladder compliance. CONCLUSION Our RSCAI technique is a reliable technique with no early or late major postoperative complications reported in this series. This technique allows patients to be operated by minimally invasive surgery with very satisfactory long-term functional results.
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Affiliation(s)
| | - Oussama Hedhli
- Department of Urology, Nantes University Hospital , Nantes, France
| | | | - Amélie Levesque
- Department of Urology, Nantes University Hospital , Nantes, France
| | - Loïc Le Normand
- Department of Urology, Nantes University Hospital , Nantes, France
| | - Jérôme Rigaud
- Department of Urology, Nantes University Hospital , Nantes, France
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Lorenzo AJ, Romao RLP. The Evolving Role of Minimally Invasive Surgery in Pediatric and Adolescent Urologic Oncology. Urology 2017; 91:180-9. [PMID: 27107196 DOI: 10.1016/j.urology.2015.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/20/2015] [Accepted: 12/14/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This review aims at evaluating the current status of minimally invasive surgery at the difficult crossroad between the attractiveness of innovation faced against the solid outcomes offered by the current gold standard, specifically concerning pediatric and adolescent urologic oncology conditions. METHODS This is a critical review of the literature and current paradigms on the use of minimally invasive surgery for pediatric and adolescent urologic oncology cancers. Focus is mainly on the use of laparoscopy for the treatment of Wilms' tumors but other neoplasms are also discussed. RESULTS We draw parallels with other similar pathologies, respecting critical lessons from international cooperative study groups. We discuss various aspects of the pros and cons of minimally invasive surgery in this patient population and make a case for the development of dedicated pediatric surgeons for urologic cancer. CONCLUSION Herein we draft a proposal suggesting a way forward with the adoption of reasonable paradigm shifts founded on carefully conducted studies for the introduction of minimally invasive surgery in the care of pediatric and adolescent urologic cancer.
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Affiliation(s)
- Armando J Lorenzo
- Department of Surgery, Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
| | - Rodrigo L P Romao
- Division of Urology, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada; Division of Pediatric General Surgery, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
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Editorial Comment. Urology 2016; 97:177. [DOI: 10.1016/j.urology.2016.06.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Howe A, Kozel Z, Palmer L. Robotic surgery in pediatric urology. Asian J Urol 2016; 4:55-67. [PMID: 29264208 PMCID: PMC5730905 DOI: 10.1016/j.ajur.2016.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/22/2016] [Indexed: 12/21/2022] Open
Abstract
While robotic surgery has shown clear utility and advantages in the adult population, its role in pediatrics remains controversial. Pediatric-sized robotic instruments and equipment are not readily available yet, so certain modifications can be made in order to make robotic surgery successful in children. While the cost of robotic surgery remains high compared to open procedures, patients experience greater satisfaction and quality of life with robotic surgery. Robotic pyeloplasty is a standard of care in older children, and has even been performed in infants and re-do surgery. Other robotic procedures performed in children include heminephroureterectomy, ureteroureterostomy, ureteral reimplantation, urachal cyst excision, bladder diverticulectomy, and bladder reconstructive procedures such as augmentation, appendicovesicostomy, antegrade continence enema, bladder neck reconstruction and sling, as well as other procedures. Robotic surgery has also been used in oncologic cases such as partial nephrectomy and retroperitoneal lymph node dissection. Future improvements in technology with production of pediatric-sized robotic instruments, along with increases in robotic-trained pediatric urologists and surgeon experience along each's learning curve, will help to further advance the field of robotic surgery in pediatric urology.
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Affiliation(s)
- Adam Howe
- Steven and Alexandra Cohen Children's Medical Center Ringgold Standard Institution - Pediatric Urology, Center for Advanced Medicine Smith Institute for Urology, New Hyde Park, NY, USA
| | - Zachary Kozel
- Long Island Jewish Medical Center Ringgold Standard Institution - Urology, Center for Advanced Medicine Smith Institute for Urology, New Hyde Park, NY, USA
| | - Lane Palmer
- Steven and Alexandra Cohen Children's Medical Center Ringgold Standard Institution - Pediatric Urology, Pediatric Urology Associates, New Hyde Park, NY, USA
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Pediatric Bladder Reconstruction. CURRENT BLADDER DYSFUNCTION REPORTS 2016. [DOI: 10.1007/s11884-016-0369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cohen AJ, Brodie K, Murthy P, Wilcox DT, Gundeti MS. Comparative Outcomes and Perioperative Complications of Robotic Vs Open Cystoplasty and Complex Reconstructions. Urology 2016; 97:172-178. [PMID: 27443464 DOI: 10.1016/j.urology.2016.06.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/06/2016] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare perioperative and surgical outcomes in a 2-center, 2-surgeon open vs robotic augmentation ileocystoplasty. MATERIALS AND METHODS We reviewed patients undergoing augmentation ileocystoplasty open vs robotically between 2008 and 2014 at 2 centers. We compared the groups' preoperative characteristics, perioperative outcomes, complications, and interim functional outcomes. RESULTS The cohort consisted of 17 and 15 patients with median follow-up of 45 and 46 months, in open and robotic groups, respectively. Median operative time (incision to closure) was longer in the robotic cohort (265 minutes vs 623 minutes, P < .001). Median length of stay (7 days vs 6 days, P = .335), time to diet (4 days vs 4 days, P = .125), and mean intravenous morphine equivalents/kg (1.23 mg/kg vs 0.56 mg/kg, P = .091) were comparable between groups for open and robotic, respectively. There were 4/17 (23.5%) of the open cohort who had an epidural for an average of 93 hours. All patients had stable or improved hydronephrosis postoperatively. Major reoperations, such as for bowel obstruction, were required in 2/17 (11.7%) in the open group and none in the robotic cohort. Minor stomal complications requiring skin-level revision or endoscopic procedure occurred in 4/17 (23.5%) in the robotic cohort and 2 (11.7%) in the open group. CONCLUSION We reveal equivalent rates of complications, length of stay, and blood loss for augmentation cystoplasty among appropriately matched controls. Prolonged operative times of the robotic cohort did not lead to additional morbidity for patients. Further steps to reduce morbidity and additional investigations should be undertaken prior to widespread adoption of the intracorporeal technique in experienced robotic centers.
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Affiliation(s)
- Andrew J Cohen
- Section of Urology, University of Chicago Medicine, Comer Children's Hospital, Chicago, IL.
| | | | - Prithvi Murthy
- Section of Urology, University of Chicago Medicine, Comer Children's Hospital, Chicago, IL
| | | | - Mohan S Gundeti
- Section of Urology, University of Chicago Medicine, Comer Children's Hospital, Chicago, IL
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Abstract
Neurogenic bladder is a heterogeneous entity that may result from a variety of conditions affecting the central or peripheral nervous systems. Regardless of etiology, the overall goals of management are primarily twofold. As a neurogenic bladder may affect the ability to store urine safely and to empty the bladder efficiently, early management is focused on optimization of bladder storage function to prevent irreversible injury to either the upper or lower urinary tracts. In older children, this goal is added to the challenge of maximizing quality of life through achievement of urinary continence and independence in bladder management that continues into the transition to adulthood. In this review, we seek to bring the reader up-to-date regarding management of the pediatric neurogenic bladder with a focus on literature published in the past year. We discuss key contributions related to fetal intervention for myelomeningocele, monitoring and medical management of the neurogenic bladder and prediction of postoperative outcomes. Put together, these studies highlight the continued need for further research to improve evidence-based medical and surgical decision-making strategies for children affected by neurogenic bladder.
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Affiliation(s)
- Renea M. Sturm
- Division of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Box 24, Chicago, IL 60611 USA
- Department of Urology, Feinberg School of Medicine at Northwestern University, 303 E. Chicago Ave, Chicago, IL 60611 USA
| | - Earl Y. Cheng
- Division of Urology, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, Box 24, Chicago, IL 60611 USA
- Department of Urology, Feinberg School of Medicine at Northwestern University, 303 E. Chicago Ave, Chicago, IL 60611 USA
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Carrasco A, Vemulakonda VM. Managing adult urinary incontinence from the congenitally incompetent bladder outlet. Curr Opin Urol 2016; 26:351-6. [PMID: 27096718 DOI: 10.1097/mou.0000000000000296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Treatment of urinary incontinence in adult patients with congenital incompetent bladder outlet (exstrophy-epispadias complex, cloacal anomalies, or neurogenic bladder secondary to myelomeningocele) is a challenging surgical problem. In this review article, we summarize and highlight recent studies in the management of incontinence in this patient population. RECENT FINDINGS The literature regarding management of urinary incontinence in this patient population is scarce. Injection of bulking agents to the bladder neck, artificial/autologous slings, artificial urinary sphincters, bladder neck reconstruction, bladder neck closure, or a combination of these are the cornerstone of management. Augmentation cystoplasty is a major adjunct procedure that can help increase continence rate and success of surgery in select patients. The level of evidence on bladder neck procedures for this patient population is low because of significant limitations, including small sample, heterogeneity of primary diagnosis/surgical techniques, variable definitions of continence, and the retrospective nature of most studies in this field. SUMMARY Standard options for treatment of urinary incontinence in the congenitally incompetent bladder outlet procedure remain unchanged. There is no single reproducible procedure to accomplish the goal of renal preservation and continence in these patients, and often patients require multiple procedures to achieve continence. Most importantly, the pediatric and adult urologist should continue to work toward achieving a well tolerated and efficient transition of care. There is a need to standardize data acquisition and reporting of outcomes. Although randomized control studies would be ideal, because of the small number of patients with these conditions, this may not be practical. Collaboration and continued discussion among experts in the field is needed to gain a better understanding of the optimal management strategy in this growing patient population.
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Affiliation(s)
- Alonso Carrasco
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, Colorado, USA
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Lopes RI, Lorenzo A. Recent Advances in Urinary Tract Reconstruction for Neuropathic Bladder in Children. F1000Res 2016; 5. [PMID: 26962441 PMCID: PMC4765717 DOI: 10.12688/f1000research.7235.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 11/25/2022] Open
Abstract
Neuropathic bladder usually causes several limitations to patients’ quality of life, including urinary incontinence, recurrent urinary tract infections, and upper urinary tract damage. Its management has significantly changed over the last few years. The aim of our paper is to address some salient features of recent literature dealing with reconstructive procedures in pediatric and adolescent patients with lower urinary tract dysfunction.
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Affiliation(s)
- Roberto I Lopes
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Armando Lorenzo
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Arlen AM, Kirsch AJ. Recent Developments in the Use of Robotic Technology in Pediatric Urology. Expert Rev Med Devices 2016; 13:171-8. [DOI: 10.1586/17434440.2016.1136211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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