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O'Brien LP, Hannan E, Antao B, Peirce C. Paediatric robotic surgery: a narrative review. J Robot Surg 2023; 17:1171-1179. [PMID: 36645643 PMCID: PMC10374698 DOI: 10.1007/s11701-023-01523-z] [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: 07/11/2022] [Accepted: 01/02/2023] [Indexed: 01/17/2023]
Abstract
The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.
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Affiliation(s)
- Lukas Padraig O'Brien
- Department of Paediatric Surgery, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Enda Hannan
- Department of Colorectal Surgery, University Hospital Limerick, St Nessan's Road, Dooradoyle, Limerick, Co Limerick, Ireland.
| | - Brice Antao
- Department of Paediatric Surgery, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin Peirce
- Department of Colorectal Surgery, University Hospital Limerick, St Nessan's Road, Dooradoyle, Limerick, Co Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
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Pyeloplasty with ureteral stent placement in children: Do prophylactic antibiotics serve a purpose? J Pediatr Urol 2022; 18:804-811. [PMID: 35501240 DOI: 10.1016/j.jpurol.2022.03.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/24/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Ureteral stents are commonly used during pyeloplasty to ensure drainage and anastomotic healing. Antibiotic prophylaxis is often used due to concerns for urinary tract infection (UTI). Although many surgeons prescribe prophylactic antibiotics following pyeloplasty, practices vary widely due to lack of clear evidence-based guidelines. We hypothesize that the rate of stent UTI does not significantly vary between children who receive antibiotics and those who do not. METHODS We reviewed the medical records of 741 patients undergoing pyeloplasty between January 2010 and July 2018 across seven institutions. Exclusion criteria were: age older than 22 years, no stent placed, externalized stents used, and incomplete records. Surgical approach, age, antibiotic use, stent duration, Foley duration, and urine culture results were recorded. Patients were categorized into two groups, those younger than four years of age and those four years and older as proxy for likely diaper use. Univariate logistic regression was conducted to identify variables associated with UTI. Multivariable backward stepwise logistic regression was used to identify the best model with Akaike information criterion as model selection criteria. The selected model was used to calculate odds ratios and 95% confidence intervals summarizing the association between prophylactic antibiotics and stent UTI while controlling for age, gender, and intra-operative urine cultures. RESULTS 672 patients were included; 338 received antibiotic prophylaxis and 334 did not. These groups differed in mean age (3.91 vs. 6.91 years, P < .001), mean stent duration (38.5 vs. 35.32 days, P < .001), and surgical approach (53.25% vs. 32.04% open vs. laparoscopic, P < .001). The incidence of stent UTI was low overall (7.59%) and similar in both groups: 31/338 (9.17%) in the prophylaxis group and 20/334 (5.99%) in the non-prophylaxis group (P = .119). Although female gender, likely diaper use, and positive intra-operative urine culture were each associated with significantly higher odds of stent UTI, prophylactic antibiotic use was not associated with significant reduction in stent UTI in any of these groups. Surgical approach, stent duration, and Foley duration were not associated with stent UTI. CONCLUSION Incidence of stent UTI is low overall following pyeloplasty. Prophylactic antibiotics are not associated with lower rates of stent UTI following pyeloplasty even after controlling for risk factors of female gender, likely diaper use, and positive intra-operative urine culture. Routine administration of prophylactic antibiotics after pyeloplasty does not appear to be beneficial, and may be best reserved for those with multiple risk factors for UTI.
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Lepore B, Autorino G, Coppola V, Borgogni R, Carulli R, Cerulo M, Califano G, Cardone R, Escolino M, Esposito C. Effectiveness of a Laparoscopic Training Model for Pediatric Surgeons During COVID-19 Pandemic: A Single-Center Experience. J Laparoendosc Adv Surg Tech A 2022; 32:907-912. [PMID: 35796708 DOI: 10.1089/lap.2022.0158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: During COVID-19 pandemic, many restrictions were applied in the field of health care. For this reason, we decided to adopt the laparoscopic simulator Laparo® Analytic to allow the trainees of our pediatric surgery training program to continue their training activity, and we determined its impact on their surgical education. Methods: We used Laparo Analytic Simulator for laparoscopic surgery training among the residents of our center. Fifteen residents from different years of the pediatric surgery program participated in this study. Each participant performed a 2-hour training session per week, consisting of three different exercises: Rubber Bands, Knotting, and Suturing. For each training session, the following parameters were analyzed: training time, economy of movement, smoothness, instrument activity (IA), instrument visibility (IV), and instrument symmetry. Results: Results were collected after the first training session (T0), at 3 months after the beginning of the study (T1) and at 6 months after the beginning of the study (T2). At T2 of training with Laparo Analytic Simulator, residents were able to complete their tasks significantly faster (P = .001) and had a significant improvement in smoothness of movements, IA, IV, and instrument symmetric movements during the tasks analyzed. Conclusion: On the basis of our results, we believe that Laparo analytic is an excellent system to adopt in minimally invasive surgery (MIS) training programs, in particular, during periods of surgical restrictions, as COVID-19 pandemic, or in centers with a limited MIS activity.
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Affiliation(s)
- Benedetta Lepore
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Giuseppe Autorino
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Vincenzo Coppola
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Rachele Borgogni
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Roberto Carulli
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Mariapina Cerulo
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Gianluigi Califano
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Roberto Cardone
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Maria Escolino
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Department of Translational Medical Science, University of Naples "Federico II," Naples, Italy
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Rague JT, Shannon R, Rosoklija I, Lindgren BW, Gong EM. Robot-assisted laparoscopic urologic surgery in infants weighing ≤10 kg: A weight stratified analysis. J Pediatr Urol 2021; 17:857.e1-857.e7. [PMID: 34635439 DOI: 10.1016/j.jpurol.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/06/2021] [Accepted: 09/23/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Robot-assisted laparoscopic (RAL) urologic surgery is widely used in pediatric patients, though less commonly in infants. There are small series demonstrating safety and efficacy in infants, however, stratification by infant size has rarely been reported. Whether a cut-off weight, below which RAL surgery is not technically feasible, safe, or efficacious has not be determined. OBJECTIVE To assess safety and efficacy of RAL urologic procedures in infants <1 year of age, weighing ≤10 kg. STUDY DESIGN A single-institution retrospective cohort study of patients <1 year of age, and ≤10 kg undergoing RAL pyeloplasty (RALP) or RAL ipsilateral ureteroureterostomy (RALUU) between January 2011 and September 2020 was performed. Demographic, operative, and post-operative data were extracted from the medical record. Patients were stratified by post-hoc weight quartiles. Outcomes, including operative time, total OR time, estimated blood loss (EBL), post-operative length of stay (LOS), post-operative radiographic improvement, and 30-day complications were assessed by weight quartile for each procedure. The Kruskal-Wallis rank test was used to assess differences in continuous outcomes between weight quartiles and Pearson's Chi-squared test was used for categorical outcomes. RESULTS Of 696 RAL urologic surgeries performed, 101 met eligibility criteria. Median (IQR) age of patients was 7.2 (6.0-9.2) months with median weight of 8.0 (7.2-8.9) kg. The lowest weight was 5.5 kg. Procedures performed included 79 RALPs (78.2%), 22 RALUUs (21.8%). We identified 97 patients (94%) with post-operative imaging, with radiographic improvement in 92%. When stratified by weight quartile, there was no difference between groups in median operative time, total OR time, LOS, EBL, or post-operative radiographic improvement for both RALP and RALUU. Post-operative complications were assessed based on Clavien-Dindo classification with the majority of complications (9/12, 75%) in the >50th percentile weight groups. DISCUSSION To our knowledge, this is the largest published series of infant RAL urologic procedures, with similar rates of radiographic improvement and post-operative complications to prior published series. There are few prior series of RALP and RALUU in infants ≤10 kg, and we show comparable outcomes regardless of patient weight. Our study is limited by the inherent biases of retrospective studies. CONCLUSION RAL urologic surgery is technically feasible, safe, and efficacious in infants ≤10 kg, without worse outcomes as weight decrease. A cut-off weight, below which RAL surgery should not be performed has yet to be identified.
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Affiliation(s)
- James T Rague
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Rachel Shannon
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Ilina Rosoklija
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Bruce W Lindgren
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
| | - Edward M Gong
- From the Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago (JR, RS, IR, BWL, EMG) and the Department of Urology, Northwestern University Feinberg School of Medicine (BLW, EMG), Chicago, IL, USA.
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Robotic upper tract surgery in infants 6 months or less: is there enough space? J Robot Surg 2021; 16:193-197. [PMID: 33751338 DOI: 10.1007/s11701-021-01231-6] [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: 12/18/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
Robot-assisted laparoscopic surgery (RALS) has recently been described in children < 1 year old. However, little data exist on robotic utilization in infants ≤ 6 months old, likely due to concerns for limited intraabdominal space and decreased distance between ports in this cohort. We hypothesized that the robotic approach can be successfully used for infants ≤ 6 months old. A prospectively collected database of patients undergoing urologic robotic surgery at our institution was reviewed. Patients ≤ 6 months and ≥ 4 kg were included. Patient demographics, intraoperative details, hospital length of stay, and complications were reviewed. Descriptive statistics were performed. Twelve patients ≤ 6 months old underwent urologic robotic surgery by three surgeons at our institution (2013-2019): pyeloplasty (6), ureteroureterostomy (4), heminephrectomy (1), and nephrectomy (1). Median age at surgery was 4.75 months (IQR 4, 6). Median weight was 7.09 kg (IQR 6.33, 7.78). Median console time was 105 min (IQR 86, 123). For all procedures, 8-mm robotic arm ports were used. No procedures were converted to open. Median post-operative hospital stay was 24 h (IQR). Febrile UTI was the only complication occurring within 30 days of surgery (n = 4, 33%; 7-20 days, Clavien grade 2). For those undergoing pyeloplasty or ureteroureterostomy (n = 10), postoperative ultrasound showed improved (n = 9) or stable hydronephrosis (n = 1). At a median follow-up of 19.73 months (IQR 4.27, 38.32), no patient required an unplanned secondary intervention. Robotic upper urinary tract surgery is feasible and safe in patients ≤ 6 months of age and can be performed successfully with the same technique as for older children.
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Urinary Tract Infection After Robot-assisted Laparoscopic Pyeloplasty: Are Urine Cultures and Antibiotics Helpful? Urology 2020; 148:235-242. [PMID: 33248143 DOI: 10.1016/j.urology.2020.09.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate how variations in peri-operative urine culture (UCx) and antibiotic prophylaxis utilization following robot assisted laparoscopic pyeloplasty (RALP) affect post-RALP urinary tract infection (UTI) rates in children, then use data to generate a standardized care pathway. METHODS Patients undergoing RALP at a single institution from January 2014 to October 2018 were retrospectively reviewed. Patients with vesicoureteral reflux, neurogenic bladder, intermittent catheterization, <=2 months follow-up after stent removal, or age >=18 years were excluded. UCx use, UCx results, and pre- and post-RALP antibiotic use were recorded. The primary outcome was symptomatic UTI, tracked until 60 days after stent removal. UTI was defined as presence of fever or urinary symptoms, a positive UCx with >=10,000 colony forming units of one uropathogen, and a positive urinalysis. RESULTS A total of 152 patients were included (72% male [73% circumcised], 61% white, and 23% Hispanic). One underwent a re-operative pyeloplasty, yielding 153 encounters. Eight patients (5.2%; 95% CI 1.7-8.7%) developed post-RALP UTI. Uncircumcised status and use of pre-operative prophylactic antibiotics were associated with post-RALP UTI (P = .03 and P < .01, respectively). Use of post-RALP antibiotics, whether prophylactic or therapeutic, was not associated with lower UTI rates (P = .92). Positive pre-RALP UCx and positive intra-operative stent removal UCx were associated with higher UTI rates (P = .03 and P < .01, respectively). CONCLUSION UTI occurred in 5.2% of our cohort of >150 patients. As post-RALP antibiotic use was not associated with lower UTI rates, prophylactic antibiotics may be reserved for patients with risk factors. A standardized care pathway could safely reduce unnecessary utilization of UA/UCx and antibiotics.
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Osumah TS, Granberg CF, Butaney M, Gearman DJ, Ahmed M, Gargollo PC. Robot-Assisted Laparoscopic Urachal Excision Using Hidden Incision Endoscopic Surgery Technique in Pediatric Patients. J Endourol 2020; 35:937-943. [PMID: 32013581 DOI: 10.1089/end.2019.0525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction: Although laparoscopic urachal excision in children has been well reported, there are limited data on a robot-assisted surgery (RAS) approach. The hidden incision endoscopic surgery (HIdES) technique is an established method of eliminating visible scars following a number of RAS urologic procedures. We report our experience of using a robotic approach to treat urachal anomalies in children, and we present the first description of utilizing the HIdES port configuration for this procedure. Materials and Methods: We retrospectively reviewed pediatric patients who underwent resection of a urachal remnant at our institution from 2013 to 2018. Surgical techniques were either the traditional open approach (OA) or RAS. HIdES trocar placement configuration was employed in all robotic cases. Patient demographics, perioperative data, pathology reports, and outcomes were abstracted and compared. Results: Twenty-three patients underwent a urachal remnant resection in the study period (RAS: 14 patients vs OA: 9 patients). RAS patients were older (8.5 vs 2.0 years, p = 0.031) and weighed more than OA patients (36.1 vs 13.9 kg, p = 0.063). Median operative time for RAS was longer than OA operative time (136 vs 33 minutes, p < 0.01). Fewer RAS patients were outpatient compared with OA (7.1% vs 66.7%, p < 0.01), but with a median length of stay of 1 day (0-1 day). Two patients (14.3%) in the RAS group experienced postoperative complications within 1 week of the procedure compared with 1 (11.1%) in the OA group. There was no significant difference in blood loss, postoperative narcotic requirements, or duration of follow-up between both groups. Conclusion: RAS is a safe and feasible alternative to open surgery for urachal anomalies. Complete excision can be achieved by using HIdES port configuration, allowing for excellent cosmetic outcomes that are superior to traditional surgical scars without limitation to essential surgical ergonomics.
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Affiliation(s)
| | | | - Mohit Butaney
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamed Ahmed
- Department of Urology, Mayo Clinic, Rochester, Minnesota
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Villanueva CA. Open vs robotic infant ureteroureterostomy. J Pediatr Urol 2019; 15:390.e1-390.e4. [PMID: 31151858 DOI: 10.1016/j.jpurol.2019.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 05/01/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION A ureteroureterostomy (UU) is often used to manage some duplication anomalies. The operation is commonly performed through a Pfannenstiel incision, but other minimally invasive approaches have been described. The objective of this study is to compare open vs robotic infant UU with regards to operative time, complications, and operative success. METHODS AND MATERIALS This is a retrospective institutional review board approved study of all infant UUs performed from July 2013 to January 2019. Before the DaVinci Xi became available (November 2017), UUs were primarily done open. All UUs after November 2017 were robotic. Surgery was recommended electively at 6 months in suspected cases of ectopic ureters or earlier for history of febrile UTI's or worsening hydronephrosis. Both open and robotic cases were started with cystoscopy and lower pole ureteral stent placement. A 5-0 polypropylene suture was tied in between in the stent and the Foley catheter. Foley and stent were removed 3-7 days after surgery in the clinic or at home by the parents. For both open and robotic approaches, patients were discharged on postoperative day (POD) 1 with the Foley draining into a double diaper on antibiotic prophylaxis. RESULTS From July 2013 to January 2019, 12 open and eight robotic infant UUs were performed. One patient in each group had a ureterocele, and the rest had ectopic ureters. Median age was 7 months for both the open and robotic groups. All patients except one had a 3.7 Fr by 10-12 cm stent placed attached to an 8-10 Fr silicone Foley catheter. The exception was the first robotic case who had a 3 Fr stent with no dangler placed after failed attempts with a 4.7 Fr stent (there were no 3.7 Fr stents that day). Median surgery time was 129 min (range 100-188, mean 133 min) for open and 130 min (range 79-226 min, mean 137 min) for robotic (P-value 0.8). In addition to the robotic case who had a 3 Fr stent placed with no dangler, an additional robotic case had to have her stent removed under anesthesia because the dangler broke or the knot got undone when the Foley was removed. One patient in the robotic arm who had the surgery done for a ureterocele had two postoperative febrile UTI's. Evaluation with VCUG and renal ultrasound (US) did not reveal hydronephrosis or reflux. She was managed conservatively. Other than the two cystoscopy and stent removals, no patient required a reoperation. DISCUSSION These data indicate that the laparoscopic robotic-assisted UU can be safely performed in infants with similar operative time compared with the traditional open Pfannenstiel approach. The two complications in the robotic arm were not related to the approach itself but to issues with the stents, which would have not been prevented by an open approach. There were no complications specific to the robotic approach. CONCLUSIONS Laparoscopic robotic-assisted infant UUs are safe, effective, and can be done in a similar time compared with the traditional open Pfannenstiel approach.
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Affiliation(s)
- C A Villanueva
- University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, United States.
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Abstract
PURPOSE OF REVIEW The goal of this article is to review the current role of robotic urologic surgery in the infant population across a spectrum of diseases and procedures. RECENT FINDINGS Robotic urological surgery has been performed in the infant population across a variety of conditions including ureteropelvic junction obstruction, vesicoureteral reflux, and duplicated and nonfunctional renal moieties. However, most of the durable evidence showing safety and success remains in the repair of the obstructed ureteropelvic junction. Included in this review are also strategies to address the limitations imposed by the unique physiology and anatomy of the infant. Robotic urologic surgery remains an alternative to other surgical approaches in the properly selected infant in the hands of experienced surgeons. As additional larger studies are performed, the utility of the robotic platform in this population will be clearer.
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Affiliation(s)
- Jeffrey Villanueva
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mary Killian
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rajeev Chaudhry
- Division of Pediatric Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Kim C. Robotic Urologic Surgery in Infants: Results and Complications. Front Pediatr 2019; 7:187. [PMID: 31139606 PMCID: PMC6527797 DOI: 10.3389/fped.2019.00187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/23/2019] [Indexed: 12/23/2022] Open
Abstract
Over the last 30 years, robotic surgery has evolved into the preferred surgical approach for many operative cases. Robotics has been associated with lower pain scales, shorter hospitalizations, and improved cosmesis (1, 2). However, its acceptance in pediatrics have been hampered by longer operative times, smaller working space, and limited fine surgical instruments. Many find these challenges even more pronounced when performing robotic surgery in infants (i.e., children <1 year old). Although the data in infants is less robust, many studies have shown benefits similar to the adult population. Specifically, multiple reports of robotic surgery in infants have shown lower postoperative analgesic use. Additionally, hospital stays are shorter, which may lead to quicker return to work for parents and guardians. Multiple reports have shown low complication rates of robotic surgery in infants. When complications have occurred, they are usually Clavien Grade 1 and 2, with occasional grade 3. Often the complications are not from the robotic technique, but are linked to other factors such as the ureteral stents (3, 4). Most importantly, the success rates of surgery are comparable to open surgery. This chapter will review indications for the most common urologic robotic surgeries performed in infants. Also, we will review reported results and complications of robotic surgery in children, with specific attention to the infant population. However, data focused only on infants is limited. Many studies have some infant patients, but their results are often mixed with all pediatric patients.
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Affiliation(s)
- Christina Kim
- Department of Urology, University of Wisconsin-Madison, Madison, AL, United States
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Fernandez N, Farhat WA. A Comprehensive Analysis of Robot-Assisted Surgery Uptake in the Pediatric Surgical Discipline. Front Surg 2019; 6:9. [PMID: 30915338 PMCID: PMC6422870 DOI: 10.3389/fsurg.2019.00009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/15/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction: Robotic assisted surgery (RAS) is one of the most recent surgical approaches that has quickly been adopted by the pediatric urology community. Over the last decade, a vast amount of manuscripts has been published, supporting the safety and applicability of RAS in the pediatric population. The quality of published literature about this innovative technology remains supported by case-reports and retrospective case-series. Historical behavior of literature productivity and implementation of laparoscopy followed a similar trend. We present the historical publication uptake of RAS in pediatric urology and other surgical disciplines using a bibliometric comparison of the most cited manuscripts. Materials and Methods: A systematic search and review of the literature was undertaken by the authors. Literature search was performed in OVID, PubMed, EMBASE, Scopus, Web of Science, and Google Scholar. The search period included all publications between 1985 and June 2018. All languages were included. Data analysis for graphical representation was performed using VOSviewer® version 1.6.8 and Impact Index Analysis was used to adjust the citations by the time since publication. Results: A total of 1,014 titles were identified. After applying exclusion criteria, 200 papers were included for the RAS arm and 402 for the laparoscopic one. Case-series was the most common type of publication. Average citations for laparoscopic manuscripts was 23 (SD ± 31) and for RAS was 20 (SD ± 31.5). The impact index analysis showed an average of 95 (SD ± 167) for laparoscopic manuscripts vs. 66 (SD ± 101) for RAS. The laparoscopic manuscript with the highest citation count had 199 citations with an impact index of 12.1. And the RAS manuscript with the highest citation count had 280 citations and an impact index of 4.3. Conclusion: Literature productivity in pediatric laparoscopic and RAS has quickly grown. Pediatric Urologists play a key role in the introduction of this innovative tool. Literature supporting its implementation and future consolidation requires to focus on increasing the level of evidence.
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Affiliation(s)
- Nicolas Fernandez
- Division of Urology, Hospital for SickKids, University of Toronto, Toronto, ON, Canada.,Department of Urology, Fundación Santa Fe de Bogota, Bogota, Colombia.,Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia
| | - Walid A Farhat
- Division of Urology, Hospital for SickKids, University of Toronto, Toronto, ON, Canada
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Does the use of 5 mm instruments affect the outcomes of robot-assisted laparoscopic pyeloplasty in smaller working spaces? A comparative analysis of infants and older children. J Pediatr Urol 2018; 14:537.e1-537.e6. [PMID: 30007500 DOI: 10.1016/j.jpurol.2018.06.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pediatric robot-assisted laparoscopic (RAL) pyeloplasty has become a viable minimally invasive surgical option for ureteropelvic junction obstruction (UPJO) based on its efficacy and safety. However, RAL pyeloplasty in infants can be a challenging procedure because of the smaller working spaces. The use of the larger 8 mm instruments for these patients instead of the 5 mm instruments is common because of the shorter wrist lengths. OBJECTIVE We hypothesized that the use of 5 mm instruments for RAL pyeloplasty in infants with smaller working spaces will have comparable perioperative parameters and surgical outcomes in comparison with older children with larger working spaces. STUDY DESIGN We compared the perioperative parameters and surgical outcomes of RAL pyeloplasties performed by a single surgeon in infants and non-infant pediatric patients over a 2 year period. All of the procedures were performed using an 8.5 mm camera and 5 mm robotic instruments. Patient demographics, operative times, perioperative complications, hospital pain medication usage, hospital length of stay, and treatment success rates were compared between the two groups. RESULTS A total of 65 pediatric RAL pyeloplasties were included in the study (16 infants and 49 non-infants, Table). There were no significant differences in gender, laterality, proportion of re-do pyeloplasty, or preoperative hydronephrosis grade between the two groups. All procedures were performed without conversion to open surgery or significant perioperative complications. There were no differences in segmental operative times (total operative time, console time, port placement time, time for dissection to UPJO, and anastomosis time), hospital pain medication usage, and hospital length of stay between the two groups (p > 0.05 for all comparisons). The treatment success rates were 93.8% (15/16) and 100% (49/49), respectively (p = 0.08). DISCUSSION We present the first comparative study of infant and non-infant pediatric RAL pyeloplasty using 5 mm robotic instruments. An advantage of the current study is the use of a single surgeon's experience to compare RAL pyeloplasty outcomes in infants with those of older children, a group in which RAL pyeloplasty has already been shown to be efficacious and safe. Operative tips for infant RAL pyeloplasty are also provided. CONCLUSIONS RAL pyeloplasty is a safe and effective surgical modality even in infants, with comparable perioperative parameters and outcomes as those in older children. The use of 5 mm instruments in infants does not affect outcomes and offers the potential for improved cosmesis.
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Abstract
A review of the current status of robotic surgery use in paediatrics.
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Affiliation(s)
- Joshua Cave
- Chelsea and Westminster NHS Foundation Trust
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14
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Abstract
PURPOSE OF REVIEW In this review, we summarize research that has evaluated the role of laparoendoscopic single-site (LESS) and robotic surgery in pediatric urology, highlighting new and/or controversial ideas. RECENT FINDINGS The newest research developments over the last several years are studies that address generalizability of these techniques, ideal patient factors, extrapolation to more complex surgeries, and comparative studies to more traditional techniques to define the associated costs and benefits, as well as patient-centered outcomes. Specifically in the field of LESS, addressing the limitations of suboptimal vision, instrument crowding, and loss of triangulation have been a focus. The literature is now replete with new applications for robotic surgery as well as descriptions of the specific technical challenges inherent to pediatrics. Robotic surgery and LESS are areas of growth in pediatric urology that allow continual innovation and expansion of technology within a surgeon's armamentarium.
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Chan YY, Durbin-Johnson B, Sturm RM, Kurzrock EA. Outcomes after pediatric open, laparoscopic, and robotic pyeloplasty at academic institutions. J Pediatr Urol 2017; 13:49.e1-49.e6. [PMID: 28288777 PMCID: PMC5353856 DOI: 10.1016/j.jpurol.2016.08.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 08/30/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Patient age and hospital volume have been shown to affect perioperative outcomes after pediatric pyeloplasty. However, there are few multicenter studies that focus on outcomes at teaching hospitals, where many of the operations are performed. OBJECTIVE The goal was to determine if surgical approach, age, case volume, or other factors influence perioperative outcomes in a large contemporary cohort. STUDY DESIGN Using the clinical database/resource manager (CDB/RM) of the University Health-System Consortium (UHC), children who underwent open, laparoscopic, or robotic pyeloplasty from 2011 to 2014 were identified at 102 academic institutions. Surgery type, age, race, gender, insurance type, geographic region, comorbidities, surgeon volume, and hospital volume were measured. Multivariable mixed-effects logistic regression analysis was used to analyze independent variables associated with complication rates, length of stay (LOS), readmission rates, and ICU admission. RESULTS A total of 2219 patients were identified. Complication rates were 2.1%, 2.2%, and 3% after open, laparoscopic, and robotic pyeloplasty, respectively. Approximately 12% of patients had underlying comorbidities. Comorbidities were associated with 3.1 times increased odds for complication (p = 0.001) and a 35% longer length of stay (p < 0.001). Age, gender, insurance type, and hospital volume had no effect on complication rates. A trend was seen towards a lower rate of complications with higher surgeon volume (p = 0.08). The mean LOS was 2.0 days in the open pyeloplasty group, 2.4 days in the laparoscopic group and 1.8 days in the robotic group. Patients who underwent robotic surgery had an estimated LOS 11% shorter than those after open surgery (p = 0.03) (Table). Patients aged 5 years and under who had robotic surgery had an estimated LOS 14% shorter than those after open surgery (p = 0.06). ICU admission and hospital readmission were not associated with any variables. DISCUSSION The study is limited by the accuracy of the data submitted by the hospitals and is subject to coding error. Complication rates remain low in all three approaches, validating their safety. Patients, including younger patients, had shorter lengths of stay after robotic surgery. The statistically significant differences between approaches were small so clinically there may not be a difference. CONCLUSIONS This large multicenter analysis demonstrates that patient comorbidity had the greatest impact upon complication rates and length of stay. Previous work showed that the benefits of laparoscopy were limited to older children. However, this large multicenter study suggests that these benefits now extend to young children with the application of robotics.
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Affiliation(s)
- Yvonne Y Chan
- Department of Urology, University of California Davis Children's Hospital, Sacramento, CA, USA
| | | | - Renea M Sturm
- Department of Urology, University of California Davis Children's Hospital, Sacramento, CA, USA
| | - Eric A Kurzrock
- Department of Urology, University of California Davis Children's Hospital, Sacramento, CA, USA.
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Turrà F, Escolino M, Farina A, Settimi A, Esposito C, Varlet F. Pyeloplasty techniques using minimally invasive surgery (MIS) in pediatric patients. Transl Pediatr 2016; 5:251-255. [PMID: 27867848 PMCID: PMC5107382 DOI: 10.21037/tp.2016.10.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Hydronephrosis is the most common presentation of ureteropelvic junction (UPJ) obstruction. We reviewed literature, collecting data from Medline, to evaluate the current status of minimally invasive surgery (MIS) approach to pyeloplasty. Since the first pyeloplasty was described in 1939, several techniques has been applied to correct UPJ obstruction, but Anderson-Hynes dismembered pyeloplasty is established as the gold standard, to date also in MIS technique. According to literature several studies underline the safety and effectiveness of this approach for both trans- and retro-peritoneal routes, with a success rate between 81-100% and an operative time between 90-228 min. These studies have demonstrated the safety and efficacy of this procedure in the management of UPJ obstruction in children. Whether better the transperitoneal, than the retroperitoneal approach is still debated. A long learning curve is needed especially in suturing and knotting.
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Affiliation(s)
- Francesco Turrà
- Department of Pediatric Surgery, "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Maria Escolino
- Department of Pediatric Surgery, "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Alessandra Farina
- Department of Pediatric Surgery, "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Alessandro Settimi
- Department of Pediatric Surgery, "Federico II" University of Naples School of Medicine, Naples, Italy
| | - Ciro Esposito
- Department of Pediatric Surgery, "Federico II" University of Naples School of Medicine, Naples, Italy
| | - François Varlet
- Department of Pediatric Surgery, CHU Saint Etienne, Saint Etienne, France
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Biles MJ, Finkelstein JB, Silva MV, Lambert SM, Casale P. Innovation in Robotics and Pediatric Urology: Robotic Ureteroureterostomy for Duplex Systems with Ureteral Ectopia. J Endourol 2016; 30:1041-1048. [DOI: 10.1089/end.2015.0645] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael J. Biles
- Some of the material in this article was presented at the 26th Congress of the European Society for Paediatric Urology (October 14–17, 2015)
- Division of Pediatric Urology, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, New York
| | - Julia B. Finkelstein
- Some of the material in this article was presented at the 26th Congress of the European Society for Paediatric Urology (October 14–17, 2015)
- Division of Pediatric Urology, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, New York
| | - Mark V. Silva
- Some of the material in this article was presented at the 26th Congress of the European Society for Paediatric Urology (October 14–17, 2015)
- Division of Pediatric Urology, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, New York
| | - Sarah M. Lambert
- Some of the material in this article was presented at the 26th Congress of the European Society for Paediatric Urology (October 14–17, 2015)
- Division of Pediatric Urology, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, New York
| | - Pasquale Casale
- Some of the material in this article was presented at the 26th Congress of the European Society for Paediatric Urology (October 14–17, 2015)
- Division of Pediatric Urology, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, New York
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Howe A, Kozel Z, Palmer L. Robotic surgery in pediatric urology. Asian J Urol 2016; 4:55-67. [PMID: 29264208 PMCID: PMC5730905 DOI: 10.1016/j.ajur.2016.06.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/22/2016] [Indexed: 12/21/2022] Open
Abstract
While robotic surgery has shown clear utility and advantages in the adult population, its role in pediatrics remains controversial. Pediatric-sized robotic instruments and equipment are not readily available yet, so certain modifications can be made in order to make robotic surgery successful in children. While the cost of robotic surgery remains high compared to open procedures, patients experience greater satisfaction and quality of life with robotic surgery. Robotic pyeloplasty is a standard of care in older children, and has even been performed in infants and re-do surgery. Other robotic procedures performed in children include heminephroureterectomy, ureteroureterostomy, ureteral reimplantation, urachal cyst excision, bladder diverticulectomy, and bladder reconstructive procedures such as augmentation, appendicovesicostomy, antegrade continence enema, bladder neck reconstruction and sling, as well as other procedures. Robotic surgery has also been used in oncologic cases such as partial nephrectomy and retroperitoneal lymph node dissection. Future improvements in technology with production of pediatric-sized robotic instruments, along with increases in robotic-trained pediatric urologists and surgeon experience along each's learning curve, will help to further advance the field of robotic surgery in pediatric urology.
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Affiliation(s)
- Adam Howe
- Steven and Alexandra Cohen Children's Medical Center Ringgold Standard Institution - Pediatric Urology, Center for Advanced Medicine Smith Institute for Urology, New Hyde Park, NY, USA
| | - Zachary Kozel
- Long Island Jewish Medical Center Ringgold Standard Institution - Urology, Center for Advanced Medicine Smith Institute for Urology, New Hyde Park, NY, USA
| | - Lane Palmer
- Steven and Alexandra Cohen Children's Medical Center Ringgold Standard Institution - Pediatric Urology, Pediatric Urology Associates, New Hyde Park, NY, USA
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Mizuno K, Kojima Y, Kurokawa S, Kamisawa H, Nishio H, Moritoki Y, Nakane A, Maruyama T, Okada A, Kawai N, Tozawa K, Kohri K, Yasui T, Hayashi Y. Robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction: comparison between pediatric and adult patients-Japanese series. J Robot Surg 2016; 11:151-157. [DOI: 10.1007/s11701-016-0633-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/23/2016] [Indexed: 01/19/2023]
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Abstract
The laparoscopic approach to the pyeloplasty procedure has proven to be safe and effective in the pediatric population. Multiple studies have revealed outcomes comparable to the open approach. However, a major drawback to laparoscopy is the technical challenge of precise suturing in the small working space in children. The advantages of robotic surgery when compared to conventional laparoscopy have been well established and include motion scaling, enhanced magnification, 3-dimensional stereoscopic vision, and improved instrument dexterity. As a result, surgeons with limited laparoscopic experience are able to more readily acquire robotic surgical skills. Limitations of the robotic platform include its high costs for acquisition and maintenance, as well as the need for additional robotic surgical training. In this article, we review the current status of the robot-assisted laparoscopic pyeloplasty, including a brief history, comparative outcomes, cost considerations, and training.
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Affiliation(s)
- Michael V Hollis
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Patricia S Cho
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Richard N Yu
- Department of Urology, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Arlen AM, Kirsch AJ. Recent Developments in the Use of Robotic Technology in Pediatric Urology. Expert Rev Med Devices 2016; 13:171-8. [DOI: 10.1586/17434440.2016.1136211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Schroeder RPJ, Chrzan RJ, Klijn AJ, Kuijper CF, Dik P, de Jong TPVM. Training potential in minimally invasive surgery in a tertiary care, paediatric urology centre. J Pediatr Urol 2015; 11:271.e1-6. [PMID: 26096439 DOI: 10.1016/j.jpurol.2015.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 03/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons. OBJECTIVE To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU). STUDY DESIGN The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12 kg. RESULTS Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation. DISCUSSION There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology. Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre. CONCLUSION Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.
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Affiliation(s)
- R P J Schroeder
- Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC Amsterdam, The Netherlands.
| | - R J Chrzan
- University Children's Hospitals AMC Amsterdam and UMC Utrecht, AMC Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - A J Klijn
- University Children's Hospitals AMC Amsterdam and UMC Utrecht, UMC (WKZ) Utrecht, Postbus 85090, 3508 AB Utrecht, The Netherlands.
| | - C F Kuijper
- University Children's Hospitals AMC Amsterdam and UMC Utrecht, AMC Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - P Dik
- University Children's Hospitals AMC Amsterdam and UMC Utrecht, UMC (WKZ) Utrecht, Postbus 85090, 3508 AB Utrecht, The Netherlands.
| | - T P V M de Jong
- University Children's Hospitals AMC Amsterdam and UMC Utrecht, UMC (WKZ) Utrecht, Postbus 85090, 3508 AB Utrecht, The Netherlands.
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Perioperative effects of caudal and transversus abdominis plane (TAP) blocks for children undergoing urologic robot-assisted laparoscopic surgery. J Pediatr Urol 2015; 11:121.e1-7. [PMID: 25921701 DOI: 10.1016/j.jpurol.2014.10.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 10/15/2014] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Regional anesthesia is often used in combination with general anesthesia for pediatric surgery, however, it is unknown if adjunctive regional blocks are beneficial to children undergoing urologic laparoscopic or robot-assisted laparoscopic (RAL) procedures. OBJECTIVE To compare perioperative outcomes in children with adjunctive caudal blocks, transversus abdominis plane (TAP) blocks, or no regional anesthesia for common RAL surgical procedures in pediatric urology. STUDY DESIGN Inclusion in this retrospective study was limited to children who underwent RAL renal or ureteral/bladder procedures and received a standardized regimen of scheduled intravenous ketorolac and oral acetaminophen for acute postoperative pain control, with opioids as needed (PRN). Perioperative outcomes were compared between patients with an adjunctive caudal block (n = 25), bilateral TAP blocks (n = 44), or no regional anesthesia (n = 51). RESULTS Children with a preoperative caudal block received less intraoperative opioids than children with TAP blocks or no regional anesthesia (p < 0.001). This difference was observed both for renal procedures (p < 0.01) and ureteral/bladder procedures (p = 0.01). Patients with caudal blocks were also the least likely to require postoperative antiemetics (p = 0.03). There were no significant differences between groups in postoperative opioid use, maximum pain scores within 6 and 24 hours postoperatively, or length of hospital stay (LOS). No complications attributable to regional blocks were identified by chart review. DISCUSSION Use of adjunctive caudal blocks for pediatric RAL renal or ureteral/bladder surgical procedures may reduce need for alternate analgesic and/or anesthetic agents intraoperatively, as well as decrease postoperative nausea and vomiting. These findings may be related, since nausea and vomiting are common side effects of opioids and inhalational anesthetics. Consideration of the potential impact of caudal blocks on general anesthetic requirements is timely in light of concerns regarding the risk of anesthetic neurotoxicity in young patients. There was no evidence of improved postoperative pain control or shorter LOS for children who received regional anesthesia. It is unknown if regional blocks would have a greater impact in the absence of scheduled pain medications, which all patients in our study received. Limitations of this study include its retrospective nature and moderate sample size. Future randomized controlled trials are necessary to provide a more definitive understanding of regional anesthesia's role in minimizing pediatric surgical and anesthetic morbidity. CONCLUSION Administration of caudal blocks should be considered for children of suitable age undergoing RAL surgery involving either the upper or lower urinary tract.
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The robotic-assisted laparoscopic pyeloplasty: gateway to advanced reconstruction. Urol Clin North Am 2014; 42:89-97. [PMID: 25455175 DOI: 10.1016/j.ucl.2014.09.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Robotic pyeloplasty is now commonly performed for children with ureteropelvic junction obstruction. Because surgical robotics is a tool that facilitates pyeloplasty and other reconstructive urologic operations, the indications for robotic-assisted laparoscopic pyeloplasty are the same as those for an open pyeloplasty but offer distinct advantages with respect to visualization, range of motion, and ease of laparoscopic suturing. In this review, the authors discuss the operative approach for robotic pyeloplasty in children and the extensions of the basic techniques to challenging clinical scenarios.
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