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Koga H, Yamada S, Takeda M, Ochi T, Seo S, Shibuya S, Yazaki Y, Fujiwara N, Arii R, Lane GJ, Yamataka A. Optical Trocar Access for Retroperitoneal Robotic-Assisted Pyeloplasty in Children with Ureteropelvic Junction Obstruction. J Laparoendosc Adv Surg Tech A 2024; 34:651-655. [PMID: 38574308 DOI: 10.1089/lap.2023.0444] [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] [Indexed: 04/06/2024] Open
Abstract
Purpose: Retroperitoneal robotic-assisted pyeloplasty (ret-RAP) for ureteropelvic junction obstruction (UPJO) requires a larger retroperitoneal space (RS) to maintain specified distances between robotic (da Vinci) trocars and between trocars and the region of interest. A modified closed technique (MOT) and conventional closed technique (COT) were compared for creating an adequate RS with optical trocars. Methods: RS access in children with UPJO who underwent ret-RAP (n = 30) was MOT (n = 15) and COT (n = 15). All patients were positioned laterally. For MOT, a 5 mm optical trocar was inserted at the angle formed between the 12th rib and the erector spinae muscles. As the trocar was advanced under direct vision, it pierced the superficial subcutaneous layer, Scarpa's fascia, lumbar fascia, internal/external oblique and transversus abdominalis muscles, and the posterior renal fascia. Once in the RS, the tip of the scope was used for blunt dissection of perirenal fat, the tip was withdrawn until it was outside the perirenal fascia, and used to dissect toward the anterior abdomen in the pararenal fat layer. Results: Ages and weights at ret-RAP were similar (MOT: 5.6 ± 1.8 years versus COT: 7.8 ± 4.6 years; MOT: 20.6 ± 10.1 kg versus COT: 27.6 ± 13.9 kg). Times for RS access were similar (MOT: 1.6 ± 0.5 minutes versus COT: 1.9 ± 0.7 minutes), but RS expansion was significantly quicker in MOT (32.3 ± 8.7 minutes versus 52.0 ± 15.1 minutes; P < .001). Peritoneal injury caused carbon dioxide leakage in 4 of 15 COT cases and 0 of 15 MOT cases. Conclusion: RS expansion with MOT was safer because there were no peritoneal injuries and MOT was quicker than COT.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shunsuke Yamada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Masahiro Takeda
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Shogo Seo
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Soichi Shibuya
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuta Yazaki
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Naho Fujiwara
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Rumi Arii
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Scoville SD, Bergus K, Diefenbach KA, Dajusta DG, Fuchs ME, Michalsky MP, Aldrink JH. Robotic-Assisted Surgery in Patients Less than 15 kg: A Single Center Review. J Laparoendosc Adv Surg Tech A 2024; 34:434-437. [PMID: 38294893 DOI: 10.1089/lap.2023.0178] [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] [Indexed: 02/02/2024] Open
Abstract
Introduction: Robotic-assisted surgery (RAS) is an increasingly utilized tool in children. However, utilization of RAS among infants and small children has not been well established. The purpose of this study was to review and characterize RAS procedures for children ≤15 kg. Methods: We performed a single institution retrospective descriptive analysis including all patients ≤15 kg undergoing RAS between January 2013 and July 2021. Data collection included procedure type, age, weight, gender, and surgical complications. Cases were further categorized according to surgical specialty: pediatric urology (PU), pediatric surgery (PS), and multiple specialties (MS). t-Tests were used for statistical analyses. Results: Since 2013, a total of 976 RAS were identified: 492 (50.4%) were performed by PU, 466 (47.8%) by PS, and 18 (1.8%) by MS. One hundred eighteen (12.1%) were performed on children ≤15 kg, consisting of 110 (93.2%) PU cases, 6 (5.1%) PS cases, and 2 (1.7%) MS cases. Procedures were significantly more common in the PU subgroup, mean of 12 cases/year, compared to PS subgroup, mean of 0.63 cases/year, (P < .01). The mean weight of PU patients (10.5 kg) was significantly less than PS patients (13.9 kg) (P < .01). Mean age was also significantly lower among PU patients (18.6 months) compared to PS (34.2 months) (P < .01). Conclusion: RAS among patients ≤15 kg is safe and feasible across pediatric surgical subspecialties. RAS was performed significantly more frequently by pediatric urologists in younger and smaller patients compared to pediatric surgeons. Further refinement of robotic technology and instrumentation should enhance the applicability of these procedures in this young group.
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Affiliation(s)
- Steven D Scoville
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Katherine Bergus
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Karen A Diefenbach
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Daniel G Dajusta
- Divisions of Urology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Molly E Fuchs
- Divisions of Urology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marc P Michalsky
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer H Aldrink
- Department of Surgery, Ohio State Wexner Medical Center, Columbus, Ohio, USA
- Divisions of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
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Wang M, Xi Y, Huang N, Wang P, Zhang L, Zhao M, Pu S. Minimally invasive pyeloplasty versus open pyeloplasty for ureteropelvic junction obstruction in infants: a systematic review and meta-analysis. PeerJ 2023; 11:e16468. [PMID: 38025670 PMCID: PMC10666611 DOI: 10.7717/peerj.16468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Background To compare the perioperative outcomes and success rates of minimally invasive pyeloplasty (MIP), including laparoscopic and robotic-assisted laparoscopic pyeloplasty, with open pyeloplasty (OP) in infants. Materials and Methods In September 2022, a systematic search of PubMed, EMBASE, and the Cochrane Library databases was undertaken. The systematic review and meta-analysis were conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with the study registered prospectively in the PROSPERO database (CRD42022359475). Results Eleven studies were included. Dichotomous and continuous variables were presented as odds ratios (OR) and standard mean differences (SMD), respectively, with their 95% confidence intervals (CI). Compared to OP, a longer operation time and shorter length of stay were associated with MIP (SMD: 0.96,95% CI: 0.30 to 1.62, p = 0.004, and SMD: -1.12, 95% CI: -1.82 to -0.43, p = 0.002, respectively). No significant differences were found between the MIP and OP in terms of overall postoperative complications (OR:0.84, 95% CI: 0.52 to 1.35, p = 0.47), minor complications (OR: 0.76, 95% CI: 0.40 to 1.42, p = 0.39), or major complications (OR: 1.10, 95% CI: 0.49 to 2.50, p = 0.81). In addition, a lower stent placement rate was related to MIP (OR: 0.09, 95% CI: 0.02 to 0.47, p = 0.004). There was no statistical difference for success rate between the MIP and OP (OR: 1.35, 95% CI: 0.59 to 3.07, p = 0.47). Finally, the results of subgroup analysis were consistent with the above. Conclusions Our meta-analysis demonstrates that MIP is a feasible and safe alternative to OP for infants, presenting comparable perioperative outcomes and similar success rates, albeit requiring longer operation times. However, it is essential to consider the limitations of our study, including the inclusion of studies with small sample sizes and the combination of both prospective and retrospective research designs.
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Affiliation(s)
- Min Wang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Yu Xi
- Nanchong Hospital of Traditional Chinese Medicine, Nanchong, China
| | - Nanxiang Huang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Pengli Wang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Li Zhang
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Mingjia Zhao
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
| | - Siyi Pu
- Nanchong Central Hospital, The Second Clinical College, North Sichuan Medical College, Nanchong, China
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Huang J, Huang Z, Mei H, Rong L, Zhou Y, Guo J, Wan L, Xu Y, Tang S. Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions. Surg Endosc 2023; 37:8404-8420. [PMID: 37721590 DOI: 10.1007/s00464-023-10399-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/14/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software. METHODS We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis. RESULTS For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model. CONCLUSION For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS.
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Affiliation(s)
- Jiangrui Huang
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Zhong Huang
- Department of Computer Science, University of Science and Technology of China, Hefei, China
| | - Hong Mei
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Liying Rong
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Zhou
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jialing Guo
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Li Wan
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yinhui Xu
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Shaotao Tang
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.
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Li P, Ma Y, Jin X, Xiang L, Li H, Wang K. Comparative efficacy and safety of different minimal invasive pyeloplasty in treating patients with ureteropelvic junction obstruction: a network meta-analysis. World J Urol 2023; 41:2659-2669. [PMID: 37566142 DOI: 10.1007/s00345-023-04559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVE In recent years, the minimally invasive surgical treatment methods of ureteropelvic junctional obstruction (UPJO) have been diverse, but its approach and choice of surgical method are controversial. This network meta-analysis (NMA) aimed to compare the safety and effectiveness of minimally invasive surgeries for UPJO, which included robotic or laparoscopic pyeloplasty, via the retroperitoneal or transperitoneal approach. METHODS We searched relevant RCTs in PubMed, Embase, Web of Science, the Cochrane Library, and CNKI. To assess the results of operative time, complications and success rate, pairwise, and NMA were carried out. The models for analyses were performed by Revman 5.3, Addis V1.16.8 and R software. RESULTS A total of 6 RCTs were included in this study involving four types of surgeries: transperitoneal laparoscopic pyeloplasty (T-LP), retroperitoneal laparoscopic pyeloplasty (R-LP), robot-assisted transperitoneal pyeloplasty (T-RALP), and robot-assisted retroperitoneal pyeloplasty (R-RALP). This study consisted of 381 patients overall. T-RALP had a quicker operational duration (SMD = 1.67, 95% CI 0.27-3.07, P = 0.02) than T-LP. According to the NMA's consistency model, T-RALP improved the surgical success rate more than T-LP (RR = 6303.19, CI 1.28 to 1.47 × 1011). Ranking probabilities indicated that RALP could be the better option than LP and retroperitoneal approach was comparable to transperitoneal approach. All procedures had high surgical success rates and few complications. CONCLUSION Outcomes for four surgical approaches used in the UPJO were comparable, with T-RALP being the most recommended approach. Selection between the transperitoneal and retroperitoneal approaches primarily depended on the surgeon's preference. Higher quality evidence is needed to further enhance the result.
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Affiliation(s)
- Puhan Li
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yucheng Ma
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xi Jin
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Liyuan Xiang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Hong Li
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Kunjie Wang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
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Hu Z, Chen S, Wang Z, Xu D, Zhang X, Lin Y, Zhang L, Wang J, Li L. The application of artificial technology in pediatric pyeloplasty the efficacy analysis of robotic-assisted laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction. Front Pediatr 2023; 11:1209359. [PMID: 37780043 PMCID: PMC10540863 DOI: 10.3389/fped.2023.1209359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/08/2023] [Indexed: 10/03/2023] Open
Abstract
Objective To investigate the clinical effect of the da Vinci robotic-assisted laparoscopic pyeloureteroplasty (RALP) in treating pediatric ureteropelvic junction obstruction (UPJO). Methods We retrospectively analyzed clinical data from 32 children with UPJO who suffered from RALP in our hospital from October 2020 to February 2023, compared with those treated with common laparoscopy at the same time. After the establishment of the robotic arm, a mesenteric approach was performed after entering the abdominal cavity to focus on the lesion site. The dilated renal pelvis was then cut and the stenotic ureter was removed; the anastomosis and the incision were sutured by layer. Results A total of 62 children (44 boys and 20 girls) with a median age of 14 months (ranging from 3 to 38 months) were included. All 62 cases had hydronephrosis caused by unilateral UPJO, and the surgery was successfully completed without conversion to open. All intraoperative blood losses amounted to less than 10 ml. In the RALP group, the average operative duration was 131.28 min (ranging from 108 to 180 min). The average catheter time was 3.66 days (ranging from 2 to 7 days). The average hematuria time was 3.84 days (ranging from 2 to 6 days). The average postoperative hospital stay was 7.8 days (ranging from 6 to 12 days). The average hospitalization costs were 59,048.31 yuan (ranging from 50,484 to 69,977 yuan). The double-J tube was removed 1 month after surgery. Only one patient suffered from complications, developing a urinary tract infection 4 weeks after surgery, and was cured with the administration of oral cefaclor anti-inflammatory drugs for 3 days. All patients were followed up for 2-28 months, with a median follow-up time of 12 months. The thickness of the renal cortex was increased after surgery [(1.95 ± 0.24) vs. (4.82 ± 0.50)] cm, and the isotope renograms revealed a definite recovery of the split renal function [(28.32 ± 1.95) vs. (37.01 ± 2.71)]%. Conclusion The robotic-assisted laparoscopic pyeloureteroplasty (RALP) in the treatment of children with upper ureteral obstruction has overall clinical efficiency. With technological advancements and an increased number of experienced surgeons, robotic surgery may become a new trend in surgery.
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Affiliation(s)
- Zhongli Hu
- Affiliated Hospital of Putian University, Putian, China
| | - Shan Chen
- Department of Laboratory, Fuzhou Second Hospital, Fuzhou, China
| | - Zhihong Wang
- Department of Hematology, Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Di Xu
- Department of Pediatric Surgery, Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Xiaolang Zhang
- Department of Pediatric Surgery, Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Yang Lin
- Department of Pediatric Surgery, Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Lin Zhang
- Department of Pediatric Surgery, Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Jianbin Wang
- Department of Pediatric Surgery, Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Lizhi Li
- Department of Pediatric Surgery, Provincial Clinical Medical College, Fujian Medical University, Fuzhou, China
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He J, Lai H, Zhang T, Ye L, Yao B, Qu H, Ma B, Guo Q, Zhang Y, Qiu J, Wang D. Enhanced recovery management in pediatric pyeloplasty: outcomes in a single institution and tips for improvement. World J Urol 2023; 41:1667-1673. [PMID: 37219585 DOI: 10.1007/s00345-023-04422-y] [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: 09/12/2022] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE We report the application of enhanced recovery after surgery (ERAS) regimens to pediatric patients undergoing laparoscopic pyeloplasty (LP), aiming to guide the practice of ERAS in pediatric LP. METHODS From October 2018, we prospectively implemented a twenty-point ERAS regimen, including a modified LP procedure, for pediatric UPJO patients in a single institution. Data from 2018 to 2021 were collected and analyzed retrospectively. The variables gathered included: demographics, preoperative details and recovery elements. Outcomes were postoperative length of stay (POS), readmission rate, operation time and blood loss. RESULTS A total of 75 pediatric patients (0-14 years) were included. The mean POS was 2.4 ± 1.4 days, shorter than that in recent studies in China (3.3 ± 1.4 days, 6 (3-16) days). None were redo, and six restenosis (8%) were improved after treatment with ureteral balloon dilatation. The mean operation time was 257.9 ± 54.4 min, and blood loss was 11.8 ± 10.0 ml. In the univariable analysis and multivariable analysis, no external drainage, sacral anesthesia, and withdrawal of the catheter on day one were independently associated with a POS of ≤ 2 d (p < 0.05). CONCLUSION The implementation of this ERAS protocol for pediatric LP has resulted in a shorter length of stay without a higher readmission rate. Surgery techniques, drainage management and analgesia are the key to further improvement. ERAS for pediatric pyeloplasty should be encouraged.
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Affiliation(s)
- Jiannan He
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Huajian Lai
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Tianyou Zhang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Lei Ye
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Bing Yao
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Hu Qu
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Bo Ma
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Qiang Guo
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Yifei Zhang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Jianguang Qiu
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China.
| | - Dejuan Wang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China.
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Hasan O, Reed A, Shahait M, Crivellaro S, Dobbs RW. Robotic Surgery for Stone Disease. Curr Urol Rep 2023; 24:127-133. [PMID: 36394772 DOI: 10.1007/s11934-022-01131-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE OF REVIEW To evaluate recent literature regarding the role of robotic technology in the treatment of nephrolithiasis with particular attention to complex technical procedures. RECENT FINDINGS Robotic platforms including single-port robotics have been widely adopted in urological practice for the treatment of both malignant and benign conditions and has led to an expansion of the utilization of robot-assisted surgery to tackle challenging clinical scenarios such as bladder neck reconstruction, upper urinary tract reconstruction, and more recently complex stone disease. Presently, the American Urological Association guidelines on the surgical management of stones advise against using robotic, open, or laparoscopic techniques as a first-line approach for most patients with stone disease with the exception for patients with anatomical abnormalities, large or complex stones, or patients requiring a concomitant reconstructive operation. Clinicians have demonstrated the safety and feasibility of surgical robotics in the treatment of stone disease for a variety of operations including robotic pyeloplasty, pyelolithotomy, ureterolithotomy, and surgical interventions in urinary diversions as well as novel technologies for robotic ureteroscopy and percutaneous access. Numerous clinicians have demonstrated the safety and feasibility of using robot-assisted surgery to treat nephrolithiasis, mainly in complex renal anatomy. Further research is necessary to identify the best candidates for utilization of robotics in complex stone disease, and further technological developments will continue to further advance the use of these platforms in the treatment of nephrolithiasis.
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Affiliation(s)
- Osamah Hasan
- Division of Urology, Cook County Health and Hospitals System, 1950 W Polk St, Chicago, IL, 60612, USA
| | - Alexandra Reed
- Rosalind Franklin University School of Medicine, North Chicago, IL, USA
| | - Mohammed Shahait
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Simone Crivellaro
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | - Ryan W Dobbs
- Division of Urology, Cook County Health and Hospitals System, 1950 W Polk St, Chicago, IL, 60612, USA.
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Lombardo AM, Gundeti MS. Review of robot-assisted laparoscopic surgery in management of infant congenital urology: Advances and limitations in utilization and learning. Int J Urol 2023; 30:250-257. [PMID: 36520939 DOI: 10.1111/iju.15105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
Abstract
As robotic-assisted (RAL) surgery expanded to treat pediatric congenital disease, infant anatomy and physiology posed unique challenges that prompted adaptations to the technology and surgical technique, which are compiled and reviewed in this manuscript. From the beginning, collaboration with anesthesia is critical for a safe, efficient case including placement of an endotracheal tube rather than a laryngeal mask (LMA) and placement of a nasogastric tube and/or rectal tube to relieve distended stomach or bowel, respectively. Furthermore, end-tidal CO2 (EtCO2 ) is important for monitoring and predicting the effects of pneumoperitoneum on caridiovascular physiology, incranial pressure, and risk of acidosis and hypercarbia. Positioning can further exacerbate these effects and affect intra-abdominal working space. For infant robotic pyeloplasty and heminephrectomy, a "beanbag" is commonly used for stabilization in the lateral decubitus position. We advise against the use of a "baby bump" because it brings the bowels and vasculature more anterior than expected. Pnuemoperitoneum pressure of 8-10 mmHg during port placement maximizes safety, but thereafter, the pneumoperitoneum pressure can be minimized to 6-8 mmHg during the procedure without compromising the visual field. Port sites should be marked after insufflation, followed by the open Hasson technique for peritoneal access and port placement under direct vision with intussusception of the trocars to avoid vascular or bowel injury. Additional tips can be obtained through this manuscript, immersive fellowships, and mini-fellowships. Ulitmately, infant robotic surgery has the potential to benefit many children but is presently limited by the lack of pediatric-specific robotic technology and its associated costs.
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Affiliation(s)
- Alyssa M Lombardo
- The University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Mohan S Gundeti
- The University of Chicago Comer Children's Hospital, Chicago, Illinois, USA
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Nguyen C, Bachtel H, Koh CJ. Pediatric robotic urologic surgery: Pyeloplasty and ureteral reimplantation. Semin Pediatr Surg 2023; 32:151264. [PMID: 36736162 DOI: 10.1016/j.sempedsurg.2023.151264] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Catherine Nguyen
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Hannah Bachtel
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Chester J Koh
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
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Laparoscopic versus robot-assisted pyeloplasty in infants and young children. Asian J Surg 2023; 46:868-873. [PMID: 36192267 DOI: 10.1016/j.asjsur.2022.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/22/2022] [Accepted: 09/11/2022] [Indexed: 02/08/2023] Open
Abstract
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.
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Vauth F, Zöhrer P, Girtner F, Rösch WH, Hofmann A. Open Pyeloplasty in Infants under 1 Year-Proven or Meaningless? CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020257. [PMID: 36832385 PMCID: PMC9955854 DOI: 10.3390/children10020257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/28/2023] [Accepted: 01/29/2023] [Indexed: 02/01/2023]
Abstract
The use of minimally invasive surgery (MIS) to treat ureteropelvic junction obstruction (UPJO) in children has significantly increased. Nowadays, open pyeloplasty (OP) seems to lose importance. The aim of this study is to evaluate the safety and efficacy of OP in infants < 1 year. Medical records of patients < 1 year with UPJO who had undergone retroperitoneal OP (January 2008-February 2022) at our institution were retrospectively analyzed. Included patients were operated on according to a modified Anderson-Hynes technique. All clinical, operative, and postoperative (1 month-5 years' follow-up) data were collected. Additionally, a nonvalidated questionnaire was sent to the patients/parents. A total of 162 infants (124 boys) met the inclusion criteria. The median age at surgery was 3 months (range: 0-11 months). The median operation time was 106 min (range: 63-198 min). None of the patients had severe surgical complication (Clavien-Dindo > 3). The nonvalidated questionnaire showed a high impact of quality of life. Follow-up was in median 30.5 months (0-162 months). OP is still a reliable procedure with good long-term results especially in infants < 1 year of age, which can be performed in a variety of centers.
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Xu D, Gao H, Yu S, Huang G, Lu D, Yang K, Zhang W, Zhang W. Ensuring safety and feasibility for resection of pediatric benign ovarian tumors by single-port robot-assisted laparoscopic surgery using the da Vinci Xi system. Front Surg 2022; 9:944662. [PMID: 36061048 PMCID: PMC9437548 DOI: 10.3389/fsurg.2022.944662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022] Open
Abstract
Background Single-port robot-assisted laparoscopic surgery (S-RALS) is rarely applied in pediatric surgery. There is still no study on the application of S-RALS for resection of pediatric benign ovarian tumors. The current study aimed to investigate the safety and feasibility of S-RALS for resection of pediatric benign ovarian tumors using the da Vinci Xi system. Methods The clinical data of three patients who underwent S-RALS for resection of benign ovarian tumors in the Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University from May 2020 to September 2021 were retrospectively analyzed. The mean age of these children was 7.9 years (5.8–9.3 years). One was a case of bilateral ovarian tumors, and the other two were cases of right ovarian tumors. Results All three patients successfully underwent the resection of ovarian tumors through S-RALS without conversion to laparotomy. The average operation time was 180 min (118–231 min). The average amount of blood loss was 20 ml (10–35 ml). No drainage tube was placed. All postoperative pathological types of ovarian tumors were mature cystic teratomas in the three cases. All patients started a liquid diet 2 h after surgery. The average length of postoperative hospital stay was 4.7 days (3–7 days). No tumor recurred, no surgical site hernia occurred, and the wound healed very well with a cosmetic scar in the lower umbilical crease during the postoperative follow-up for 6–18 months. Conclusion S-RALS has the advantages of less surgical trauma, quick postoperative recovery, and a cosmetic scar in the lower umbilical crease. It is safe, effective, and feasible for pediatric benign ovarian tumors.
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Affiliation(s)
- Deqiang Xu
- Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Heyun Gao
- Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shanzhen Yu
- Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Guangbin Huang
- Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dan Lu
- Department of Ultrasound Imaging, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kun Yang
- Department of Urology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wei Zhang
- Department of Gynaecology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wen Zhang
- Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Correspondence: Wen Zhang
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Risk Factors of Urinary Tract Infection in Pediatric Patients with Ureteropelvic Junction Obstruction after Primary Unilateral Pyeloplasty. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3482450. [PMID: 35872951 PMCID: PMC9307364 DOI: 10.1155/2022/3482450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
Abstract
Objective Ureteropelvic junction obstruction (UPJO) represents to a leading cause of fetal hydronephrosis, which is associated with urinary tract infection (UTI) and urinary stone disease. This study is aimed at investigating risk factors of UTI in pediatric patients with UPJO after primary unilateral pyeloplasty. Methods The records of a consecutive series of patients undergoing primary pyeloplasty at a single institution between June 2015 and November 2021 were retrospectively reviewed. Demographic and clinical characteristics, including age, gender, weight, height, body mass index (BMI), creatinine (Cr), blood urea nitrogen (BUN), estimated glomerular filtration rate (eGFR), neutrophil ratio, lymphocyte ratio, neutrophil/lymphocyte ratio, renal pelvis anteroposterior diameter (APD), renal cortex thickness, caliectasis, open or laparoscopic pyeloplasty, and internal drainage or external drainage, were collected and analyzed. The incidence of postoperative UTI and its risk factors was analyzed. Results A total of 504 patients were enrolled in the study, and they were classified into the UTI group (n = 188) and non-UTI group (n = 361). Univariate analysis of the incidence of UTI revealed that age, gender, weight, height, BMI, surgical modality, Cr level, BUN level, neutrophil ratio, lymphocyte ratio and neutrophil/lymphocyte ratio, renal cortex thickness, and postoperative drainage modality were associated with UTI incidence after pyeloplasty in pediatric patients with UPJO. Multivariate analysis revealed that male gender, <19 months, weight < 11.5 (kg), height < 83 (cm), BMI < 17.09, BUN > 4.08 (mmol/L), and internal drainage were risk factors of postoperative UTI in pediatric patients with UPJO. Conclusion Our study demonstrated that male gender, <19 months, weight < 11.5 (kg), height < 83 (cm), BMI < 17.09, BUN > 4.08 (mmol/L), and internal drainage were risk factors of UTI in pediatric patients with UPJO after primary unilateral pyeloplasty, which may provide reference for prophylactic antibiotics for those patients with risk factors.
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Blanc T, Abbo O, Vatta F, Grosman J, Marquant F, Elie C, Juricic M, Laraqui S, Broch A, Arnaud A. Transperitoneal Versus Retroperitoneal Robotic-assisted Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children. A Multicentre, Prospective Study. EUR UROL SUPPL 2022; 41:134-140. [PMID: 35813254 PMCID: PMC9257661 DOI: 10.1016/j.euros.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Robotic-assisted laparoscopic pyeloplasty (RALP) has been gaining acceptance among paediatric urologists. Objective To compare surgical variables and clinical outcomes, including complications and success rate, with RALP using the transperitoneal (T-RALP) and retroperitoneal (R-RALP) approaches. Design, setting, and participants We performed a multicentre, prospective, cohort study (NCT03274050) between November 2016 and October 2021 in three paediatric urology teaching centres (transperitoneal approach, n = 2; retroperitoneal approach, n = 1). The diagnosis of ureteropelvic junction obstruction (UPJO) was confirmed by renal ultrasound and mercaptoacetyltriglycine-3 renal scan or uro–magnetic resonance imaging with functional evaluation. The exclusion criteria were children <2 yr old, persistent UPJO after failed pyeloplasty, and horseshoe and ectopic kidney. Intervention We performed dismembered pyeloplasty using running monofilament 6-0 absorbable suture. Outcome measurements and statistical analysis We assessed intra- and postoperative morbidity (primary outcome) and success (secondary outcome). Data were expressed as medians and interquartile range (25th and 75th percentiles) for quantitative variables, and analysed comparatively. Results and limitations We operated on 106 children (T-RALP, n = 53; R-RALP, n = 53). Preoperative data were comparable between groups (median age 9.1 [6.2–11.2] yr; median weight 26.8 [21–40] kg). Set-up time (10 vs 31 min), anastomotic time (49 vs 73 min), and console time (97 vs 153 min) were significantly shorter with T-RALP than with R-RALP (p < 0.001). No intraoperative complications occurred. No conversion to open surgery was necessary. The median hospital stay was longer after T-RALP (2 d) than after R-RALP (1 d; p < 0.001). Overall, postoperative complication rates were similar. No failure had occurred at the mean follow-up of 25.4 (15.1–34.7) mo. Conclusions In selected children, RALP is safe and effective using either the transperitoneal or the retroperitoneal approach, with a shorter hospital stay after R-RALP. Patient summary In our multicentre, prospective study, we compared the results and complications of robotic-assisted laparoscopic pyeloplasty (RALP) using the transperitoneal and retroperitoneal approaches. We found that RALP is safe and effective using either approach, with a shorter hospital stay after R-RALP.
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Chen J, Xu H, Lin S, He S, Tang K, Xiao Z, Xu D. Robot-assisted pyeloplasty and laparoscopic pyeloplasty in children: A comparison of single-port-plus-one and multiport surgery. Front Pediatr 2022; 10:957790. [PMID: 36340736 PMCID: PMC9634126 DOI: 10.3389/fped.2022.957790] [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] [Received: 05/31/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to compare the effects of various trocar placements in robot-assisted and laparoscopic pyeloplasty involving children diagnosed with obstruction of the ureteropelvic junction (OUPJ). METHODS We retrospectively collected the data on 74 patients under 14 years of age who had been diagnosed with OUPJ; these patients underwent either robot-assisted or laparoscopic pyeloplasty in our hospital between January 2015 and November 2021. There were four groups, as follows: •Laparoscopic multiport pyeloplasty (LMPY),•Laparoscopic single-port pyeloplasty (LSPY),•Robotic-assisted multiport pyeloplasty (RMPY),•Robotic-assisted single-port-plus-one pyeloplasty (RSPY).Patients' characteristics as well as their perioperative and follow-up data were collected and evaluated. RESULTS There was no significant difference in the data regarding patients' characteristics. These data included the grade of hydronephrosis according to the Society of Fetal Urology (SFU grade), anterior and posterior diameter of the renal pelvis and ureter (APDRPU), and the differential degree of renal function (DRF) at following time points: preoperative, postoperative, and comparison of preoperative and postoperative. There was no difference among these groups. During surgery, the time of trocar placement, urethroplasty time, and total operative time in the robotic groups (RMPY and RSPY) were longer than those in the laparoscopic groups (LMPY and LSPY). However, the ratio of the urethroplasty time and full operative time (UT/WT) in the robotic groups (RMPY and RSPY) was lower than that in the laparoscopic groups (LMPY and LSPY) (P = 0.0075). Also, the volume of blood loss was lower in the robotic groups (RMPY and RSPY) than that in the laparoscopic groups (LMPY and LSPY), although there was no statistical difference (P = 0.11). There were, however, significant differences in hospitalization days (P < 0.0001) and parents' cosmetic satisfaction scores (P < 0.001). There were no differences in fasting time, the length of time that a ureteral catheter remained in place, or the number of postoperative complications. CONCLUSION Our study shows that both robotic multiple-port and single-port-plus-one approaches are comparable, with laparoscopic multiple-port and single-port approaches equally effective in resolving OUPJ in children. Robotic and single-port-plus-one approaches may be associated with some advantages in hospitalization time and cosmetic outcomes; therefore, these approaches may be useful in urologic surgery that requires precise suturing, especially in pediatric patients.
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Affiliation(s)
- Jianglong Chen
- Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China.,Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Huihuang Xu
- Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China.,Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Shan Lin
- Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China.,Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Shaohua He
- Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China.,Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Kunbin Tang
- Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China.,Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Zhixiang Xiao
- Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China.,Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
| | - Di Xu
- Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, China.,Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China
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Farrugia MK. RAL-P in infants: expert tips for success. Nat Rev Urol 2021; 18:641-642. [PMID: 34493874 DOI: 10.1038/s41585-021-00519-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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