Robot-assisted extravesical ureteral reimplantation: outcomes and conclusions from 78 ureters

Is Postoperative Voiding Cystourethrogram Routinely Indicated Following Robotic-assisted Laparoscopic Ureteral Reimplantation in Children: Time to Define the New Standards?

OBJECTIVE

To examine the need to routinely obtain voiding cystourethrogram (VCUG) to confirm vesicoureteral reflux (VUR) resolution following robotic-assisted laparoscopic ureteral reimplantation (RALUR) in children.

METHODS

A single-center, prospectively maintained database was reviewed for patients <18 years old who underwent RALUR for VUR. Patient charts were reviewed for baseline characteristics and surgical details. Patients were routinely followed up by renal bladder ultrasound at 6-8 weeks and VCUG at 3 months postoperatively. The primary endpoint was radiological success defined as the absence of VUR on postoperative VCUG. The secondary endpoints were clinical success, defined as the absence of postoperative febrile urinary tract infection, postoperative urinary retention, and reoperation for persistent VUR or RALUR complications.

RESULTS

Between 2018 and 2023, 42 children (48 refluxing ureters) underwent extravesical RALUR at the study institution at a mean age of 70.4 + 23.7 months. A majority of 81% were females, and 85.7% had associated bladder and bowel dysfunction. Six patients (14.3%) had bilateral RALUR. Of the ureters, 83.4%(40/48) had grade III or higher VUR, and 20.8%(10/48) had duplex kidneys. Postoperative VCUG was completed in 36(85.7%) patients. Radiological reflux resolution was confirmed in 87.5%(35/40) of ureters. The remaining five ureters had VUR downgrading to grade I or II; all remained asymptomatic, and none required reoperation. One patient required ureteral stenting for 6 weeks for an unidentified unilateral ureteral injury without long-term consequences. Postoperative urine retention requiring short-term catheterization occurred in three patients. The clinical success rate was 97.6%.

CONCLUSION

After bypassing the learning curve, VCUG is not routinely indicated following RALUR for VUR.

Robot-assisted Laparoscopic Ureteral Reimplantation in Pre-toilet Trained Children With Vesicoureteral Reflux

OBJECTIVE

To evaluate the outcomes of pre-toilet trained children undergoing robot-assisted laparoscopic ureteral reimplantation (RALUR) for the treatment of primary VUR at our institution and compare these to an older cohort.

MATERIALS AND METHODS

This retrospective study analyzed data from a single institution's registry, comparing outcomes between pre-toilet trained and toilet trained children who underwent RALUR for primary VUR. Preoperative parameters, surgical details, and postoperative outcomes were evaluated.

RESULTS

The study included 158 patients, with 24 in the pre-toilet trained group and 134 in the toilet trained group. Both cohorts exhibited similar demographics and preoperative characteristics. Operative times, complication rates, and surgical outcomes were comparable between the groups, despite the pre-toilet trained group presenting with more severe VUR grades. Incidence of febrile urinary tract infection after surgery and need for further intervention did not significantly differ between the cohorts.

CONCLUSION

The current study demonstrates the feasibility, success, and safety of RALUR in pre-toilet trained compared to toilet trained children and thus supports the stance that it is a viable alternative to open surgery.

Robot-Assisted Extravesical Ureteral Reimplantation (REVUR) in Pediatric Patients: A New Standard of Treatment for Patients with VUR-A Narrative Review

Robot-assisted extravesical ureteral reimplantation (REVUR) was described for the first time in 2004. Since then, the surgical approach of vesicoureteral reflux (VUR) has changed dramatically. The benefits of this technique are great when compared to the laparoscopic or traditional open approaches. A literature search of PubMed was performed to identify articles covering any aspect of REVUR in the pediatric population. A total of 108 papers published over the period 2004-2024 were collected. Of these, 40 studies were considered valuable in terms of obtaining a complete overview of the REVUR technique. This review aimed to describe the current state of the art of REVUR and define it as the new standard technique for surgical management of selected patients with VUR.

Advancements in Surgical Management of Megaureters

PURPOSE OF REVIEW

To review and describe the recent evolution of surgery for the various types of pediatric megaureter.

RECENT FINDINGS

Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.

A review of complications after ureteral reconstruction

Objective

This study aimed to provide a comprehensive overview of the complications unique to ureteral reconstruction in adults, emphasizing their presentation, diagnosis, and management in the treatment of ureteral structure disease.

Methods

This review involves an in-depth analysis of existing literature and case studies pertaining to ureteral reconstruction, with a focus on examining the range of complications that can arise post-surgery. Special attention is given to the presentation of each complication, the diagnostic process involved, and the subsequent management strategies.

Results

Ureteral reconstruction can treat ureteral stricture disease with low morbidity; however, complications, although uncommon, can have severe consequences. The most notable complications include urinary extravasation, stricture recurrence, urinary tract infections, compartment syndrome, symptomatic vesicoureteral reflux, and Boari flap necrosis. Each complication presents unique diagnostic challenges and requires specific management approaches.

Conclusion

Ureteral reconstruction is a highly effective treatment for ureteral stricture disease. Having a strong understanding of the potential complications that patients may experience following ureteral reconstruction is not only critical to adequately counsel patients but also facilitate prompt diagnosis and management of complications when they arise.

Minimally Invasive versus Open Ureteral Reimplantation in Children: A Systematic Review and Meta-Analysis

PURPOSE

 We performed a systematic review and meta-analysis to compare the safety and efficacy of minimally invasive surgery (MIS) versus open ureteral reimplantation (OUR) in children.

METHODS

 Literature searches were conducted to identify studies that compared MIS (laparoscopic ureteral reimplantation or robot-assisted laparoscopic ureteral replantation) and OUR in children. Parameters such as operative time, blood loss, length of hospital stay, success rate, postoperative urinary tract infection (UTI), urinary retention, postoperative hematuria, wound infection, and overall postoperative complications were pooled and compared by meta-analysis.

RESULTS

 Among the 7,882 pediatric participants in the 14 studies, 852 received MIS, and 7,030 received OUR. When compared with the OUR, the MIS approach resulted in shorter hospital stays (I 2 = 99%, weighted mean difference [WMD] -2.82, 95% confidence interval [CI] -4.22 to -1.41; p < 0.001), less blood loss (I 2 = 100%, WMD -12.65, 95% CI -24.82 to -0.48; p = 0.04), and less wound infection (I 2 = 0%, odds ratio 0.23, 95% CI 0.06-0.78; p = 0.02). However, no significant difference was found in operative time and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications.

CONCLUSION

 MIS is a safe, feasible, and effective surgical procedure in children when compared with OUR. Compared with OUR, MIS has a shorter hospital stay, less blood loss, and less wound infection. Furthermore, MIS is equivalent to OUR in terms of success rate and secondary outcomes such as postoperative UTI, urinary retention, postoperative hematuria, and overall postoperative complications. We conclude that MIS should be considered an acceptable option for pediatric ureteral reimplantation.

Does previous endoscopic subureteric injection (STING) effect the outcomes of robot-assisted laparoscopic ureteral reimplantation surgery (RALUR) in children?

BACKGROUND

There is lack of evidence on the success of robot-assisted laparoscopic ureteral reimplantation (RALUR) for the treatment of vesicoureteral reflux (VUR) who had prior intervention.

OBJECTIVE

This study aimed to evaluate the effect of previous unsuccessful STING on the outcomes of RALUR in children.

STUDY DESIGN

A total of 67 children treated with RALUR by a single surgeon for the treatment of VUR were scanned between February 2018 and April 2022. Two patients were excluded from the final data analysis due to the presence of a megaureter. Patients were divided into two groups: those with a history of STING (Group A - n:14) and those without STING (Group B - n:51). Patient characteristics, previous numbers of injections, console time, total operative time, perioperative and postoperative complications and clinical success data were collected. Clavien Dindo and Satava complication scales were used as the standard record of peri and postoperative complications. Radiographic success was defined as absence of reflux detected on postoperative voiding cystourethrography, whereas clinical success was defined as the absence of a febrile urinary tract infection during the follow-up. Mann-Whitney U and Chi-square tests and Fisher exact test were used where appropriate.

RESULTS

A total of 36 (55.3%) female versus 29 (44.6%) male patients were operated for 96 refluxive ureters. Nearly half of the patients were with bilateral VUR (n = 31). The mean follow-up was 20.2 ± 15.4 months. The median age of patients was 59 ± 31 (range: 28-132 months) versus 46 ± 33.1 (range: 7-206 months) for groups A and B respectively (p = 0.22). Gender, age, peri- and postoperative complication rates, and clinical success were comparable between the two groups. The median operative time and the console time was significantly higher in children with history of STING (op time: 142.5 ± 27.4 versus 120 ± 24.9 min (p = 0.008), console time: 117.5 ± 28.2 versus 100 ± 24.5 min (p = 0.011) for groups A and B, respectively. A total of six complications (9.2%) occurred with none of them were greater than Clavien grade 3b. The overall clinical success rate was 97%, with 2 cases of clinical failure. In both cases, VCUG demonstrated absence of VUR.

DISCUSSION

The outcomes of our study provided that RALUR is effective with more than 95% success rates despite failed endoscopic injection procedures.

CONCLUSION

The previous history of STING neither changes the success nor the complication rates of RALUR. However, this can lead to more challenging surgery by increasing the total operative times.

Single-port-plus-one robot-assisted laparoscopic modified Lich-Gregoir direct nipple ureteral extravesical reimplantation in children with a primary obstructive megaureter

Purpose

To introduce a new technique of single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation and ascertain its validity in the treatment of pediatric primary obstructive megaureter.

Methods

Between January 2021 and November 2021, we retrospectively analyzed the clinical data of 12 children with primary obstructive megaureter who were admitted to the Department of Pediatric Surgery of Fujian Provincial Hospital. All 12 children were treated with single-port-plus-one robotic laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation. Five of them were female and seven were male, including nine cases were simple obstructive type, while the remaining three cases were obstructive with reflux type. The mean age of the children was 17.33 ± 6.99 (10-36) months and the mean follow-up time was 14.16 ± 1.75 (12-17) months. Changes in preoperative and first-year postoperative parameters were compared.

Results

The mean operative time for all 12 children was 123.58 ± 10.85 (110-145) min, with a mean internal operative time of 101.42 ± 0.85 (90-120) min, a mean operative bleeding time of 2.42 ± 0.67 (2-4) ml, and a mean hematuria duration of 16.08 ± 1.44 (14-19) h. The mean indwelling catheterization time was 2.25 ± 0.45 (2-3) days and the mean hospitalization time was 3.83 ± 0.39 (3-4) days. At the postoperative first year, the ureteral diameter, calyceal diameter, and anterior-posterior renal pelvic diameter were found to be significantly smaller than at the preoperative period (18.83 ± 3.21 mm vs. 6.83 ± 1.27 mm, 13.99 ± 3.58 mm vs. 3.5 ± 2.90 mm, and 34.92 ± 4.25 mm vs. 10.08 ± 1.88 mm, P < 0.001). There was a significant increase in renal cortical thickness and the percentage of differential renal function (3.63 ± 1.66 mm vs. 5.67 ± 1.88 mm, 33.75 ± 2.77 mm vs. 37.50 ± 1.31 mm, P < 0.001). The resolution rate of obstruction was 100% and no child developed DeNovo vesicoureteral reflux.

Conclusion

The technique of modified Lich-Gregoir direct nipple ureteral extravesical reimplantation can help maintain the physiological direction of the ureter and at the same time enhance the effectiveness of antirefluxing in robotic surgery. The design of a single-port-plus-one wound can produce a cosmetic appearance by concentrating and hiding the wound around the umbilicus. This modified reimplantation procedure has the potential to become a promising technique in the robot-assisted treatment of primary obstructive megaureter.

The LUAA Gundeti Technique for Bilateral Robotic Ureteral Reimplantation: Lessons Learned over a Decade for Optimal (Resolution, Urinary Retention, and Perioperative Complications) Trifecta Outcomes

Background

Ureteral reimplantation is the gold standard treatment for high-grade vesicoureteral reflux (VUR) in pediatric patients. Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) using the LUAA technique has emerged as a viable alternative to traditional open and laparoscopic surgical correction.

Objective

To evaluate the outcomes, reflux resolution, urinary retention, and complications associated with bilateral RALUR-EV for primary VUR using the LUAA Gundeti technique in pediatric patients.

Design setting and participants

A retrospective study was conducted at a single academic center, involving 34 consecutive pediatric patients who underwent RALUR-EV for bilateral VUR management between December 2008 and December 2022. The study included only patients who were evaluated with postoperative voiding cystourethrogram (VCUG).

Surgical procedure

The LUAA extravesical ureteral reimplantation technique was performed, involving the identification and mobilization of the ureter, creation of a peritoneal window, dissection close to the neurovascular bundle, Y dissection at the ureterovesical junction, detrusorotomy, detrusorrhaphy with advential inclusion, and apical alignment suture.

Measurements

The primary outcome was radiographic resolution of VUR on VCUG. The secondary outcomes included urinary retention and Clavien-Dindo grade III complications.

Results and limitations

The overall radiographic resolution rate was 85.2%, with success rates of 76.7%, 75%, and 96.7% across the three distinct patient cohorts. The overall Clavien-Dindo grade III complication rate was 5.8%, and transient urinary retention was 8.8%. Resolution of urinary retention occurred within 7-28 d. The study's limitations include the small sample size, single-center design, and retrospective nature.

Conclusions

The LUAA technique demonstrates sustainable outcomes for VUR resolution with a low incidence of transient urinary retention and complications. A thorough understanding of pelvic anatomy is essential for successful dissection and minimization of the risk of complications. Further studies are needed to evaluate the effectiveness of different approaches in reducing the incidence of transient urinary retention following bilateral extravesical reimplantation.

Patient summary

In this study, we examined the results of the Gundeti LUAA surgical technique for treating primary vesicoureteral reflux in children. We identified various essential modifications that increase the likelihood of achieving favorable outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Vesicoureteral Reflux: Current Care Trends and Future Possibilities

Although investigations over the past 2 decades have improved our understanding of the natural history of vesicoureteral reflux (VUR) and helped identify those at higher risk of both VUR itself as well as its potential severe sequelae, debate exists regarding key aspects of care, including when to perform diagnostic imaging and which patients benefit from continuous antibiotic prophylaxis. Artificial intelligence and machine learning have the potential to distill large volumes of granular data into practical tools that clinicians can use to guide diagnosis and management decisions. Surgical treatment, when indicated, remains highly effective and is associated with low morbidity.

Modified technique for robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter

PURPOSE

To describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants.

MATERIALS AND METHODS

Between April 2017 and July 2019, sixteen infants with primary obstructive megaureter (POM) (Age range: 4-12 months) underwent robot-assisted ureteral reimplantation were reviewed in this series. In addition to the conventional Lich-Gregoir technique, the detrusor tunnel has been extended to the mobilized anterior bladder wall to guarantee sufficient tunnel length/ureter diameter ratio and avoid ureteral angulation. All patients underwent repeated ultrasound, diuretic renal dynamic imaging and voiding cystourethrography (VCUG) perioperatively and the outcomes were documented.

RESULTS

All operations were completed with robotic assisted approach without conversion. Bilateral and unilateral reimplantation were respectively performed in two and fourteen patients. The mean operative time was 115.0 ± 19.5 min and the mean blood loss was 10.0 ± 1.8 ml. There were no high-grade complications (III-IV on Clavien-Dindo classification) except for one patient. The distal ureteric diameter was reduced from pre operative 1.7 ± 0.5 to 0.6 ± 0.5 cm 6 months post operatively (p < 0.05). One child (6.3%) required the second reimplantation for stenosis. The overall operative success rate was 94.4% (17 of 18 ureters) with a mean follow-up of 15.9 ± 7.4 months with no flux detected.

CONCLUSION

Our preliminary experience suggests that our modified robot-assisted laparoscopic extravesical ureteral reimplantation is feasible in infants with good results.

Development and Validation of a Scoring System for Assessment of Clinical Failure after Pediatric Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation: A Multi-Center Study

We aimed to develop and validate a scoring system as an objective assessment tool for predicting clinical failure after pediatric robotic extravesical ureteral reimplantation. Data for this multi-institutional retrospective cohort was obtained from two tertiary referral hospitals. We defined clinical failure as incomplete radiographic resolution or post-operative febrile UTI. Patients were stratified into low, intermediate, and high-risk groups according to the score. External validation was performed using the model projected to the external validation cohort. An amount of 115 renal units in the development cohort and 46 renal units in the validation cohort were analyzed. The prediction score was calculated with weighted points to each variable according to their regression coefficient as age (year) + BMI + BBD times 10 + VUR grade times 7 + console time (h) + hospital stay times 6. The C-index of our scoring system was 0.850 and 0.770 in the development and validation cohorts, respectively. Clinical failure was significantly different among risk groups: 0% (low-risk), 3.3% (intermediate-risk), and 22.2% (high-risk) (p = 0.004) in the development cohort. A novel scoring system using multiple pre- and intra-operative variables provides a prediction of children at risk of failure after robotic extravesical ureteral reimplantation.

Armamentarium to treat primary vesicoureteral reflux in children

Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.

Outcomes of complex robot-assisted laparoscopic ureteral reimplantation after failed ipsilateral endoscopic treatment of vesicoureteral reflux

BACKGROUND

Endoscopic injection (EI) has been considered a minimally invasive option with high success rates. However, in clinical settings where EI has failed, and after repeat injections or worsening clinical presentation, different treatment modalities may be offered. Open ureteral reimplantation has emerged as a safe option in patients who have failed EI for VUR treatment. Currently there is limited literature describing success of complex robot-assisted laparoscopic ureteral reimplantation (RALUR) following primary EI for vesicoureteral reflux (VUR).

OBJECTIVE

We aim to describe our surgical technique and outcomes using RALUR approach following failed EI for VUR. We hypothesize RALUR can be a safe, salvage option in patients who have failed EI for VUR in the setting of recurrent VUR or ureterovesical junction obstruction (UVJO).

METHODS

A single site, retrospective study using electronic medical records of all patients who underwent RALUR between 2013 and 2019 following history of previous ipsilateral EI using dextranomer/hyaluronic acid (DHA) for diagnosis of vesicoureteral reflux (VUR) was conducted. Primary outcomes were radiographic resolution and/or clinical resolution.

RESULTS

A total of 17 RALUR procedures were reviewed in 16 patients. There were 14 females (87.5%) and 2 males (12.5%). Seven patients had two prior EI. Median (range) age at time of RALUR was 10.1 (5.7-17.9) years, and the average time between EI and RALUR was 5.9 years [1-13]. The average VUR recurrence grade after failed EI was 3 (ranges 2-4) on preoperative VCUG. History of bilateral EI using dextranomer/hyaluronic acid (DHA), was observed in 14 patients. Surgical diagnosis at time of RALUR included persistent VUR (N = 10) or symptomatic ureterovesical junction obstruction (UVJO, N = 6). Mean console times were 102 min (range 70-240 min) for RALUR vs 128 min (range 70-180 min) for cases requiring ureteral tailoring. Six complications occurred in 16 patients (37.6%): Using the Clavien-Dindo classification scale, four patients (25%) were grade I, one (6.3%) grade II, and one (6.3%) was grade IIIb, which required additional procedures for ureteral obstruction.

CONCLUSION

RALUR after failed EI should be considered a reasonably safe and effective surgical approach in older children with persistent VUR or acquired UVJO.

Robot‑Assisted Laparoscopic Extra-Vesical Ureteral Reimplantation (Ralur/Revur) for Pediatric Vesicoureteral Reflux: A Systematic Review of Literature

This literature review aimed to assess the outcomes of robot-assisted laparoscopic extra-vesical ureteral reimplantation (RALUR/REVUR) in standard, complex and re-operative cases. Twenty-two studies (period 2008-2019) containing 1362 children receiving RALUR/REVUR, were included. Unilateral repair was faster compared to bilateral (P = .0000). The overall patient success rate was 92%. The mean post-operative complications rate was 10.7%. The mean re-operations rate was 3.9%. The available data show that RALUR/REVUR can be a first line surgical approach for pediatric vesicoureteral reflux at most centers with the caveat that learning curves for the surgeons are expected as with most new surgical procedures.

Parental preferences for vesicoureteral reflux treatment: Profile case best-worst scaling

INTRODUCTION

Vesicoureteral reflux is a common pediatric urologic condition that often has several reasonable treatment options depending on condition severity. In order to choose the best treatment for their child, parents are expected to make judgements that weigh attributes such as treatment cost, effectiveness, and complication rate. Prior research has shown that factors such as treating hospital and surgeon also influence patient treatment choice.

OBJECTIVES

This study evaluates parental preferences for reflux treatment using profile case best-worst scaling, an emerging technique in both urologic and health care preference estimation. The study also uses latent class analysis (LCA) to identify parental sub-classes with different preferences.

STUDY DESIGN

Data were collected from a community sample of parents via a multimedia best-worst scaling survey instrument published to Amazon's Mechanical Turk online community. After extensive review of the literature, reflux attributes and attribute levels were selected to correspond with available treatments. The profile case best-worst scaling exercise elicited preferences for granular attributes of reflux treatments. Data were analyzed using multinomial logistic regression and class analysis to distinguish preference heterogeneity. Probability scaled values (PSVs) reflected the order of desirability of the attributes. Attribute preference importance was rescaled into dollar units for comparison as well.

RESULTS

We analyzed data for 248 respondents. The highest treatment effectiveness was more desirable than all other leveled treatment attributes (PSV 17.8, all p < 0.01) (Table). Low complication rate and doctor recommendation were amongst the other most desirable treatment attributes (PSV 11.3 and 9.0, respectively). Latent class analysis identified a class with more extreme preferences, for whom doctor recommendation and avoiding hospitalization were particularly desirable.

DISCUSSION

In this community-based sample, high treatment effectiveness and low complication rate were the most desirable treatment attributes to parents, though parents likely have heterogenous treatment preference structures. Shared parent-physician decision-making that incorporates parental preferences will likely allow more effective, targeted decision-making in the future.

Preoperative Bladder Bowel Dysfunction Is the Most Important Predictive Factor for Postoperative Urinary Retention After Robot-Assisted Laparoscopic Ureteral Reimplantation via An Extravesical Approach: A Multi-Center Study

Introduction: Postoperative acute urinary retention (pAUR) is a known occurrence after robot-assisted laparoscopic ureteral reimplantation via an extravesical approach (RALUR-EV). We hypothesized that the risk factor of pAUR after RALUR-EV might be similar to that of pAUR after open reimplantation. We aimed at performing a retrospective multi-institutional study to evaluate the risk factors for pAUR after RALUR-EV. Materials and Methods: Perioperative data collected from two tertiary referral hospitals included demographics and perioperative variables such as bladder bowel dysfunction (BBD) status, vesicoureteral reflux (VUR) grade, and laterality. pAUR was defined as the need for urethral catheter replacement after removal of the initial postoperative catheter. Univariate and multivariate analyses were performed to identify risk factors for pAUR. Results: A total of 117 patients with 174 renal units from the 2 hospitals were enrolled in this study. The median age at the time of surgery was 5 (0.3-19) years. Bilateral RALUR-EV was performed in 57 (48.7%) cases. pAUR rate was 3.4% in all patients and 7.0% in 57 patients with bilateral VUR. All four cases of pAUR occurred after bilateral surgery. Univariate analysis showed age (p = 0.037), weight (p = 0.039), height (p = 0.040), and bilaterality (p = 0.037) as risk factors of pAUR. In a multivariate analysis, BBD was the only significant risk factor of pAUR (p = 0.037). Conclusion: Urinary retention after RALUR-EV occurred less frequently when compared with the previously reported open surgery series. pAUR was seen only in bilateral cases in our series. Preoperative history of BBD, but not male gender or length of surgical time, was the only risk factor of pAUR after RALUR-EV.

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

Introduction:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Robotics in Pediatric Urology: Evolution and the Future

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

Instituting robotic pediatric urologic surgery in the Canadian healthcare system: Evaluating the feasibility and outcomes of robot-assisted pyeloplasty and ureteric reimplantation

INTRODUCTION

Robotic pediatric urologic surgery has gained wide-spread adoption over the last decade. This article describes our experience in instituting the first pediatric urologic robotic surgery program in Canada. We evaluated the feasibility and safety of instituting pediatric robot-assisted urologic surgery and report our early outcomes for robot-assisted pyeloplasty (RAP) and ureteric reimplantation (RUR).

METHODS

We prospectively evaluated all patients undergoing RAP and RUR by a single surgeon from June 2013 to March 2019. Demographic and clinical data were prospectively collected and included sex, age, and preoperative grade of hydronephrosis or reflux. Descriptive statistics were performed, and comparisons were made using Student's t-tests where appropriate. Success was defined as resolution or significant improvement of hydronephrosis following RAP and absence of recurrent urinary tract infection (UTI) and/or persistent vesicoureteric reflux (VUR) following RUR. Complications were described using the Clavien-Dindo system.

RESULTS

A total of 52 RAPs and 24 RURs were performed with a minimum of six months followup. Forty-five RAP patients met criteria for success, while diagnostic imaging of success in the form of MAG-3 Lasix renograms was documented in the remaining seven for an overall success of 100%. Sixteen RUR patients met criteria for success and seven showed resolution of VUR on imaging following their first UTI, for an overall success rate of 96%. Operative times progressively improved from 204±35 minutes to 121±15 minutes in the RAP group and from 224±52 to 132±39 minutes in the RUR group. In the RAP cohort, one Clavien grade II and four Clavien grade III complications were noted, while three Clavien grade III complications were noted in the RUR cohort.

CONCLUSIONS

Despite limited case volumes, robotic pediatric urologic surgery can be integrated into the Canadian healthcare system with success rates comparable to reported literature. However, compared to open surgery, RAP, and especially RUR, warrant further study to ensure lack of significant complications noted in our study.

Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'?

Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections.

Robotic Ureteral Reimplantation

Minimally invasive techniques have gained popularity in pediatric surgery. Among these, is the robotic approach for ureteral reimplantation in children with vesico-ureteral reflux. We describe main indications of this surgery, our surgical technique as well as trouble shooting of anatomical variants and the post-operative management. We also provide a description of other techniques described in the literature and a brief review of outcomes of published series.

Open versus robot-assisted laparoscopic ureteral reimplantation: Hospital charges analysis and outcomes at a single institution

PURPOSE

Robot-assisted laparoscopic extravesical ureteral reimplantation has previously been described as a viable minimally invasive option to open surgery. However, concerns for robotic surgery have been raised owing to assumed higher costs and heterogeneous clinical outcomes. We hypothesized that similar hospital charges and clinical outcomes occur when comparing open and robotic cases in matched cohorts.

MATERIALS AND METHODS

Open and robotic reimplantation cases from 2013 to 2015 for primary vesicoureteral reflux were matched by age using 1:1 nearest neighbor matching. The matched cohorts were analyzed and compared for their direct itemized hospital charges per surgical case, complications, and clinical outcomes.

RESULTS

There were 38 patients in each group after age-matching the 135 patients. Operating room charges were higher for the robotic group compared to the open group (p=0.002), whereas pharmacy and laboratory costs were lower for the robotic group. However, there were no significant differences in total overall charges between the open and robotic groups with cystoscopy or without cystoscopy (p=0.345, p=0.533), since the median hospital stay length was shorter for the robotic group (p<0.001). Clinical success rates were identical for the two groups (open 94.8% vs robotic 94.8%). There were also no significant differences in number of complications between the two cohorts.

CONCLUSIONS

This is the first age-matched study comparing hospital charges and clinical outcomes of pediatric open and robotic reimplantation. While operating room charges were higher for the robotic cohort, lower hospitalization charges led to comparable overall hospital charges, as well as equivalent clinical outcomes for both cohorts.

LEVEL OF STUDY

Level III (Retrospective comparative study) TYPE OF STUDY: Retrospective Study.

Prevalence of Bladder and Bowel Dysfunction in Toilet-Trained Children With Urinary Tract Infection and/or Primary Vesicoureteral Reflux: A Systematic Review and Meta-Analysis

Introduction: Urinary tract infection (UTI) in children leads to renal scarring in 10-15% of patients. Urinary tract anomalies and bladder and bowel dysfunction (BBD) are documented risk factors for recurrent UTIs. Estimates of baseline prevalence of BBD in children with UTI will help the clinician in the management strategy. Hence, a systematic review and meta-analysis was conducted to estimate the pooled prevalence of BBD. Methods: MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) databases were searched for articles related to UTI, primary vesicoureteral reflux (VUR), and BBD. We included studies that provided prevalence of BBD in toilet-trained patients aged 1-18 years with UTI and/or VUR. BBD was defined based on clinical history or questionnaire or urodynamic studies. Two authors independently reviewed, assessed, and abstracted data from studies. Pooled prevalence was calculated based on a random effects model. Results: Forty-three studies fulfilling the eligibility criteria were selected from a total of 1,731 studies. Among patients presenting with UTI without primary VUR, pooled prevalence of BBD was 41% (95% CI: 26-55; nine studies, 920 patients, I ² = 96.0%), whereas its prevalence in patients with primary VUR was 49% (43-56; 30 studies, 5,060 patients, I ² = 96.0%). Weighting by the study design and quality did not affect the prevalence. In patients with primary VUR, prevalence of BBD was higher in females (53%; 42-65) than in males (44%; 15-73). In studies where urodynamic study was used for the diagnosis of BBD, prevalence was 63%. The presence of BBD in patients with primary VUR increased risk of recurrent UTIs [relative risk (RR): 2.1; 1.7-2.5]. In five studies that reported separate data on constipation, pooled prevalence of constipation was 27% (16-37). Conclusion: Almost half of the patients with primary VUR have BBD, and its presence increases the risk of recurrent UTIs. Trends of high BBD prevalence were also observed in patients presenting with UTI without VUR. These prevalence estimates suggest that all toilet-trained children presenting with UTI with or without VUR should be assessed for BBD, which will help in their further management.

Robot-assisted laparoscopic ureteroneocystostomy in adults: A single surgeon experience and literature review

OBJECTIVE

To present our experience and technique with robot-assisted ureteroneocystostomy (RAUN) procedure in adults.

METHODS

Between February 2015 and August 2018, a total of 30 (34 ureters) patients who underwent RAUN surgery under a single surgeon were retrospectively reviewed. Perioperative data such as age, sex, body mass index (BMI), American society of anesthesiologists score, estimated blood loss, surgical technique, operative time, complications, length of hospital stay, and stent removal time were recorded. During the follow-up, patients underwent renal function test, urinalysis, and renal ultrasound examination for evaluation. Success was defined as symptomatic and radiologic relieve. Lastly, a literature search was conducted to review all published articles regarding RAUN surgery in adults.

RESULTS

The patients' mean age, BMI, EBL, operative time, and follow-up period were 45.4 years, 23.1 kg/m2, 65.6 mL, 182.9 min, and 21.3 months, respectively. The two most common indications for the surgery were benign ureteral strictures and ureteric injuries secondary to a previous radical hysterectomy. Of the 34 cases, 26 (76.5%) and 8 (23.5%) patients received primary RAUN and RAUN with psoas hitch technique, respectively. Refluxing RAUN method was performed in all cases. No intraoperative complications were found. Two patients had a radiologic and symptomatic recurrence; one was managed with a repeat surgery while the other received ureteral dilatation treatment.

CONCLUSION

Both our study and the published literature showed that RAUN is a safe, less invasive, and effective surgical technique that can easily replicate the open ureteroneocystostomy for managing lower ureteral diseases.

Parental Preferences for Vesicoureteral Reflux Treatment: A Crowd-sourced, Best-worst Scaling Study

OBJECTIVE

To quantitatively evaluate parental preferences for the various treatments for vesicoureteral reflux using crowd-sourced best-worst scaling, a novel technique in urologic preference estimation.

METHODS

Preference data were collected from a community sample of parents via 2 best-worst scaling survey instruments published to Amazon's Mechanical Turk online community. Attributes and attribute levels were selected following extensive review of the reflux literature. Respondents completed an object case best-worst scaling exercise to prioritize general aspects of reflux treatments and multiprofile case best-worst scaling to elicit their preferences for the specific differences in reflux treatments. Data were analyzed using multinomial logistic regression. Results from the object-case provided probability scaled values (PSV) that reflected the order of importance of attributes.

RESULTS

We analyzed data for 248 and 228 respondents for object and multiprofile case BWS, respectively. When prioritizing general aspects of reflux treatment, effectiveness (PSV = 20.37), risk of future urinary tract infection (PSV = 14.85), and complication rate (PSV = 14.55) were most important to parents. Societal cost (PSV = 1.41), length of hospitalization (PSV = 1.09), and cosmesis (PSV = 0.91) were least important. Parents perceived no difference in preference for the cosmetic outcome of open vs minimally invasive surgery (P = .791). Bundling attribute preference weights, parents in our study would choose open surgery 74.9% of the time.

CONCLUSION

High treatment effectiveness was the most important and preferred attribute to parents. Alternatively, cost and cosmesis were among the least important. Our findings serve to inform shared parent-physician decision-making for vesicoureteral reflux.

Robotic Urologic Surgery in Infants: Results and Complications

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.

Robot-assisted laparoscopic ureteral reimplantation in children: a valuable alternative to open surgery

INTRODUCTION

Robot-assisted laparoscopic surgical systems have led to new minimally invasive options for complex reconstructive procedures in children including for vesicoureteral reflux (VUR). Robot-assisted laparoscopic ureteral reimplantation has been shown to be a viable minimally invasive surgical option for children with VUR. However, higher-than-expected complication rates and sub-optimal reflux resolution rates at some centers have also been reported.

METHODS

This article provides a focused literature review as well as current perspectives on open reimplantation and robot-assisted laparoscopic ureteral reimplantation as non-endoscopic surgical options for pediatric VUR.

RESULTS

The heterogeneity of surgical outcomes may, in part, be due to the learning curve inherent with all new technology and procedures. As a result, the current gold standard surgical option for VUR continues to be open ureteral reimplantation. While it remains to be seen if robot-assisted laparoscopic surgery will gradually replace open surgery as the most utilized surgical option for VUR in pediatric patients, robot-assisted laparoscopic ureteral reimplantation with the current robotic surgical systems may be just one step toward an eventual minimally invasive option that all experienced surgeons can offer with the requisite high success rates and low major complication rates.

CONCLUSION

Robot-assisted laparoscopic ureteral reimplantation remains a viable minimally invasive surgical option for children with VUR, but with the expected learning curve associated with all new technologies.

Robotic Assisted Surgery in Pediatric Urology: Current Status and Future Directions

The evolution of robotic surgical technology and its application in Pediatric Urology have been rapid and essentially successful. Further development remains limited in three key areas: procedural inefficiencies, cost and integration of surgical and clinical information. By addressing these challenges through technology and novel surgical paradigms, the real potential of surgical robotics in pediatric, as well as adult applications, may ultimately be realized. With this evolution, a continued focus on patient-centered outcomes will be essential to provide optimal guidance to technical innovations.

The Robot-Assisted Extravesical Anti-reflux Surgery: How We Overcame the Learning Curve

Management of vesicoureteral reflux (VUR) has evolved over the past several decades, with a trend toward a decrease in surgical management. In spite of this, ureteral reimplantation remains a commonly performed procedure by pediatric urologists in selected cases. Although the basic tenets of the ureteral reimplant procedure remain the same, the extra- vs. intravesical approach, and the traditional open vs. minimally invasive approach remain the primary options to correct reflux. Considering the advantages conferred by the robotic surgery platform, many leading centers have preferentially adopted robot-assisted laparoscopic extravesical anti-reflux surgery, or in common surgical parlance, the robot-assisted laparoscopic ureteral reimplantation (RALUR), over pure laparoscopic or open approaches. Predicated on our experience of performing over 170 cases of RALUR, we have made technical modifications which we posit reduce the morbidity of the procedure while offering acceptable outcomes. This review highlights the evolution and establishment of RALUR as a standardization of care in the surgical management of VUR at our institution. In particular, we emphasize the technical nuances and specific challenges encountered through the learning curve in hopes of facilitating this process for others.

Robotic Ureteral Reconstruction in the Pediatric Population

Robot-assisted laparoscopic (RAL) surgery is a safe, minimally invasive technique that has become more widely used in pediatric urology over recent decades. With several advantages over standard laparoscopy, robotic surgery is particularly well-suited to reconstructive surgery involving delicate structures like the ureter. A robotic approach provides excellent access to and visualization of the ureter at all levels. Common applications include upper ureteral reconstruction (e.g., pyeloplasty, ureteropelvic junction polypectomy, ureterocalicostomy, and high uretero-ureterostomy in duplex systems), mid-ureteral reconstruction (e.g., mid uretero-ureterostomy for stricture or polyp), and lower ureteral reconstruction (e.g., ureteral reimplantation and lower ureter-ureterostomy in duplex systems). Herein, we describe each of these robotic procedures in detail.

Robotic surgery in pediatric urology: Current status

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

Has the robot caught up? National trends in utilization, perioperative outcomes, and cost for open, laparoscopic, and robotic pediatric pyeloplasty in the United States from 2003 to 2015

INTRODUCTION

Since 2010, there have been few new data comparing perioperative outcomes and cost between open (OP) and robotic pyeloplasty (RP). In a post-adoption era, the value of RP may be converging with that of OP.

OBJECTIVE

To 1) characterize national trends in pyeloplasty utilization through 2015, 2) compare adjusted outcomes and median costs between OP and RP, and 3) determine the primary cost drivers for each procedure.

STUDY DESIGN

We performed a retrospective cohort study using the Premier database, which provides a nationally representative sample of U.S. hospitalizations between 2003 and 2015. ICD9 codes and itemized billing were used to abstract our cohorts. Trends in utilization and cost were calculated and then stratified by age. We used propensity scores to weight our cohorts and then applied regression models to measure differences in the probability of prolonged operative time (pOT), prolonged length of stay (pLOS), complications, and cost.

RESULTS

During the study period 11,899 pyeloplasties were performed: 75% open, 10% laparoscopic, and 15% robotic. The total number of pyeloplasty cases decreased by 7% annually; OP decreased by a rate of 10% while RP grew by 29% annually. In 2015, RP accounted for 40% of cases. The largest growth in RPs was among children and adolescents. The average annual rate of change in cost for RP and OP was near stagnant: -0.5% for open and -0.2% for robotic. The summary table provides results from our regression analyses. RP conferred an increased likelihood of pOT, but a reduced likelihood of pLOS. The odds of complications were equivalent. RP was associated with a significantly higher median cost, but the absolute difference per case was $1060.

DISCUSSION

Despite advantages in room and board costs for RP, we found that the cost of equipment and OR time continue to make it more expensive. Although the absolute difference may be nominal, we likely underestimate the true cost because we did not capture amortization, hidden or down-stream costs. In addition, we did not measure patient satisfaction and pain control, which may provide the non-monetary data needed for comparative value.

CONCLUSION

Despite an overall decline in pyeloplasties, RP utilization continues to increase. There has been little change in cost over time, and RP remains more expensive because of equipment and OR costs. The robotic approach confers a reduced likelihood of pLOS, but an increased likelihood of pOT. Complication rates are low and similar in each cohort.

Robotic-assisted laparoscopic ureteral re-implant (RALUR): Can post-operative urinary retention be predicted?

OBJECTIVE

Urinary retention following robotic-assisted laparoscopic extravesical ureteral reimplantation (RALUR) is proposed to be due to traction or injury of the pelvic parasympathetic nerve plexus during distal ureteral dissection. Nerve-sparing techniques have been employed to avoid injury to the pelvic plexus, either directly or indirectly. This single-center study assessed postoperative urinary retention rates after extravesical RALUR and investigated whether demographic or operative factors could predict this occurrence.

METHODS

All RALUR cases entered into an Institutional Review Board-approved registry were retrospectively reviewed, and the rate of postoperative retention was determined. Postoperative urinary retention was defined as the need for catheterization at any time in the postoperative period during hospital admission or within 1 week after the operation. This included acute urinary retention episodes (AUR) as well as high post-void residuals (>50% of expected bladder capacity). Univariate analysis was performed to analyze for predictors of postoperative retention. Factors assessed included age, gender, clinical presentation, bowel bladder dysfunction (BBD), pre-operative urinary tract infection (UTI), procedure length, grade of vesicoureteral reflux (VUR), and operative laterality.

RESULTS

A total of 128 patients underwent extravesical RALUR in 179 ureters during the study period 2012-2016. Male:female ratio was 1:2.6. Median age at surgery was 4 years. Bilateral RALUR was performed in 52 cases (40.6%), and unilateral in 76 (59.4%). Urinary retention requiring catheterization occurred in 11 cases (8.59%). Of these, seven were post-bilateral RALUR, while the remaining four were unilateral. In seven cases, postoperative retention occurred within 24 h following RALUR. The remaining four instances occurred within 1 week, despite successful voiding in the immediate postoperative period. Univariate analysis revealed male gender (P = 0.009) and operating room time (P = 0.029) as predictors of retention. No association was found with age, weight, BBD, pre-operative UTI, grade of VUR, or laterality.

CONCLUSION

Urinary retention after RALUR was an infrequent complication. When it did occur, urinary retention appeared to be secondary to covariates such as male gender and length of surgical time - possibly an indication of technical difficulty - rather than laterality of repair.

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

BACKGROUND

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve.

OBJECTIVE

To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons.

DESIGN AND METHODS

We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure.

RESULTS

In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure.

DISCUSSION

We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients.

CONCLUSIONS

Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.

Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children

PURPOSE OF REVIEW

Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases.

RECENT FINDINGS

Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant.

SUMMARY

Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.

Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of robot-assisted laparoscopic ureteral reimplantation (RALUR) and open ureteral reimplantation (OUR) in treating primary pediatric vesicoureteral reflux (VUR) based on published literature.

METHODS

A comprehensive literature search of PubMed, Embase, Cochrane Library, CBM, CNKI and VIP databases was conducted to identify studies comparing the outcomes of RALUR with OUR for treating primary pediatric VUR. The last search was in January 2017. Summarized mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the differences in outcomes between RALUR and OUR.

RESULTS

A total of six studies containing 7122 children with primary VUR were included in this analysis. Significantly longer operation time was needed for RALUR than OUR (MD 66.69 min, 95% CI 41.71-91.67, P < 0.00001), while the RALUR group had significantly fewer days of hospital stay (MD - 17.80 h, 95% CI - 21.18 to - 14.42, P < 0.00001) and postoperative Foley placement (MD - 0.32 days, 95% CI - 0.57 to - 0.07, P = 0.01). No significant differences were found in estimated blood loss during operation, success rate, complications, and postoperative analgesia usage between the two groups. In subgroup analyses, a significantly higher rate of short-term postoperative complications in RALUR was found compared with OUR (OR 3.17, 95% CI 1.72-5.85, P = 0.0002).

CONCLUSIONS

Our study indicates that compared with OUR, RALUR is also an effective surgical approach for primary pediatric VUR and could help patients return to society more quickly; however, short-term postoperative complications of RALUR should be considered cautiously.

Robot-assisted extravesical ureteral reimplantation (revur) for unilateral vesico-ureteral reflux in children: results of a multicentric international survey

PURPOSE

This multicentric international retrospective study aimed to report the outcome of robot-assisted extravesical ureteral reimplantation (REVUR) in patients with unilateral vesico-ureteral reflux (VUR).

METHODS

The medical records of 55 patients (35 girls, 20 boys) underwent REVUR in four international centers of pediatric robotic surgery for primary unilateral VUR were retrospectively reviewed. Patients' average age was 4.9 years. The preoperative grade of reflux was III in 12.7%, IV in 47.3% and V in 40%. Twenty-six patients (47.3%) presented a loss of renal function preoperatively and 10 (18.1%) had a duplex system.

RESULTS

Average robot docking time was 16.2 min (range 5-30). Average total operative time was 92.2 min (range 50-170). No conversions or intra-operative complications were recorded. All patients had a bladder Foley catheter for 24 h post-operatively. Average hospital stay was 2 days (range 1-3). Average follow-up length was 28 months (range 9-60). We recorded three (5.4%) postoperative complications: 1 small urinoma resolved spontaneously (II Clavien) and 2 persistent reflux, only one requiring redo-surgery using endoscopic injection (IIIb Clavien).

CONCLUSION

REVUR is a safe and effective technique for treatment of primary unilateral VUR. The procedure is easy and fast to perform thanks to the 6° of freedom of robotic arms. The learning curve is short and it is useful to begin the robotics experience with a surgeon expert in robotic surgery as proctor on the 2nd robot console. The high cost and the diameter of instruments remain the main challenges of robotics applications in pediatric urology.

Minimally Invasive Management for Vesicoureteral Reflux in Infants and Young Children

Minimally invasive ureteral reimplantation is an attractive and useful tool in the armamentarium for the management of complicated vesicoureteral reflux (VUR). Subureteric dextranomer/hyaluronic acid injection, laparoscopic extravesical ureteric reimplantation and pneumovesicoscopic intravesical ureteral reimplantation with or without robotic assistance are established minimally invasive approaches to management of VUR. The high cost and the limited availability of robotics have restricted accessibility to these approaches. Laparoscopic and/or robotic ureteral reimplantation continues to evolve and will have a significant bearing on the management of complicated VUR in infants and young children.

Is robot-assisted laparoscopic bilateral extravesical ureteral reimplantation associated with greater morbidity than unilateral surgery? A comparative analysis

INTRODUCTION

Voiding dysfunction after bilateral extravesical ureteral reimplantation for vesicoureteral reflux has long remained a concern. Robotic approach with improved visualization that enables focused and minimal dissection may help with this concern.

OBJECTIVES

To compare postoperative outcomes after bilateral robot-assisted laparoscopic ureteral reimplantation to unilateral robot-assisted laparoscopic ureteral reimplantation.

STUDY DESIGN

This was a retrospective study using data abstracted from an institutional review board-approved registry prospectively maintained at our institution since 2012. Patient demographics, preoperative characteristics, and postoperative outcomes were analyzed. Patients with postoperative febrile urinary tract infection (UTI) underwent voiding cystourethrogram (VCUG). Surgical success is defined as absence of febrile UTI or febrile UTI with negative VCUG.

RESULTS

92 patients with a median follow-up of 14 (25th and 75th IQR 5, 28) months. Median operative time (150 vs. 178 min, p = 0.01) and median hospital stay (33 vs. 37 h, p = 0.01) were longer in the bilateral cohort. Weight-adjusted morphine equivalents requirement was also higher in the bilateral group (0.45 vs. 0.59, p = 0.019).

DISCUSSION

Early postoperative voiding dysfunction is influenced by anesthesia, postoperative pain, analgesics, age, surgical dissection, and preoperative voiding issues. Effective preoperative management of voiding dysfunction, minimizing surgical dissection and cautery, and minimizing opiate use will aid improving outcomes after surgery and enable bilateral surgeries on uretero-vesical junction. A robotic approach to facilitate such strategies could help outcomes after bilateral ureteral reimplantation. Limitations of this study include its retrospective design, the absence of routine postoperative VCUG after ureteral reimplantation, and unknown confounding variables.

CONCLUSION

Robot-assisted laparoscopic bilateral extravesical ureteral reimplantation is not associated with an increased risk of postoperative morbidity compared with unilateral surgery.

Advances in paediatric urology

Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system. In this Series paper, we highlight advances in the surgical management of six paediatric urological disorders. The management of vesicoureteral reflux is evolving, with advocacy ranging from a less interventional assessment and antimicrobial prophylaxis to surgery including endoscopic injection of a bulking agent and minimally invasive ureteric reimplantation. Evidence supports early orchidopexy to improve fertility and reduce malignancy in boys with undescended testes. A variety of surgical techniques have been developed for hypospadias, with excellent outcomes for distal but not proximal hypospadias. Pelvi-ureteric junction obstruction is mostly detected prenatally; indications for surgery have been refined with evidence, and minimally invasive pyeloplasty is now standard. The outlook for patients with neurogenic bladder has been transformed by a combination of clean intermittent catheterisation, algorithms of diagnostic investigations, and innovative medical and surgical therapies. Posterior urethral valves are associated with considerable mortality; fetal diagnosis allows stratification of candidates for intervention, but ongoing bladder dysfunction in patients after valve ablation remains a cause of long-term morbidity.

Our experiences with robot- assisted laparoscopic surgery in pediatric patients: the first case series from Turkey

OBJECTIVE

Robotic surgery is a leading treatment option for minimally invasive surgery and has an increasing popularity in pediatric population, as well. In this article, we reported our case series of robot-assisted laparoscopic surgery in pediatric population.

MATERIAL AND METHODS

We retrospectively reviewed 29 consecutive pediatric patients who underwent robot- assisted procedures between May 2014 and October 2016. Patient demographics, hospitalization time, estimated blood loss, robotic time and total operative and peri-, and post-operative complications were evaluated.

RESULTS

A total of 24 ureter units (18 patients) with grade 1-5 vesicoureteral reflux in 13 female and 5 male, 1 male patient with vesicoureteral stenosis were underwent robot- assisted laparoscopic ureteral reimplantation (RALUR). All patients had complete resolution after surgery. Robot-assisted laparoscopic pyeloplasty (RALP) was performed in 6 patients with ureteropelvic junction obstruction. All patients had complete resolution after surgery. Completely intracorporeal robotic assisted laparoscopic augmentation ileocystoplasty (RLAIC) was applied to two patients with neurogenic bladder. The symptoms and preoperative hydronephrosis were regressed on the first month of follow-up. Robot-assisted laparoscopic reduction cystoplasty (RALRC) was performed in 14-year-old boy with a bladder diverticula and recurrent urinary tract infection. The last case was eleven- year-old female patient with non-functioning kidney. She had recurrent urinary tract infections and was treated with robotic assisted laparoscopic nephrectomy (RALN).

CONCLUSION

Robot-assisted laparoscopic surgery is safe and efficient in pediatric population. Although open surgery is still the gold standard for many pediatric diseases, inherent reconstructive advantages of robotic assisted laparoscopy have a chance to change this view.

[Application of robotic-assisted versus conventional laparoscopy in ureteral reimplantation with psoas hitch]

OBJECTIVE

To compare the efficacy of robotic-assisted laparoscopic and conventional laparoscopic ureteral reimplantation with psoas hitch.

METHODS

We retrospectively analyzed the data of 10 patients undergoing robotic-assisted laparoscopic ureteral reimplantation with psoas hitch and 6 undergoing conventional laparoscopic ureteral reimplantation between June, 2013 and December, 2014 in the General Hospital of PLA. The indications, surgical techniques and outcomes of the two procedures were compared.

RESULTS

All the patients completed the laparoscopic procedures without conversion to open surgery. Robotic-assisted and conventional laparoscopic procedures were comparable in terms of the mean operation time (165.50=52.57 vs 152.50=73.60 min), mean volume of blood loss (81.00=69.35 vs 46.67=31.41 mL), mean duration of catheter retention (6.75=1.74 vs 7.50=2.43 days), and mean postoperative hospital stay (7.10=2.08 vs 8.67=3.14 days). The patients were followed up for a mean of 13.5 months, during which none of the patients experienced anastomotic leak, vesicoureteral reflux or hydronephrosis.

CONCLUSION

There are no significant differences in surgical indications, surgical techniques or postoperative effect between robotic-assisted and conventional laparoscopic procedures of ureteral reimplantation with psoas hitch, but robotic-assisted laparoscopy can reduced the complexity in operation and increase the surgical precision in patients with a history of pelvic surgery, pelvic adhesion or secondary reimplantation.

Lessons learned over a decade of pediatric robotic ureteral reimplantation

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.

Robot-assisted laparoscopic extravesical ureteral reimplant: A critical look at surgical outcomes

BACKGROUND

Published reports of outcomes of robot assisted laparoscopic ureteral reimplantation (RALUR) show mixed results that, on average, are inferior to open ureteral reimplant. We present a retrospective analysis of a prospective series of children who had RALUR from 2013 to June 2015. We hypothesized that surgical outcomes are based on identifiable risk variables. We provide a critical analysis of the relationship between patient characteristics and several surgical and non-surgical outcomes.

METHODS

We reviewed the records of children who had Robot-Assisted Laparoscopic (RAL) Ureteral Reimplant (UR) at Nationwide Children's Hospital. Patient age and gender, preoperative presentation, presence of preoperative bladder and bowel dysfunction (BBD), VUR grade and laterality, indication for operation, operative time, surgical outcome, surgical complications, post-operative prevalence of UTI, and pre- and post-operative status of BBD were recorded. We also recorded techniques for ureteral dissection, and closing the detrusorrhaphy. Surgical outcome was defined by post-operative VCUG. We define BBD based on publications by the standardization committee of International Children's Continence Society (ICCS). All statistical calculations were performed with STATA version 11.

RESULTS

We performed extravesical RALUR on 54 children for a total of 72 ureters. Overall the study children were 74% female. The mean and median age was 5.2 and 4.9 years, respectively. Mean overall hospital length of stay (LOS) was 1.64 days. The mean LOS was 1.26 for unilateral (RALUUR) and 2.39 days for bilateral (RALBUR) surgeries and was significant (p < 0.05). Overall surgical success was 85.2% of ureters and 84.7% of children. Stratified by unilateral and bilateral surgeries, unilateral success was 91.7%, and bilateral success was 77.8% of ureters, and 72.2% of children. In the 3 failures in the RALUUR group the mean postoperative VUR grade was 1.3 from a pre-op mean grade of 3.3, whereas in the RALBUR group, the mean VUR grade among the failures was 3.0 from a mean pre-op VUR grade of 3.7. Urinary leak from ureteral injury, and urinary obstruction were more common in the RALBUR group. Post-operative urinary retention occurred in 4 children in the RALBUR and none in the RALUUR groups. Four with VUR after RALBUR and one child after RALUUR had open ureteral reimplant. Post-op UTI and non-surgical readmissions were higher in the RALBUR group.

CONCLUSIONS

Bilateral RALUR is associated with higher failure rates, higher complication rates, higher re-operation rates, and more postoperative UTIs and nonsurgical readmissions compared with unilaterasl RALUR.